Every finding on record at PruittHealth-Durham

Based on record review, observations, staff and provider interviews, the facility failed to ensure adequate staffing to ensure 1 of 5 residents (Resident # 17) received ongoing assessments of a stage 4 pressure ulcer and were able to recognize the pressure ulcer was not improving and involve a wound provider. On admission, 4/20/26, the wound measurements were 2.5 centimeters (cm) in length, 1.5 cm in width, and 0.5 cm in depth. When the wound provider assessed the pressure ulcer on 5/21/26 the wound measured 10 cm in length, 2.5 cm in width, and 1 cm in depth.Cross refer to F686 Based on record review, observations, staff and provider interviews, the facility failed to ensure 1 of 5 residents (Resident # 17) received ongoing assessments of a stage 4 pressure ulcer. The facility failed to recognize the pressure ulcer was not improving and involve a wound provider. On admission, 4/20/26, the wound measurements were 2.5 centimeters (cm) in length, 1.5 cm in width, and 0.5 cm in depth. When the wound provider assessed the pressure ulcer on 5/21/26 the wound measured 10 cm in length, 2.5 cm in width, and 1 cm in depth.

Based on record review, observations, staff and provider interviews, the facility failed to ensure 1 of 5 residents (Resident # 17) received ongoing assessments of a stage 4 pressure ulcer. The facility failed to recognize the pressure ulcer was not improving and involve a wound provider. On admission, 4/20/26, the wound measurements were 2.5 centimeters (cm) in length, 1.5 cm in width, and 0.5 cm in depth. When the wound provider assessed the pressure ulcer on 5/21/26 the wound measured 10 cm in length, 2.5 cm in width, and 1 cm in depth.Findings Included: Review of the hospital Discharge summary dated [DATE] revealed Resident #17 was discharged to the facility with multiple wound care needs, including a former enterocutaneous fistula site (an abnormal opening connecting the intestine to the skin) requiring daily wound care, wounds to the groin, perineum, and thighs requiring treatment, a left ischial wound requiring ongoing dressing changes, and pressure injury prevention interventions.Review of the hospital physician orders dated 4/20/26 revealed Resident #17 had wound care orders for the left ischium (the lower portion of the pelvis commonly referred to as the sit bone). The orders directed staff to change the dressing every three days and as needed if soiled, cleanse the wound with Vashe (a wound cleansing solution used to clean wounds and reduce bacteria), apply a silver-containing antimicrobial dressing to the wound to help prevent infection, and cover the wound with a protective foam dressing.Resident #17 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the bladder (bladder cancer), muscle weakness, epilepsy, cerebral palsy, and a stage 4 pressure ulcer located on the left ischium (the lower portion of the pelvis commonly referred to as the sit bone). A stage 4 pressure ulcer is the most severe stage of pressure injury and involves full-thickness tissue loss with damage extending into muscle, tendon, or bone.Review of the facility admission skin assessment dated [DATE] revealed Resident #17 was identified as being at risk for pressure ulcers. The skin assessment documented a pressure ulcer to the left ischium (the lower portion of the pelvis commonly referred to as the sit bone) measuring 2.5 centimeters (cm) in length, 1.5 cm in width, and 0.5 cm in depth.Review of Resident #17's care plan dated 4/21/26 revealed Resident #17 was care planned for impaired skin integrity related to a Stage 4 pressure ulcer of the left ischium. Interventions included treatment as ordered, wound consultation as needed, reporting signs of infection, failure to improve or decline in the wound to the provider, providing ADL assistance to maintain clean and dry skin, reporting signs of skin breakdown, and utilizing a specialty mattress as indicated. Review of the care plan did not reveal refusal of wound treatment.The admission Minimum Data Set (MDS) assessment for Resident #17 dated 4/26/26 revealed Resident #17 was cognitively intact, had no documented behavioral symptoms, was dependent upon staff for toileting hygiene, required staff assistance with bathing, dressing, transfers, and wheelchair mobility, and utilized a manual wheelchair. The MDS further documented Resident #17 had a Stage 4 pressure ulcer located at the left ischium and was coded for pressure ulcer-related interventions, including a pressure-reducing device for the bed, a pressure-reducing device for the chair, a turning and repositioning program, wound care, and nutrition/hydration interventions.Review of the Nurse Practitioner (NP) progress note dated 4/27/26 revealed Resident #17's diagnoses included a Stage 4 pressure ulcer of the left buttock. Under the physical examination, the NP documented the exposed skin appeared clean, dry, and intact and indicated no open wounds were noted.Review of the medical record revealed a weekly wound assessment and pressure ulcer assessment were not documented as completed on 4/27/26 for Resident #17's Stage 4 pressure ulcer.Review of the medical record revealed there was no documented weekly wound assessment or pressure ulcer assessment completed on 5/4/26 for Resident #17's Stage 4 pressure ulcer.Review of the NP progress note dated 5/4/26 revealed Resident #17 had an enterocutaneous fistula with stool drainage and documented dressing changes were being performed by the Wound Nurse. Under the physical examination, the NP documented the exposed skin appeared clean, dry, and intact and indicated no open wounds were noted. Review of the medical record revealed there was no documented weekly wound assessment or pressure ulcer assessment completed on 5/11/26 for Resident #17's Stage 4 pressure ulcer.Review of the medical record revealed there was no documented weekly wound assessment or pressure ulcer assessment completed on 5/18/26 for Resident #17's Stage 4 pressure ulcer to the left ischium.Review of the NP progress note dated 5/18/26 revealed Resident #17 had a diagnosis of a Stage 4 pressure ulcer of the left ischium and was being followed by the wound provider. Under the physical examination, the NP documented the exposed skin appeared clean, dry, and intact and indicated no open wounds were noted. Review of the Wound Provider initial assessment dated [DATE] revealed Resident #17 was evaluated for a Stage 4 pressure ulcer to the left ischium that was present on admission. The wound measured 10 cm in length, 2.5 cm in width, and 1 cm in depth. The wound assessment documented 40% granulation tissue, which is healthy new tissue that forms during the wound healing process; 30% necrotic tissue, which is dead or nonviable tissue that can delay healing and increase the risk of infection; and moderate serous drainage, which is a moderate amount of clear to pale yellow fluid commonly produced by wounds. The assessment documented no signs of local or systemic infection. The Wound Provider documented the wound was pressure-related and recommended daily wound treatment.Review of the wound assessment dated [DATE] revealed Resident #17 was assessed as having a stage 4 pressure ulcer to the left ischium that was documented as present on admission. The wound assessment documented the wound measured 10 centimeters (cm) in length, 2.5 cm in width, and 1 cm in depth with moderate serous drainage. Review of the Wound Provider progress note dated 5/28/26 revealed Resident #17 was unavailable for evaluation, and no wound assessment was completed.Review of the medical record revealed there was no documented weekly wound assessment or pressure ulcer assessment completed on 6/01/26 for Resident #17's Stage 4 pressure ulcer to the left ischium.Review of the Wound Provider progress note dated 6/4/26 revealed Resident #17 refused treatment, and no wound assessment was completed.Review of the medical record revealed there was no documented weekly wound assessment or pressure ulcer assessment completed on 6/08/26 for Resident #17's Stage 4 pressure ulcer to the left ischium.Review of the Wound Provider progress note dated 6/11/26 revealed Resident #17's Stage 4 pressure ulcer to the left ischium measured 8.9 cm in length, 2.7 cm in width, and 0.7 cm in depth. The wound assessment documented 70% granulation tissue, moderate serous drainage, and no signs of local or systemic infection. The Wound Provider documented the wound was improving and recommended continuation of the current treatment regimen.On 06/11/2026 at 12:15 PM, an observation was conducted of the Wound Care Physician and Wound Care Nurse providing wound care to Resident #17. The Wound Care Physician assessed and measured the resident's wound while the Wound Care Nurse completed the wound treatment. The Wound Care Physician measured the left ischial wound as 8.9 cm in length, 2.7 cm in width, and 0.7 cm in depth. No undermining, which is tissue destruction extending under the wound edges, or tunneling, which is a channel extending from the wound into surrounding tissue, was identified. The wound bed consisted of beefy red granulation tissue, and the periwound area was intact.On 06/11/2026 at 5:15 PM, an observation was conducted of Resident #17. Resident #17 was observed seated in a wheelchair. A foam pressure-relieving cushion was observed in place on the wheelchair seat.On 06/09/2026 at 1:00 PM, an interview was conducted with Resident #17. Resident #17 stated he was aware of the wound on his left ischium and reported staff routinely provided wound care. Resident #17 stated he did not recall staff measuring the wound and reported he had not been informed of the wound measurements or whether the wound was improving or worsening. Resident #17 further stated he did not refuse wound care; however, he reported he frequently attended outside medical appointments and believed he may have missed visits from the wound provider as a result. Resident #17 further stated it was difficult for him to see the wound and know what was occurring with it because the wound was located behind him.On 06/09/2026 at 2:25 PM, an interview was conducted with the Wound Nurse. The Wound Nurse stated she was responsible for providing wound care to Resident #17 in accordance with the wound physician's orders and reported she routinely cleaned and treated the wound. The Wound Nurse stated she was expected to complete weekly wound assessments, including obtaining wound measurements; however, she acknowledged she had not completed any weekly wound assessments for Resident #17. The Wound Nurse stated she was frequently reassigned from her duties as the Wound Nurse to work as a floor nurse, which affected her ability to complete her wound care responsibilities. The Wound Nurse stated she often did not have sufficient time to complete the weekly wound assessments and would forget to complete the assessments and wound measurements. The Wound Nurse stated the weekly wound measurements were important because they were used to track the progression or deterioration of the wound and to determine whether notification of the wound provider was necessary. When asked whether she was aware if Resident #17's wound had deteriorated, the Wound Nurse stated she was unaware because she had not completed the wound measurements. When asked when she first notified the facility physician or wound provider regarding Resident #17's wound, the Wound Nurse stated the first notification occurred when she completed the initial wound assessment on 5/25/26. The Wound Nurse stated she did not notify the physician or wound provider of any changes in the wound prior to that time because she had not completed the weekly wound assessments or obtained wound measurements to monitor the wound's progression.On 06/12/2026 at 3:45 PM, a phone interview was conducted with Nurse #14 regarding Resident #17's Stage 4 pressure ulcer. Nurse #14 stated he worked every weekend as a Registered Nurse and Weekend Supervisor and had routinely worked on Resident #17's unit during the past three months. Nurse #14 stated he frequently provided wound care to residents when the Wound Nurse was unavailable on weekends and documented wound treatments in the medical record and on the MAR. Nurse #14 stated he was aware Resident #17 had a Stage 4 pressure ulcer and routinely observed the wound while providing care. Nurse #14 stated he recognized the pressure ulcer had deteriorated because the wound had increased in size over time, contained slough tissue, and had drainage. Nurse #14 stated he did not notify the Wound Nurse, NP, wound provider, or nursing management regarding the wound's deterioration because he believed the increase in the wound's size represented normal wound deterioration. Nurse #14 stated if a wound was deteriorating, staff should take action and notify the appropriate clinical staff. Nurse #14 acknowledged he did not report the observed increase in the wound's size or deterioration. Nurse #14 stated he would typically notify a physician or provider only if a wound was bleeding or had an odor. Nurse #14 stated he was aware wound assessments were expected to be completed; however, he did not complete wound assessments or obtain wound measurements because he did not have access to the Wound Nurse's wound documentation system. Nurse #14 stated that when he provided wound care to Resident #17, he should have also measured the wound to monitor for changes in the wound's condition. On 06/12/2026 at 9:00 AM, a phone interview was conducted with the NP regarding Resident #17's Stage 4 pressure ulcer. The NP stated she became aware of the pressure ulcer upon Resident #17's admission to the facility on 4/20/26 after reviewing the hospital discharge summary. The NP stated she assessed Resident #17 on 4/21/26, 5/4/26, and 5/18/26 and believed Resident #17's Stage 4 pressure ulcer was being followed by the wound doctor. The NP stated she did not actively follow the wound because she believed the wound doctor was managing the wound and reported that when a resident is admitted with a wound, the wound doctor is routinely consulted. The NP stated monitoring a resident's wound is a shared responsibility between the Wound Nurse and the NP. The NP acknowledged she was expected to assess wounds in person even when a resident is being followed by a wound doctor. The NP stated the Wound Nurse did not communicate concerns regarding the wound's progression to her. The NP further stated she should have provided additional follow-up regarding the wound and should have recognized that the wound had increased in size. The NP acknowledged she failed to identify the wound's deterioration because she was not actively following the wound and believed the wound doctor was managing it. The NP stated she was concerned that weekly wound measurements had not been completed because wound measurements are used to track the progression or deterioration of a wound. The NP stated the wound measurements would have assisted her in identifying changes in the wound's condition and determining whether additional interventions or notification of the wound provider were necessary. When asked whether she was aware the wound had deteriorated, the NP stated she was unaware of the wound's progression. The NP stated that if the wound had been followed more closely, earlier interventions could have been implemented. On 06/10/2026 at 3:17 PM, an interview was conducted with the Wound Doctor and Regional Clinical Manager regarding Resident #17's Stage 4 pressure ulcer. The Wound Doctor stated the initial wound evaluation was completed on 5/21/26 after the Wound Nurse made them aware of the chronic wound. The Wound Doctor stated Resident #17 refused the wound evaluation on 6/4/26 because he preferred to remain in his wheelchair rather than return to bed. The Wound Doctor stated alternative options were offered; however, Resident #17 continued to refuse the assessment. The Wound Doctor stated the expectation would be for the Wound Nurse to follow up later that day and continue the resident's daily wound treatment plan. The Wound Doctor stated the wound care company had not received any reports from the Wound Nurse regarding concerns with the wound, changes in the wound, or repeated refusals of wound assessments. The Wound Doctor stated wounds are measured during each weekly wound evaluation in accordance with company policy. The Wound Doctor stated wound measurements are important because they allow providers to monitor the progression or deterioration of a wound and determine whether additional interventions are necessary. The Wound Doctor further stated delays in wound care or failure to identify changes in a wound could increase the risk of infection, sepsis, and progression to a bone infection. The Wound Doctor stated the facility should have initiated and obtained routine wound measurements and was responsible for ongoing monitoring and follow-up of the wound. The Wound Doctor stated the role of the wound care company was to evaluate and treat the wound, while the facility remained responsible for daily monitoring and notification of changes in the resident's condition. The Wound Doctor stated if wound care was provided, the care should have been documented. The Wound Doctor further stated that earlier identification of wound deterioration could have resulted in earlier interventions to address the wound and potentially slow the progression of the wound. On 06/12/2026 at 2:02 PM, an interview was conducted with the Facility Provider regarding Resident #17's Stage 4 pressure ulcer. The Facility Provider stated that when a resident is admitted with a Stage 4 pressure ulcer, he would expect wound care orders to be initiated upon admission and the wound to be followed in accordance with physician orders. The Facility Provider stated wound progression is determined through direct assessment of the wound and measurement of the wound's size. The Facility Provider stated he relies on wound measurements provided by facility staff when making treatment decisions regarding wounds. When asked what nursing staff should do if a wound is observed to be increasing in size, the Facility Provider stated nursing staff should immediately notify the provider. The Facility Provider stated the nursing staff should have completed wound assessments and documented wound measurements. The Facility Provider further stated that if wound assessments had been completed as expected, the wound measurements would have reflected any changes in the wound's size and condition. The Facility Provider stated the wound nurse did not do their best documenting the wound and indicated wound documentation should be completed during each assessment. The Facility Provider further stated that because Resident #17 had multiple underlying health conditions, including cancer, ongoing wound monitoring and measurements were especially important. The Facility Provider stated wound measurements are necessary to track the wound's progression, identify deterioration, evaluate the effectiveness of treatment interventions.On 06/12/2026 at 4:00 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #17's Stage 4 pressure ulcer. The DON stated the admission nurse is expected to complete a head-to-toe skin assessment upon admission and document all wounds identified. The DON stated the Wound Nurse is also expected to complete an assessment to ensure all wounds are identified and documented. The DON confirmed Resident #17 was admitted with a pressure ulcer. The DON stated staff should be made aware of wounds through admission documentation, hospital records, and communication from nursing staff. The DON stated weekly wound assessments and wound measurements are expected to be completed by the Wound Nurse and wound provider. The DON stated any changes in the wound should be documented, communicated to the provider, and reported to the resident and resident's family. The DON stated if a wound is observed to be increasing in size or deteriorating, staff are expected to complete an assessment and immediately notify the provider and wound provider. The DON stated the provider is expected to assess wounds during routine visits, particularly when there has been a change in the wound's condition. The DON stated that based on her review of the medical record, the weekly wound assessments were not completed by the Wound Nurse. The DON stated the facility normally relies on wound reports and wound measurements to determine whether a wound is improving or worsening; however, there was no wound report documenting ongoing weekly measurements for Resident #17. The DON stated the last documented wound measurements were obtained on 5/21/26. The DON stated wound measurements and assessments are important because without documentation the facility cannot accurately determine how a wound is progressing. The DON further stated that if wound measurements had been obtained sooner, staff could have more closely monitored the wound's progression and implemented interventions sooner. The DON stated she was not satisfied with the care and monitoring provided for Resident #17's wound and acknowledged the wound worsened. The DON stated the wound nurse being reassigned to floor nursing duties was not an acceptable reason for failing to complete wound assessments, measurements, documentation, and follow-up responsibilities.On 06/12/2026 at 5:45 PM, an interview was conducted with the Administrator regarding Resident #17's Stage 4 pressure ulcer. The Administrator stated he was not aware of concerns related to the progression of Resident #17's pressure ulcer. The Administrator stated residents with pressure ulcers are expected to be followed by nursing staff, the Wound Nurse, and the wound provider to ensure wounds are monitored and treated appropriately. The Administrator stated the facility conducts clinical meetings Monday through Friday during which staff discuss residents with clinical concerns, including residents at risk for decline. The Administrator stated he does not routinely attend the wound meetings but expects concerns regarding worsening wounds to be communicated through the facility's clinical process. The Administrator stated he was not aware Resident #17's pressure ulcer had increased in size. The Administrator stated the Wound Nurse did not meet facility expectations because the required wound assessments were not documented. The Administrator stated the facility relies on wound assessments, wound measurements, and documentation to monitor residents with wounds and determine whether additional follow-up or interventions are needed. The Administrator stated that if wound assessments and measurements are not completed and documented, the facility cannot accurately determine whether a wound is improving or worsening. The Administrator further stated failure to complete and document weekly wound assessments was not consistent with facility expectations and negatively impacted the facility's ability to monitor Resident #17's wound progression and identify changes in the wound's condition.

Based on observation, record review, resident and staff interviews, the facility failed to maintain personal privacy and dignity for 3 of 5 residents reviewed for resident rights. The facility failed to ensure privacy when a Resident #17 was left naked with his genitals exposed and visible to the public. Resident #17 stated he felt angry, embarrassed, and as though he was on display as a result of the incident. The facility also failed to treat Resident #57 in a dignified manner when staff did not provide privacy during activities of daily living, exposing Resident #57's buttocks and private areas during bathing and wound care. Additionally, the facility failed to protect the dignity and privacy of Resident #80 by failing to provide a privacy cover while Resident #80 was dressed only in an adult incontinence brief and visible to the public. These failures resulted in residents experiencing embarrassment, loss of dignity, and compromised privacy. Findings Included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the bladder (Bladder Cancer), muscle weakness, epilepsy, cerebral palsy, neurogenic bowel, colostomy status, and a Stage 4 pressure ulcer located on the left ischium (the lower portion of the pelvis commonly referred to as the sit bone). The admission Minimum Data Set (MDS) assessment for Resident #17 dated 4/26/26 revealed Resident #17 was cognitively intact, had no documented behavioral symptoms and was dependent upon staff for toileting hygiene. On 06/08/2026 at 12:27 PM, while standing in the hallway outside Resident #17's room, Resident #17 was observed lying in bed near the window with the right side of the bed facing the doorway. Resident #17 was fully naked with his genital area exposed and visible from the hallway through the open doorway. The room door was fully open. The bed was positioned at its highest level. At the time of the observation, no staff member was present in the room. At 12:38 PM, the Wound Nurse returned to Resident #17's room to resume care. On 06/08/2026 at 1:30 PM, an interview was conducted with the Wound Nurse. The Wound Nurse stated that during her afternoon rounds on 06/08/2026 she discovered Resident #17's colostomy bag had burst and observed a large amount of feces on Resident #17 and his clothing. The Wound Nurse stated she removed Resident #17's clothing and intended to place the soiled items in a soiled linen bag. The Wound Nurse stated she left Resident #17's room to obtain disposable trash bags and soiled linen bags. The Wound Nurse stated she forgot to return to Resident #17's room because she had been pulled away by a nurse on a different hall to assist another resident. The Wound Nurse acknowledged that Resident #17 was left naked while she was out of the room. The Wound Nurse did not offer an explanation why she did not provide privacy to the resident prior to leaving the room. When asked why she did not cover the resident with a sheet or blanket before leaving the room, the Wound Nurse stated she did not know. The Wound Nurse stated she should have closed the door to provide privacy for Resident #17. On 06/08/2026 at 2:00 PM, an interview was conducted with Resident #17. Resident #17 stated he was receiving wound care and assistance with bathing and dressing from the Wound Nurse. Resident #17 stated the Wound Nurse completed the dressing change for the wound and informed him she would return to get him dressed. Resident #17 stated he was unsure why the Wound Nurse left and stated she was gone for a while. Resident #17 reported he was angry that he had been left naked in bed with the room door open. Resident #17 stated he felt embarrassed because he was unclothed and was concerned that someone might see him. Resident #17 reported feeling further embarrassed when surveyor staff observed him in that condition. Resident #17 stated he attempted to use the edge of his bed sheet to cover his genital area but was unsuccessful. Resident #17 expressed concern that staff of family passing by his room may have been able to see him while he was unclothed. On 06/12/2026 at 4:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation when providing personal care is to maintain the resident's privacy. The DON stated the resident's room door should be closed during personal care and should remain closed to protect the resident's privacy. The DON stated staff should obtain all necessary supplies prior to beginning care to avoid leaving a resident unattended during the care process. The DON stated it was disappointing that Resident #17 had been left unclothed with the room door open and indicated this was not consistent with facility expectations. On 06/12/2026 at 4:45PM, an interview was conducted with the Administrator. The Administrator stated that when providing personal care, resident privacy should be maintained by closing the room door or privacy curtain. The Administrator stated that these measures were necessary to protect the resident's privacy during personal care. 2. Resident #80 was admitted to the facility on [DATE] with diagnoses of muscle weakness, reduced mobility, unspecified pain, and rash with other nonspecific skin eruptions. The quarterly Minimum Data Set (MDS), dated [DATE], showed that Resident #80 was cognitively intact and did not exhibit behaviors or reject care. On 6/9/26 from 2:40 PM to 2:52 PM, an observation from the hallway revealed Resident #80 sitting upright in the bed that was closest to the door wearing only an adult incontinence brief. The bedroom door was wide open to the public hallway, where housekeeping staff were cleaning rooms. Resident #80 was clearly visible from the hallway and had no sheet, clothing, or cover on his body. He repeatedly called out loudly for staff to get him a sheet or blanket for about 10 minutes. A housekeeping staff member passed his room multiple times while cleaning surrounding rooms. NA #3 walked past his open doorway as he called out and entered a room three doors down. When NA #3 later returned to the hallway, she stood approximately 20 feet from his open door while he continued calling out. On 06/09/26 at 2:48 PM, NA #3 was interviewed in the hallway while Resident #80 continued loudly calling out that he needed assistance. NA #3 stated that Resident #80 did not want to be covered by a sheet or blanket and preferred to lie completely uncovered. She reported that it was common for Resident #80 to refuse to have the privacy curtain drawn or the door closed, so she did not pull the privacy curtain or shut the door when she left his room after she provided him with incontinence care. NA #3 stated Resident #80 liked to sit in his bed that way. On 06/09/26 at 2:52 NA #3 entered Resident #80's room and asked what he needed. Resident #80 replied that he wanted a sheet or a blanket to cover up with. NA #3 provided a top sheet and laid it across his lap, and the resident adjusted it, leaving his legs and chest uncovered. During an interview in Resident #80's room on 06/09/26 at 2:52 PM, Resident #80 stated that NA #3 had changed his bedding and adult incontinence brief 30 to 40 minutes earlier, then left the room with the soiled linens and told him she would return with clean linen. He explained that he frequently felt hot and preferred not to wear clothing because it irritated his skin, but he explicitly wanted a sheet or blanket to cover himself so people passing by the open hallway door could not see him exposed. He stated that he preferred the door and privacy curtain to remain open only after care was completed and he had a sheet to cover himself. He stated he felt like he was on display for anyone to see. On 06/06/10/26 at 3:54 PM, an interview with the Director of Nursing (DON) revealed that staff were aware of Resident #80's preference to avoid wearing shirts or pants due to feeling hot. However, she stated she had no prior knowledge or observation of the resident being left to lie in bed without a sheet or blanket covering his lap. It was her expectation that staff were to utilize privacy curtains or provide linens to cover Resident #80 and it was her expectation that all residents receive care consistent with their individual preferences. 3. Resident #57 was admitted to the facility on [DATE] with diagnoses of muscle weakness and cognitive communication deficit. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #57 was cognitively intact. She was assessed as needing partial to moderate assistance with bathing. On 6/11/26 at 10:33 AM an observation was conducted for activities of daily living (ADL) care for Resident #57. Resident #57's bed was closest to the door of the room. NA #2 was providing Resident #57 a bed bath with the door closed and privacy curtain pulled between Resident #57 and her roommate who was resting in bed. This surveyor was standing at the foot of Resident #57's bed during the observation when Nurse #1 simultaneously knocked on and opened the door to the resident's room. Resident #57's bare bottom was exposed to the hallway while being washed. No other staff or visitors were observed in the hallway. Nurse #1informed NA #2 that the hospice NA needed to visit Resident #57's roommate then told hospice NA #1 she could enter and shut the door. NA #2 attempted to close the privacy curtain next to the door, but it failed to move due to multiple missing hooks, approximately a 2-foot span, that connected the privacy curtain to the ceiling. However, hospice NA #1 proceeded to enter the room and walked past Resident #57 whose bottom remained exposed and visible to the hospice NA as she walked past the resident. NA #2 was interviewed on 6/11/26 at 10:55 AM. NA #2 explained in this job you do what the nurse tells you to do when asked why she did not inform Nurse #1 that patient care was being done and the privacy curtain did not work. NA #2 continued to explain Nurse #1 allowed hospice NA #1 to enter. The privacy curtain would not pull all the way around so we could not give Resident #57 privacy. On 6/11/26 at 11:12 AM Nurse #1 was interviewed. Nurse #1 stated she was unaware the privacy curtain was broken before she allowed hospice NA #1 to enter Resident #57's room. Nurse #1 explained hospice NA #1 was on a set schedule, and if she was not allowed to go in to take care of Resident #57's roommate when she asked to go in then hospice NA #1 would have left. According to Nurse #1, she should have waited for a response and then she should have spoken with Resident #57's nurse to discuss the care both residents needed before sending the hospice NA in the room. The Unit Manager (UM) was interviewed on 6/11/26 at 11:14 AM who stated Nurse #1 should have knocked and spoken with the staff helping Resident #57 before allowing hospice NA #1 to enter the room. The UM further stated hospice NA #1 should have been asked to wait outside the room until Resident #57's care was completed. Hospice NA #1 was interviewed on 6/11/24 at 11:24 AM and stated she had been working with Resident #57's roommate for approximately two months and during that time Resident #57's privacy curtain had always been messed up. Hospice NA #1 stated she would have remained in the hallway if she had been informed Resident #57 was receiving patient care. Hospice NA #1 further stated she had multiple residents in the building she worked with, and she would have returned to complete the roommate's care later that day if she had been informed she could not enter the room. The Director of Nursing (DON) was interviewed on 6/12/26 at 2:02 PM and stated staff should have provided privacy for Resident #57 even if it meant using a blanket or towel to cover her so she maintained her privacy. On 6/12/26 at 2:55 PM the Administrator was interviewed and stated the privacy curtain should have been maintained in a functional order, and that Resident #57 should not have had an issue related to lack of privacy.

Based on observations and staff interviews, the facility failed to keep the dumpster area free of accumulated trash and debris for 3 of 3 dumpsters observed. This practice had the potential to attract pests and rodents.Findings included:On 6/8/26 at 10:40 AM an observation was conducted of the dumpster area located behind facility. There were 3 large green dumpsters. While facing the dumpsters the dumpster on the left side was observed with the lid and the sliding side doors closed. The middle dumpster was observed to contain broken down folded cardboard boxes that were protruding from an opening in the front. The lid was closed. The dumpster to the right had the lid and the side sliding door open. This dumpster was observed to contain food waste not contained in bags and bagged waste. Flies were observed on the waste in this dumpster. Non-contained waste debris was observed littering the ground in front of, between, beside and behind the dumpsters. This debris included disposable plates, cups, empty and full condiment packets, and soiled napkins. Food waste was also observed on the ground, and a squirrel was foraging in the food. Behind the dumpsters, leaf litter was observed approximately 3 inches deep dispersed with various trash items and debris, including empty plastic bottles and juice cartons. On 06/9/2026 at 9:42 AM a second observation of the dumpster area and an interview were conducted with the Maintenance Assistant. He reported he had been in his position for the past 2 years. He stated he normally arrived at work in the morning between 6:30 AM and 7:00 AM. He indicated that when he got to the facility in the morning, he could see the dumpster area from where he parked his car. He reported that he also he saw the dumpster area on 06/8/26 when he arrived at work at his usual time, and there was trash everywhere. He reported there had been trash on the ground including cups, plates, bowels, and other paper trash. He reported on 06/8/26, the dumpster area was the worst he has ever seen it. He reported the city waste corporation serviced the facility, and he thought the trash was falling out when the dumpsters were emptied. He stated he did not know what the trash collection schedule was. He indicated his usual workday priority was managing the inside of the building, and then when he could get to it, he worked outside the building after the sun came out. He stated on 6/8/26 around 11:00 AM, he went out to the dumpsters and cleaned up what he could. He stated there was still currently trash, including empty plastic bottles, cups, lids, condiment packets, plastic utensils, and food waste on the ground in front of, behind, and between the 3 dumpsters. He indicated the dumpsters did not have numbers, but the left and right dumpsters, if you were facing them were for normal waste including kitchen and food waste, and the middle dumpster was for cardboard. He confirmed that the side sliding door on the left dumpster was open, and unbagged food waste, and flies were observed. The top of the left dumpster was open, and the middle dumpster lid was open, and cardboard was sticking out above the rim of the dumpster. The right dumpster lid was closed, but the side door was open, and unbagged food waste and flies were present. He stated the lids and side doors of all dumpsters should always remain closed, to prevent attracting insects and animals. He confirmed that behind the cement wall of the kitchen ramp near the dumpster area, there was an approximately 30-gallon plastic trash bag filled with empty aluminum cans, and on the ground beside this bag, were approximately 100 loose empty aluminum cans. He indicated these cans had been there at least since 6/4/26 or 6/5/26, because he had seen them last week. He stated he thought one of the staff collected them for recycling, but he did not know who. He indicated regular monitoring and cleaning of the dumpster area was not something he recalled ever being assigned. He reported he felt that the housekeeping and kitchen staff should do this. He reported he sometimes did it, because he didn't want to wait for someone else. He stated he had never seen mice or rats at the dumpster area, but he had seen racoons and squirrels On 6/9/26 at 10:01 AM Floor Tech #1 was observed to arrive at the dumpster area and deposit bagged trash into the left trash dumpster and closed the side door. In an interview at this time, he reported his duty was to ensured that floors were cleaned in the building, and trash was emptied and disposed of. He stated there were times when he needed to break down cardboard and place this in the middle dumpster that was for cardboard waste. He indicated that he knew that the lids and sliding side doors of dumpsters should always be closed. He reported he was not sure whose responsibility it was to make sure there was no trash or waste outside the dumpsters, and the lids were closed, but he thought kitchen staff should be responsible for the dumpsters. He reported he had never been assigned this duty. On 06/10/2026 9:25 AM an interview with the Maintenance Director indicated he started his role with the facility on 06/8/26. He reported that because the trash that went into the dumpsters was from housekeeping and dietary departments, he thought they would be responsible for managing the dumpster area. He stated the maintenance department was responsible for cleaning the perimeter of the building like the parking lot but were not responsible for maintaining the dumpster area. On 06/9/2026 10:21 AM an observation of the facility's dumpster and an interview were conducted with the Administrator. He indicated the trash observed on the ground in the dumpster area, and the aluminum cans on the side, should not be present. He reported this was a sanitation issue. He reported the boxes should be broken down, and the lids and side doors to the dumpsters should be kept closed at all times to contain refuse. He indicated he believed the issue was that when the waste management company emptied the dumpsters; they were spilling the trash onto the ground. He indicated the maintenance staff should be doing frequent monitoring of the dumpster area and ensuring that the area was kept clean and free from debris. He reported he thought the breakdown in the process was because there was a misunderstanding among the staff regarding what their roles and responsibilities were.

Based on observation, record review, and staff interviews, the facility failed to keep the floors and walls behind the deep fryer and stove clean and free of dirt and oil. Staff failed to keep the oven, stove, deep fryer, and steam table backsplash clean and free of burnt food and food stains. Staff failed to label food stored for use in 1 of 1 reach in refrigerator and ensured that dry food with a scoop inside it was covered and labeled with the correct name. In addition, the facility failed to keep trash containers in the kitchen covered, failed to store cleaning equipment away from clean dishes, and failed to discard chipped plates and remove cups with dried food on them from the tray line. Dietary staff with facial hair failed to use facial hair covers to cover their facial hair for 2 of 2 staff observed. The facility also failed to maintain the ceiling to prevent peeling paint. These failures had the potential to affect food served to residents.Findings included:1a. Observation on 6/10/26 at 11:13 AM revealed that the kitchen floor had a wet appearance and had pieces of paper and food particles scattered across it. The floor near the stove and preparation area was very greasy and slippery. The floor between the stove and the deep fryer and the wall behind the deep fryer had a thick layer of oil and dried food, and the area appeared greasy and sticky.During an interview on 6/10/26 at 11:15 AM, the Dietary [NAME] stated that the dietary staff were in the process of cleaning the kitchen because the breakfast meal had just been completed and the lunch meal had been prepared. The Dietary [NAME] stated he had tried to clean the area between the fryer and the stove, but it had been greasy for so long that it was very difficult to remove.1b. Observation on 6/10/25 at 11:30 AM revealed that the oven had dark brown burnt stains on the inside of the door and on the shelves. The base of the oven had dark brown burnt food on it. Three racks placed over the oven were dark brown and had burnt food stains. Burnt food particles were also on top of the oven. Observation of the gas stove revealed that the front panel, stove knobs, and side splash guard had oil and food stains. The splash guard had brown stains on it. Observation of the deep fryer revealed burnt food in the oil and on the fryer. Observation of the steam table revealed a clear plastic backsplash placed on one side of the steam table with white stains.During an interview on 6/10/26 at 11:45 AM, the Dietary [NAME] stated he cleaned the oven and deep fryer every Friday and that the last cleaning was done on 6/5/26. He indicated there was no cleaning schedule for the dietary staff to follow and stated he was usually responsible for cleaning the oven, stove, and deep fryer.During an interview on 6/11/26 at 2:20 PM, the Dietary Supervisor stated there was no cleaning schedule and that all staff were responsible for cleaning after cooking. The Dietary Supervisor stated the dietary cook cleaned the oven and fryer every Thursday and that the oil was changed on that day. He also stated that staff should clean the backsplash after each meal.2a. Observation of the reach in refrigerator on 6/10/26 at 11:25 AM revealed four individual green cups with lids that had no label or date. The reach in refrigerator also contained a tray with 16 individual closed cups containing beverages. A store bought opened cardboard box with soda cans had been placed on top of these cups. During an interview on 6/10/26 at 11:25 AM, the Dietary Supervisor stated staff should not store any boxes over the drinks intended for the afternoon lunch service. The Dietary Supervisor stated the four individual cups contained cream pie and fruit from the previous day's meal.2b. On 6/10/26 at 11:20 AM and on 6/11/26 at 2:10 PM, observations revealed a transparent bin with no lid containing a white powdered substance labeled as sugar, with a scoop inside the bin, resting on the powdered substance. The white powdered substance was open-to air. This transparent bin was placed on a rack, under the table which was near the hand-washing sink. During an interview on 6/11/26 at 2:11 PM, the Dietary Supervisor stated the white powder in the bin was a thickening product used to thicken liquids during meals. He stated the scoop should be removed and a lid should be placed on the bin after each use.2c. On 6/10/26 at 11:20 AM, an opened half loaf of bread that was not labeled or dated was observed near the prep area. On 6/11/26 at 2:30 PM, a package containing six bread rolls, opened and not labeled or dated, was observed on the steam table.During an interview on 6/11/26 at 2:30 PM, the Dietary Supervisor stated the opened bread loaf observed on 6/10/26 had been used for pureed bread at breakfast. He further stated the bread rolls were leftovers from lunch. The Dietary Supervisor indicated the bread and bread rolls should have been labeled and properly stored after use.3a. A continuous observation on 6/10/26 from 11:13 AM to 11:55 AM revealed two blue trash containers with no lids. One trash container was located near the rack holding clean dishes for air drying, and the other was near the kitchen side door. The kitchen side door was propped open. The trash containers near the door was almost filled with trash and the other one was half filled with trash.Observation on 6/11/26 at 2:20 PM revealed the same two blue trash containers, still without lids. One trash container was near the kitchen door, and the other was near the coffee dispenser. Both the trash containers had trash in them.During an interview on 6/11/26 at 2:23 PM, the Dietary Supervisor stated he was unsure where the lids were. He looked around the kitchen but did not find the lids for the trash containers. The Dietary Supervisor stated the trash containers should always be closed with a lid.3b. Observation of the dishwashing area on 6/10/26 at 11:30 AM revealed the Dietary [NAME] mopping the kitchen floor using a yellow mopping bucket and a mop. He later placed the bucket and mop near a rack with cleaned dishes stored to air dry. The end of the mop handle was touching the rack.During an interview on 6/10/25 at 11:30 AM, the Dietary [NAME] stated the cleaning solution used for the floor was located at the end of the three compartment sink, close to the drying racks where clean dishes from the sink were placed. He stated the bucket and mop were usually kept in that area.During an interview on 6/10/26 at 11:40 AM, the Dietary Supervisor stated the dietary staff usually placed the cleaning bucket and mop at the end of the three compartment sink near the drying racks because the cleaning solution was hooked on the wall in that area. The Dietary Supervisor indicated there was no other place to place the cleaning bucket and mop.3c. Observations on 6/10/26 at 1:00 PM and on 6/11/26 at 2:33 PM revealed a cleaning brush with blue bristles and a long handle, and a squishy broom with a long handle, hanging on the wall below a rack holding clean dishes that were air drying. A cutting board was hanging from the rack. The cleaning tools were approximately 1 to 1.5 feet away from the mop handle and broom handles.During an interview on 6/11/26 at 2:33 PM, the Dietary Supervisor stated the hooks used to hang the brooms and brushes were located on the wall beneath the drying rack. He further stated the dietary staff had always hung the brooms there and that there was no other place to store them.4. The tray line observation also revealed four out of 15 plates were chipped, and four out of 15 white cups had dried food on them. The Dietary Supervisor stated chipped plates and dirty cups should not be used for plating food and that the plates may have chipped during the washing process.5. Observation on 6/10/25 at 12:12 PM revealed Dietary Aide #1 assisting in bringing out the prepared beverages from the reach in refrigerator for the tray line. Dietary Aide #1 had facial hair near his chin (approximately a 1 1.5 inch long) and was not wearing a facial covering. During an interview on 6/10/25 at 12:13 PM, Dietary Aide #1 stated he had trimmed his beard the day before and did not think he needed to wear a facial covering for what he believed was a short length of facial hair.Observation on 6/11/25 at 2:13 PM revealed Dietary Aide #2 filling the ice box with ice. He had facial hair and was not wearing a facial covering.During an interview on 6/11/25 at 2:15 PM, Dietary Aide #2 stated he had just returned to the kitchen after his break and had forgotten to wear a facial covering.During an interview on 6/11/25 at 2:20 PM, the Dietary Supervisor stated all dietary staff should cover their hair with hairnets and cover facial hair with appropriate face coverings.7. Observation of the kitchen ceiling revealed multiple areas where paint was peeling. One area above the racks containing trays for the tray line measured approximately 2 feet by 2 feet, with a section measuring about 1 foot by 1 foot where paint was hanging from the ceiling. Additional areas of peeling paint measured approximately 4 feet by 4 feet near the steam table passage, 2 feet by 2 feet near the meal preparation area, as well as other smaller areas throughout the kitchen.During an interview on 6/10/26 at 3:00 PM, Maintenance Assistant #2 stated that management had been informed a year earlier that the kitchen ceiling needed repainting. He stated the facility had indicated it would look into hiring private contractors to complete the work, but no painting had been done since.During an interview with the Dietary Supervisor on 6/11/26 at 2:10 PM, he stated he had notified the Administrator on May 20, 2026 that the kitchen ceiling needed a new paint was peeling, and no action had been taken since.During an interview on 3/11/26 at 4:15 PM, the Administrator stated the cleaning of the kitchen should be delegated to all dietary staff and should occur on a regular basis. The Administrator stated the Dietary [NAME] and Dietary Supervisor knew how to clean the oven and other equipment and should have been cleaning the equipment even without a formal schedule. He stated all equipment should be cleaned regularly and the steam table guard should be cleaned after each meal. The Administrator reiterated that all dietary staff should be cleaning the kitchen routinely. The Administrator stated leftover food should be labeled and dated, and any opened food should be properly closed, labeled, and dated. He stated food stored in the refrigerator should be discarded within 3 to 5 days. The Administrator indicated all staff should wear hairnets and beard guards to cover any hair. The Administrator stated he was unsure why the trash containers were not covered. Regarding the peeling paint on the ceiling, the Administrator stated the kitchen roof had a major issue in August and September 2025. The roof had a hole that was patched and repaired. He stated the maintenance staff could paint the ceiling and complete the task.

Based on observation, record review, and interviews with residents, resident representative and staff, the facility failed to ensure residents' menus and/or individual food plans met their nutritional needs, prescribed diet consistencies, and documented food preferences for 2 of 9 residents reviewed for food plans (Residents #89 and #116). The facility failed to follow standard recipes and failed to serve the indicated serving size during the lunch meal for 1 of 1 tray line observation. This practice had the potential to affect food served to residents. Findings included: 1. Review of the hospital discharge summary for Resident #89 dated 1/19/26 documented no known allergies and a regular diet. Resident #89 was admitted to the facility on [DATE] with diagnoses including hepatic encephalopathy, mild protein calorie malnutrition, dietary zinc deficiency, and unspecified vitamin deficiency. The admission Minimum Data Set (MDS) dated [DATE] showed Resident #89 was cognitively intact and his oral/dental status was normal. Review of the allergy documentation showed on 1/19/26 no known allergies was entered by the Associate Director of Nursing (ADON). On 1/20/26 multiple drug allergies and a food allergy to shellfish were entered by the Director of Nursing. Review of the care plan indicated on 1/29/26 a long-term goal for Resident #89 was to be free from significant weight changes and signs of dehydration through multiple interventions. Interventions included providing adaptive equipment for meals as ordered including built-up utensils; Clearly label tray cards with food allergy to avoid allergic reactions; Clearly label tray cards with food allergy to avoid allergic reactions; assess resident's food preferences as needed; provide diet as ordered. Resident #89 had a physician order dated 1/31/26 for regular diet, double portions for breakfast and lunch, and required built-up utensils. Review of the allergy documentation showed on 3/23/26 the Nurse Practitioner deleted the shellfish allergy. On 3/30/26 the Nurse Practitioner deleted all drug allergies and entered No Known Allergies. On 6/8/26 at 12:10 PM, during an interview, Resident #89 stated the facility was not serving meals according to the posted menu and that he was receiving single portions instead of ordered double portions. Resident #89 reported he had no known allergies, but his meal ticket stated he was allergic to shellfish and shrimp. Resident #89 reported his favorite meal included fish and shellfish. He stated that he reported these concerns to ADON in early February 2026 and again to the Director of Nursing in March 2026. He further stated that the allergy list was corrected in March 2026, but the incorrect allergy information still appeared on his meal ticket, so he was never served meals with fish. He stated this made him feel frustrated because his concerns had not been resolved and he had reported it to facility leadership 5 months ago. During an observation and interview on 6/8/26 at 1:08 PM, Resident #89's lunch meal ticket listed allergies to seafood and shrimp and documented double portions and built-up utensils. The meal tray contained food that was not on the menu provided to Resident #89. The meal tray contained standard metal utensils, single portions of beef stir fry instead of double portions, and white rice instead of tricolor pasta. The medical record documented no known allergies. Resident #89 stated he had been served no fish due to the listed allergies and that he found this upsetting because fish was one of his preferred foods. On 6/9/26 at 1:14 PM, a second meal observation for Resident #89 showed the lunch meal ticket again listed seafood and shrimp allergies and the food served was not the same as the menu provided. The meal tray contained single portions of tuna salad, three bean salad, a dinner roll, beets, one cookie, tea, and water. The printed tray ticket listed green bean casserole, tuna noodle casserole, a snickerdoodle cookie, beverages, built up utensils, double portions, and dietary restrictions of no shellfish and no shrimp. On 6/9/26 at 1:20 PM, Resident #89 stated it was frustrating to receive meals that were not what he ordered, small portions, and not what was listed on the ticket. He stated he often lost his appetite when this occurred and felt exhausted having to repeatedly request correct foods, preferences, or built up utensils. He declined to eat his meal. At 1:20 PM on 6/9/26, a Speech Therapist entered the room and encouraged the resident to attempt eating. Resident #89 stated the meal was not what he had requested. The Speech Therapist described her role in coaching him to eat safely using modified utensils and posture. Resident #89 declined Speech Therapy services and declined the lunch tray. No alternate meal was requested. On 6/10/26 at 1:45 PM, the Dietary Manager stated that resident dietary preferences were collected on the day of admission using the corporate form, which included diet history, appetite, portion preferences, allergies, intolerances, cultural and religious needs, beverage preferences, and food dislikes. The Dietary Manager stated nursing entered diet orders into the electronic record, and those orders automatically populated Meal Tracker. The Dietary Manager stated he added resident dislikes and preferences to the bottom portion of each tray ticket; however, he was not yet trained on how to modify the clinical diet information at the top of the ticket, including texture or allergy fields. He stated that he relied on nursing to notify him of any preference updates and he updated the tickets daily. The Dietary Manager described the tray line as a two check process in which the cook checked diet consistency and the servers checked preferences and the accuracy of the ticket. He stated errors occurred when staff failed to read the meal ticket. The Dietary Manager stated that if residents received items they disliked, staff replaced the tray, although he believed this occurred infrequently. The Dietary Manager stated that when the kitchen ran out of a menu item, a substitution notice was posted at the nursing station, and nursing staff were responsible for informing residents of the change. He stated his expectation was that dietary staff read and follow the information printed on the tray tickets. When asked about residents receiving trays with outdated allergies or incorrect textures, the Dietary Manager stated he had not been notified of changes and could not modify the top section of the ticket. He stated he updated only the preference information printed at the bottom. On 6/10/26 at 3:54 PM, the Director of Nursing reported she expected trays to match the ordered diets and that incorrect trays should not be served. She stated she had previously entered allergy information for Resident #89 based on a prior medical record and later updated it in March 2026 when provider records confirmed no known allergies. She also stated dietary staff controlled the Meal Tracker system and nursing had no access to make changes. The Director of Nursing sated she was not aware that nursing was expected to notify residents when Dietary provided the daily menu and it was an alternate. 2. Resident #116 was admitted on [DATE] with diagnoses traumatic brain injury, gingivitis, dysphagia of the oropharyngeal phase, and feeding difficulties. The annual Minimum Data Set, dated [DATE] indicated Resident #116 was cognitively intact. At 11:00 AM on 6/8/26, Resident #116 reported that meals often did not match the meal ticket and that he received foods he could not chew due to poor dentition. He stated both he and his Responsible Party had reported this to nursing and leadership. On 6/8/26 at 1:04 PM, during an observational interview, the Associate Director of Nursing (ADON) provided feeding assistance for Resident #116. The meal ticket documented mechanical ground meat and a mechanical soft diet. The ADON stated the beef on the tray was served in large chunks and did not meet the mechanically ground requirement. She stated she intended to cut the beef into smaller pieces. The ADON attempted to feed green beans cut into approximately one inch pieces. Resident #116 refused, stating they were too tough. After further cutting with a spoon, Resident #116 again refused the ADON's spoonful of green beans. She then combined two pieces of green bean with a piece of beef and attempted to feed it to Resident #116. Resident #116 stated he could not chew it. When reminded of the resident's ordered diet, the ADON removed the tray and ordered the correct diet from the dietary services. During an interview on 6/8/26 at 1:08 PM, the [NAME] Health Clinical Competency Coordinator stated staff were trained during orientation and as needed to compare meal tickets to the items served. Incorrect trays were to be returned and replaced by contacting the kitchen. The Clinical Competency Coordinator asked the ADON where the meal try was that the ADON had attempted to feed Resident #116 and asked to review the meal ticket and tray together. During an interview with the Administrator at 1:45 PM on 6/8/26, he stated the facility had a Speech Therapist and Registered Dietitian who provided oversight for diet orders. He stated diet changes by therapy or the Registered Dietitian were expected to be communicated to nursing and dietary services. He reported that nursing staff entered diet and allergy orders into the medical record, updated the Meal Tracker software application, and dietary staff followed the information printed on the meal ticket. On 6/8/26 at 2:06 PM, the Physical Therapy Director reported the Speech Therapist screened all admissions for swallowing and cognition and completed evaluations upon request of nursing, the provider, the resident, or family. At 2:06 PM on 6/8/26, the Speech Therapist (ST) stated she completed swallowing and cognitive screenings at admission and determined the safest diet texture. She stated she notified nursing and dietary of diet changes and provided education as needed. The ST stated mechanical soft diets must include minced and moist textures and that items inconsistent with prescribed diets increased aspiration risk for those residents. ST stated she had not provided recent education to staff about Resident #116's diet modifications. She reported that Speech Therapy had created feeding safety instructions for staff and family and it was posted above Resident #116's bed. ST stated the meal ticket should reflect the ordered consistency and the residents' preferences and limitations due to allergies. ST stated it was unsafe to serve a resident food that was not consistent with the ordered diet, modifications, and limitations. On 6/8/26 at 4:30 PM, Resident #116's Responsible Party stated that she observed foods such as rice and corn on 6/3/26, which she stated the resident could not chew and were listed as restricted on his meal ticket. The RP also reported that approximately two weeks earlier, around 6/5/26, she observed his tray containing two bone in chicken legs with steamed vegetables. She stated the chicken was not chopped or ground. She stated no alternate meals were offered when he could not safely eat the food served. The RP stated she reported the incidents on 6/3/26 and 6/5/26 to the Director of Nursing. On 6/10/26 at 1:45 PM, the Dietary Manager stated that Speech Therapy or Nursing services entered modified diet orders into the electronic record, and those orders automatically populated in the Meal Tracker software. The Dietary Manager described the tray line as a two check process in which the cook checked diet consistency and the servers checked preferences and the accuracy of the ticket. He recalled the 6/8/26 incident in which he ground food himself after Resident #116 received the wrong diet texture. He stated errors occurred when staff failed to read the meal ticket. He reported that staff were trained on reviewing meal tickets and remembering to ask questions when unsure, and notify him when errors occurred. He stated his expectation was that dietary staff read and follow the information printed on the tray tickets. On 6/10/26 at 2:56 PM, the Administrator stated he had been unaware of ongoing meal ticket and dietary accuracy concerns. He stated the previous Dietary Manager left two months earlier and the new manager had been in the role for three weeks. He stated nursing entered diet orders into the medical record, and dietary staff updated Meal Tracker. The Administrator was not aware the Dietary Manager had not been trained in how to edit the clinical diet information at the top of the ticket. He reported the Dietary Manager was expected to be trained in that task. He confirmed dietary staff were expected to follow the diet orders, allergies, preferences, and consistencies listed on the meal ticket. On 6/10/26 at 3:54 PM, the Director of Nursing reported she expected trays to match the ordered diets and that incorrect trays should not be served. She stated nursing could downgrade a diet for preference or safety but could not upgrade a diet without a provider order. She also stated dietary staff controlled the Meal Tracker system and nursing had no access to make changes. She reported that Resident #116's RP had made multiple complaints about meals. The Director of Nursing could not recall details of the 6/3/26 and 6/5/26 food complaints and reported she was working with Dietary services to address them. 3a. The menu for 6/10/25 read as follows, Shepard's pie, Eggplant Parmesan (vegetarian), macaroni and cheese, seasoned green peas, Italian Blend vegetables and peach cobbler. The menus did not indicate the serving size. A continuous tray line observation was conducted on 6/10/25 from 11:55 AM to 12:15 PM. At 12:00 PM, the Dietary Supervisor began plating meals. The scoop size used for the menu item Shepherd Pie was 3 ounces. He was observed placing one 3 ounce scoop of [NAME] Pie onto each plate. After three meal trays were plated, the tray line was stopped, and the Dietary Supervisor was asked to review the residents' lunch meal ticket. The lunch meal ticket indicated a required serving size of 6 ounces for [NAME] Pie. The Dietary Supervisor had been serving 3 ounces instead of the 6 ounce portion indicated on the meal ticket. A continuous observation of the tray line was conducted on 6/10/26 from 12:35 PM to 1:20 PM. During this observation, Dietary Aide #3 was plating meals instead of the Dietary Supervisor. She was observed plating only 3 ounces (one scoop) of [NAME] Pie instead of the required 6 ounces (two scoops). Dietary Aide #3 was stopped and asked to review the scoop size and meal ticket. After reviewing them, she stated the menu item required double scooping. She reported she had not reviewed the meal ticket and had overlooked the required quantity, resulting in her serving only 3 ounces of the entrée. She stated it was common practice to use the white 3 ounce scoop for meats and the green 4 ounce scoops for vegetables and starches. During an interview with the Dietary Supervisor on 6/11/26 at 2:45 PM, he stated he had not reviewed the meal ticket or scoop size while serving lunch on the tray line. 3b. A continuous tray line observation was conducted on 6/10/26 from 12:35 PM to 1:20 PM. The main entrée on the lunch menu was Shepherd Pie. At 12:45 PM, the Dietary Aides on the tray line began plating meals for residents on the 3rd floor. Staff plated 12 meal trays and loaded them onto the mobile cart used to transport food to the 3rd floor. At that time, staff observed there was no remaining [NAME] Pie available to continue plating. Approximately 30 additional meal trays were still required for residents on the 3rd floor. The Dietary Aides notified the Dietary Cook. The Dietary [NAME] stated he had extra meat and mashed potatoes in the oven that needed to be reheated to prepare a new batch. A new batch of [NAME] Pie was prepared, and the tray line was restarted at 1:15 PM after a 30 minute delay. During an interview on 6/10/26 at 1:00 PM, the Dietary [NAME] stated he knew how to estimate the amount of food needed for residents. When asked whether he used standardized recipes or production sheets (a detailed plan that outlines exactly what needs to be produced, in what quantities, and when, for a specific meal service or shift), the Dietary [NAME] stated there were no recipe books available in the kitchen. He stated he had been a cook for four years and knew what ingredients were needed for each menu item. The Dietary [NAME] indicated he had searched online for the recipe on his phone because this was the first time the item had been used on the menu. He stated there was no printed production sheet and that he cooked the meal by estimation. The Dietary [NAME] further stated the production sheets might be in the dietary office. He stated the previous Dietary Manager used to bring the production sheets and recipes for daily meals, and staff would follow them, but now they were stored in the dietary office. During an interview on 6/11/26 at 2:40 PM, the Dietary Supervisor stated the production sheets were not printed and the kitchen had no printed recipes for the menu items. He stated the cook needed to ask if he needed a recipe for the menu item. The Dietary Supervisor stated the Dietary [NAME] had been working for a long time and was familiar with the menu recipes. During a telephone interview on 6/11/26 at 1:30 PM, the Executive Director of Nutrition and Dining (Corporate staff) stated that Corporate had a contract with Meal Tracker (a dietary management software program used by facilities to plan, analyze, and manage menus) and, based on resident preferences, the menus were individualized for each facility. The menu followed a five week cycle with two seasonal rotations (spring/summer and fall/winter). Meal Tracker analyzed the menu to ensure it was nutritionally balanced. The Meal Tracker program included recipes and production sheets for each menu item, and managers had access to them. Dietary Managers could print them daily or weekly based on their needs. This also helped managers review the menu at a glance, determine what was planned for a particular day, compare it with available inventory, and identify what needed to be ordered. The menu also specified the serving size, and the Dietary Managers were responsible for ensuring staff served the correct portions. During an interview on 3/11/26 at 4:15 PM, the Administrator stated the Dietary [NAME] might have a different way of making food more appetizing for residents. He stated he did not know whether standard recipes were needed to be followed or whether items could be altered to improve taste. He stated the kitchen should follow scoop sizes based on the daily menu, and production sheets should be printed daily

Based on staff interviews, the facility failed to employ a qualified food and nutrition services manager with the competencies and skills required to carry out food and nutrition services for 115 of 116 residents who received meal trays. Finding included:During an interview on 6/11/26 at 3:00 PM, the Registered Dietitian stated she was hired a month prior to the start of survey. She further stated she worked part-time and came to the facility once a month and was available to staff if needed on the phone.During an interview on 6/11/126 at 3:10 PM, Dietary Supervisor stated he was supervising the kitchen for the past month. The Dietary Supervisor indicated that the Dietary Manager had quit her job without notice and he was asked to supervise the kitchen. The Dietary Supervisor stated he did not have Certified Dietary Manager (CDM) certification and was going to start a ServSafe (food and beverage safety training and certificate program administered by the US National Restaurant Association) course on 6/25/26. He indicated he did not have any certification or dietary education.During a telephone interview on 6/11/26 at 1:30 PM, the Executive Director of Nutrition and Dining (Corporate staff) stated that if the facility did not have a Certified Dietary Manager or a full-time dietitian then the facility could reach out to their sister facilities for a Registered Dietitian. She further stated that there was also a consultant dietitian who could be reached for assistance and guidance if the facility did not have certified staff to assist with the kitchen. During an interview on 6/12/26 at 9:10 AM, the Housekeeping Manager indicated she had a ServSafe certification and was helping the Dietary Supervisor with printing the meal tickets, production sheets, ordering food and taking resident's food preferences. Review of the ServSafe certification revealed she had acquired it in 2025 and the certification expired on 5/14/30. When asked if she was assigned to the kitchen, overlooking and monitoring the staff, she indicated she only helped as needed.During an interview on 6/11/26 at 4:30 PM, the Administrator, he stated the facility had a Certified Dietary Manager who quit without notice a month ago. The facility was actively trying to hire a new Dietary manager with CDM certification.

Based on observations, resident and staff interviews the facility failed to ensure 2 urinals (Resident #5 and #88) and 6 bath basins (Resident #5, #88, #21, #38, #65, and #85) were labeled for each resident and stored in a sanitary manner. The facility failed to ensure a privacy curtain was clean and was free from coming into contact with the floor (Resident #116). The facility also failed to ensure resident rooms were clean as evidenced by soiled and sticky floors (Resident #89 and #116), a sticky floor (Resident #6), failed to keep a Packaged Terminal Air Conditioner (PTAC) unit from dust and debris (Resident #57), and failed to keep a resident's room wall surface smooth and intact as evidenced by damaged sheetrock and missing paint (Resident #91). This deficient practice affected 11 of 16 residents (Resident #5, #6, #21, #38, #57, #65, #85, #88, #89, #91, and #116) reviewed for environment. Findings included: 1. a. An observation was completed on 06/08/26 at 12:02 PM of the bathroom for Resident #5 and Resident #88, who resided in the same room. The observation revealed 3 bath basins, which appeared dry, stacked together sitting on the side of the sink with no resident identifiers, and stored in a sanitary manner. The observation also revealed 2 urinals hanging on the hand grip rail beside the toilet with no names on them. One urinal was empty; one had approximately 100 milliliters (ml) of brown liquid in the bottom of it with no odors present. b. An observation was completed on 06/08/26 at 12:08 PM of the bathroom for Resident #21 and Resident #38, who resided in the same room. The observation revealed 2 bath basins stacked together sitting on the sink with no resident identifiers. One bath basin appeared to be wet, and the other one was dry. c. An observation was completed on 06/08/26 at 12:13 PM of the bathroom for Resident #65 and Resident #85, who resided in the same room. The observation revealed 1 wet bath basin sitting on the sink with no resident identifier. A continuous observation and interview were conducted on 06/08/26 from 12:17 PM through 12:31 PM with Nursing Assistant (NA) #4. Na #4 verified she was the direct care NA for Resident #5, #88, #21, #38, #65, and #85 from 7:00 AM-3:00 PM on 06/08/26. She stated she was new and she wasn't familiar with the facilities way of storing the bath basins or urinals. She stated she had been working at the facility since October 2025 (8 months ago). Na #4 explained she was aware the basins and urinals should have the resident's name on them and should be in separate plastic bags to prevent cross contamination. NA #4 indicated the storage room on the 200 hall did not stay stocked with needed supplies and she had not gone to another hall to look in the other storage closets. When she opened the door to the storage closet on the 200 hall an observation revealed bath basins, too numerous to count, and other supplies, including at least 9 urinals. NA #4 was observed discarding the bath basins and retrieving new ones for Resident #5, #88, #21, #38, #65, and #85's bathrooms, but none of the newly distributed supplies were observed to be being labeled by NA #4. NA #4 was observed gathering the basins, urinals, and plastic bags and she stated she would label them and redistribute them. An interview was conducted on 06/08/26 at 12:34 PM interview with Nurse #3, who was assigned to the 200 hall. She stated she had not realized the bath basins were not labeled for each resident and was not aware they were not stored in a sanitary manner in resident rooms. She then stated the storage closet was normally fully stocked and if they were to need something that was not in there they would just go to another floor and get it. An interview was conducted on 06/12/26 at 2:03 PM with the Director of Nursing (DON). The DON stated she would expect bath basins and urinals to be stored with a resident identifier and kept in separate plastic bags. She further stated she was unaware that the basins and urinals were being stored without resident names and not placed in plastic bags. 2a. During an observation conducted on 6/8/26 at 11:00 AM the floor in Resident #116's room was found to be sticky and tacky from the entry door to the window on the other side of the room as the floor was walked upon. The privacy curtain was observed to be in contact with the floor, and not suspended above the floor, and when the curtain was open and closed, the lower part of the curtain dragged along the floor. The portion of the curtain in contact with the floor had a black sticky residue and the bottom of the curtain was stained dark brown and black. Further observation revealed the lower portion of the curtain which was in contact with the floor was physically stuck to floor, and the curtain had to be manually pulled free of the floor. During an observation conducted on 6/9/26 at 9:00 AM, the floor in Resident #116's room remained in the same condition as the observation conducted on 6/8/26 at 11:00 AM with the floor being sticky, the status of the curtain being dirty and in contact with the floor, and the curtain being adhered to the floor. b. During an observation of Resident #89's room conducted on 6/9/26 at 11:00 AM the floor was sticky and tacky when walked upon from the entry doorway to the window on the other side of the room and visibly soiled with a dried discolored liquid on the floor, the area approximately the size of a watermelon. A follow up observation of Resident #116's room was conducted on 6/10/26 at 9:00 AM. The observation revealed the floor remained sticky and tacky when walked upon from the entry doorway to the window on the other side of the room and visibly soiled with a dried discolored liquid on the floor, the area approximately the size of a watermelon. During an interview conducted on 6/9/26 at 9:45 AM, Housekeeping staff #1, who was assigned to Resident # 89 and Resident #116's room, reported she had not yet reached Resident #116 or Resident #89's rooms for cleaning that morning. On 6/10/26 at 9:44 AM, Nurse #13 was interviewed, on conjunction with an observation of Resident #116's room. The nurse stated she was assigned to provide support to the Associate Director of Nurse (ADON) and worked on the unit where Resident #89 and Resident #116 resided. Nurse #13 reported she was called in from another location to provide support on the unit for the ADON. She reported she had been into both resident rooms since she arrived at the unit at 7:00 AM that morning and walked around the unit. During an observation Nurse #13 stated the floors in both rooms were visibly soiled and when walked upon the floors were found to be sticky and tacky. As the observation continued, Nurse #13 stated the soiled curtain draped on the floor in Resident #116's room should have been reported and replaced with a clean curtain of proper length. Nurse #13 explained Resident #116's curtain was too long and dragged on the floor. Nurse #13 stated when she observed small spills like a spilled drink or food, she wiped them up with water and paper towels and she reported larger soiled areas to housekeeping. Nurse #13 stated soiled curtains were to be entered into the work order system and reported to the Unit Manager. In an interview with Housekeeping Staff #1 on 6/10/26 at 9:56 AM, she reported being assigned to the side of the unit where Resident #89 and Resident #116 resided on 6/8/26, 6/9/26, and 6/10/26. Housekeeping Staff #1 described routine cleaning tasks she completed including disinfecting surfaces, cleaning bathrooms, changing trash bags, mopping resident rooms and bathrooms, and changing mopheads between each room. She reported she completed all of these tasks on each day (6/8/26, 6/9/26, and 6/10/26) for Residents #89 and #116. Housekeeping Staff #1 stated a chemical treatment was used on sticky floors and had been applied in Resident #89 and #116's rooms. Housekeeping Staff #1 stated she was still in training and had not learned the procedure for reporting or replacing soiled curtains. She stated the curtain in Resident #116's room had been soiled since her supervised unit orientation began on 6/8/26. Housekeeping Staff #1 stated she was not aware that the privacy curtains were part of her housekeeping duties or she would have reported their soiled condition to her supervisor. Housekeeping Staff #1 stated she didn't know if they did scheduled deep cleaning of resident rooms and she had just been covering daily or routine cleaning tasks. On 6/9/26 at 10:15 AM, the Assistant Housekeeping Manager reported she was training Housekeeping Staff #1 and had just begun teaching her that privacy curtains were the responsibility of housekeeping to manage. She explained she had planned to instruct Housekeeping Staff #1 on the process for reporting soiled curtains but had not yet provided that training. She further stated the housekeeping department communicated environmental concerns and received direction through a group text message chat on their work cell phones. The Assistant Housekeeping Manager reported that housekeeping services completed deep cleaning once weekly on weekends, when unit traffic was lower, and on an as needed basis. She reported it took around 5 to 6 weeks to get all resident rooms on a unit deep cleaned, which included washing the windows, washing baseboards and cabinetry, and stripping floors of protective barrier coating and reapplying a new coat of the protective barrier. The Assistant Housekeeping Manager did not have a schedule available for review. She stated she had not trained Housekeeping Staff #1 on the weekly deep cleaning schedule, explaining that initial training had focused on basic tasks as the priority. She reported her supervisor would be able to provide more specific information about the floor products and deep cleaning schedule. On 6/10/26 at 10:20 AM, the Housekeeping Supervisor stated the floor cleaning product utilized by the housekeeping staff caused the floors to be sticky. The Housekeeping Supervisor stated that on 6/8/26 due to her concern of the floor being sticky from use of the floor-cleaning product she decided to utilize a different product for cleaning the floors. The Housekeeping Supervisor stated curtains should not touch the floor and must be ordered according to room dimensions, and she stated Resident #116's curtain was an oversized curtain borrowed from another facility two weeks earlier while awaiting replacements. She stated they have a weekly deep cleaning process where they clean the unit floors in sections on the weekends. The Housekeeping Supervisor stated the recent holiday in May had put them behind schedule. She stated there was not sufficient time to fully remove the sticky residue because the product needed repeated applications to break it down and remove it. On 6/10/26 at 2:56 PM, the Administrator stated he was unaware of the sticky or soiled floors in the rooms of Residents #89 and #116. The Administrator stated the expectation was for Housekeeping Services to identify and address soiled floors and to work with nursing and other departments to maintain a clean care environment. The Administrator further stated the expectation was for resident rooms and care areas to be kept clean, sanitary, and free of environmental hazards. The Administrator was not aware of what their cleaning routines and schedules were for daily tasks and deep cleaning and recommended talking with Housekeeping Manager for those details. 3. An observation of Resident #57's room was conducted on 6/8/26 at 9:44 AM. The Packaged Terminal Air Conditioner (PTAC) unit was noted to have brown and white fuzzy debris all around the outer perimeter of the unit with chunky brown debris inside the unit and across the vents. The PTAC was running during the observation. On 6/10/26 at 2:38 PM a follow-up observation was completed of the PTAC in Resident #57's room. The PTAC was observed to remain in the same condition as observed on 6/8/26 with brown and white debris all around the outer perimeter of the unit with chunky brown debris inside the unit and across the vents. The PTAC was running during the observation. An interview was conducted in conjunction with an observation with Housekeeper #2 of the PTAC in Resident #57's room on 6/11/26 at 2:40 PM. The observation revealed the PTAC unit remained in the same condition as the observation completed on 6/10/26. Housekeeper #2 explained she normally cleaned the odd numbered rooms of the 200-hall where Resident #57 resided. According to Housekeeper #2, she was supposed to wipe down the outside of the PTAC when she cleaned each resident's room with daily cleaning, and she must have just missed cleaning the PTAC because Housekeeper #2 had already cleaned Resident #57's room earlier on 6/11/26. However, Housekeeper #2 stated the maintenance department was responsible for deeper cleaning inside the PTAC because it required specialty tools to reach inside. According to Housekeeper #2, resident rooms only were deep cleaned once a resident was discharged because most residents did not like the smell of the cleaning chemicals. On 6/11/26 at 2:48 PM the Housekeeping Director was interviewed and stated she had been filling in as Maintenance Director since the facility had not had one for a while (she did not declare as to how long the facility had not had a Maintenance Director). According to the Housekeeping Director, the PTAC in Resident #57's room was an older model, and the facility was in the process of changing out older PTAC units since they were hard to reach inside to clean. However, Resident #57's room was not on the list to have the PTAC changed at the time of the survey. The Assistant Housekeeping Director was interviewed on 6/11/26 at 2:55 PM. The Assistant Housekeeping Director stated Resident #57's room had an older PTAC unit, and the facility was in the process of replacing the older units. According to the Assistant Housekeeping Director, both residents and families would place flowers and plants on top of the PTAC units which caused plant debris to drop down into the units. He explained that the entire front of the PTAC unit had to be removed to vacuum inside, but it was difficult to clean all the units due to the housekeeping and maintenance departments being short staffed. The Assistant Housekeeping Director stated he was unsure when Resident #57's PTAC unit was last cleaned inside. On 6/12/26 at 2:55 PM the Administrator was interviewed and stated the maintenance department should have removed the front of the PTAC unit in Resident #57's room to clean it inside and out. 4. Resident #91 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #91 was cognitively intact. On 6/8/26 at 11:37 AM, an observation of Resident #91's room, conducted in conjunction with an interview with Resident #91, revealed wall damage to the left side of the room. The paint had peeled away, exposing the drywall. The damaged area was located to the right of the Packaged Terminal Air Conditioner (PTAC) and measured approximately 3 feet in length and 2 feet in height, extending upward from the baseboard. Resident #91 stated he noticed the wall damage in his room about a couple months ago but was unsure how long it had been there. Resident #91 added he had not spoken to anyone in the facility about the wall damage On 6/10/26 at 9:37 AM a follow up observation was completed of Resident #91's room. The peeling paint and damaged drywall remained in the same condition as observed on 6/8/26 with paint that had peeled away from the wall exposing drywall. During an interview on 6/11/26 at 9:53 AM with the Housekeeping Director, who stated she had been filling in as Maintenance Director while the facility did not have one, stated she was not aware of the wall damage in Resident #91's room and there was no record indicating the maintenance department had been notified. The Housekeeping Director revealed staff received training on two options for reporting maintenance concerns which included staff could write the concerns in a notebook monitored by the Maintenance Department or enter the concerns in the online facility management system, which included work orders. She further stated housekeepers monitored the rooms daily during cleaning and if concerns were observed they also notified the Maintenance Department by using the notebook or entering the problem into the computer system. An interview was completed with Nurse Assistant (NA) #12 on 6/11/26 at 3:39 PM. NA #12 indicated she had not noticed wall damage in Resident #91's room. She stated staff reported concerns to the Maintenance Department by entering them into the computer system or by writing the concern in a notebook that is monitored by the Maintenance Department. During an interview with Nurse #11 on 6/12/26 at 9:12 AM she indicated that had not noticed wall damage in Resident #91's room. She stated staff reported concerns to the Maintenance Department by entering them into the online work order system or by writing the concern in a notebook that is monitored by the Maintenance Department. 5. On 6/8/26 at 11:53 AM, an observation of Resident #6's room revealed the floor throughout the room was sticky when walked upon despite there being no visible spills. On 6/9/26 at 9:13 AM a follow up observation was completed of Resident #6's room. The floor in the room remained in the same condition. The floor was observed to be sticky despite no visible spills or debris. During an interview on 6/11/26 at 9:53 AM with the Housekeeping Director, who stated she had been filling in as Maintenance Director while the facility did not have one, explained she was aware of issues with sticky floors throughout the facility. The Housekeeping Director explained the sticky floors were caused by a vendor provided floor cleaning product. Her corporate support had directed her to resume use of the product about one month earlier despite the historical persistent stickiness they had experienced with the same product about a year ago. The Housekeeping Director stated over the last few weeks she observed the floors had become sticky again because of the floor cleaning products. She indicated on 6/08/26 she switched to a different cleaner and had been monitoring the floors to determine if the change resolved the sticky cleaner buildup currently on the floors. She stated the floors throughout the facility were still sticky on 6/11/26. During an interview completed with the Administrator on 6/12/26 at 3:24PM he stated his expectation was for all rooms to be maintained in good repair and to provide a safe, home-like environment.

Based on a review of the Resident Council meeting minutes and interviews with Resident Council members, the facility failed to resolve concerns voiced by the Resident Council members during 4 of the 7 previous Resident Council meetings (Resident Council meetings held on 3/30/26, 4/23/26, 5/20/26, and 5/27/26).Findings included:The Resident Council meeting minutes from January 2026, February 2026, March 2026, April 2026, and May 2026 were reviewed.The Resident Council meeting minutes dated 3/30/26 revealed residents voiced concerns the coffee was always cold, linen was not being stocked on all floors, call lights were not being answered, snacks and ice were not being passed out, and they were not being given a choice of cereal.No grievance report was located for the concerns voiced by the Resident Council from the 3/30/26 meeting.The Resident Council meeting minutes dated 4/23/26 revealed residents voiced concerns about cold coffee, snacks and ice not being passed out, call lights not being answered, staff being on their phone during work hours, and staff not going to the first floor to get sandwiches when asked and instead saying that there weren't any. The minutes further revealed the Administrator was present at this meeting.No grievance report was located for the concerns voiced by the Resident Council from the 4/23/26 meeting.The Resident Council meeting minutes dated 5/20/26 revealed residents voiced the concern they had not seen any changes since the last meeting. They voiced concerns regarding the food being overcooked, staff were not passing ice, water, snacks or sandwiches, and the coffee was cold.No grievance report was located for the concerns voiced by the Resident Council from the 5/20/26 meeting.The Resident Council meeting minutes dated 5/27/26 revealed residents voiced the concern they had not seen any changes since the last meeting. They voiced concerns about staff being on their phones during work hours and the food was overcooked food. The minutes further revealed the Administrator was present at this meeting.No grievance report was located for the concerns voiced by the Resident Council from the 5/27/26 meeting.A meeting of the Resident Council was conducted on 6/9/26 at 11:30 AM. Five cognitively intact members of the Resident Council attended the meeting including the Resident Council President. During this meeting, residents reported although they expressed the same concerns at Resident Council meetings, nothing ever changed. They stated they felt they weren't getting any responses to their concerns.On 06/10/2026 at 3:33 PM in an interview with the Activities Director she reported Resident Council members had repeatedly complained to her during Resident Council meetings that they were not getting a response to their concerns. She stated in an attempt to remedy the concerns not being resolved, she just started having resident council twice monthly in May 2026. She indicated the first monthly Resident Council meeting was to get the concerns and the second one was to ensure that the issues were responded to. She reported she did not fill out a written grievance complaint form for concerns expressed during Resident Council meetings. The Activities Director stated she went to each department head and talked with them about the concerns expressed during Resident Council, and what they were going to do to fix the problem. She reported she thought the reason the issues kept coming up was the issues were not getting adequately addressed. She indicated she was not sure why she wasn't filling out a grievance for the concerns reported by the Resident Council.On 6/10/26 at 4:39 PM an interview with the Administrator revealed he began getting invited to attend Resident Council meeting within the past 3 months. He reported he felt if there had been grievance forms completed for the group concerns that would have been super helpful. He stated while it was good for the Activities Director to bring the concerns expressed during Resident Council meetings to the team to discuss, concerns expressed by the Resident Council would definitely be grievances. He reported he did not know why the Activities Director was not completing grievances forms for these concerns in accordance with the facility's grievance policy. The Administrator stated the facility did not have a plan of correction in place for this issue.

Based on observations, record reviews, resident and staff interviews, the facility failed to maintain complete and accurate medical records for wound care (Resident #4, Resident #17, and Resident #76) for 3 of 6 residents reviewed for wound care. Findings Included: 1a. Review of the April 2026 Medication Administration Record (MAR) revealed treatment for the pressure ulcer to the left ischium was documented by Nurse #6 on 04/20/26, 04/21/26, 04/25/26, 04/26/26, and 04/27/26. Review of the May 2026 Medication Administration Record (MAR) revealed treatment for the Stage 4 pressure ulcer to the left buttock/ischium was documented by Nurse #6 on 05/26/26, 05/27/26, 05/28/26, and 05/29/26. Review of the June 2026 Medication Administration Record (MAR) revealed treatment for the Stage 4 pressure ulcer to the left buttock/ischium was documented by Nurse #6 on 06/01/26, 06/02/26, 06/03/26, 06/09/26, 06/10/26, and 06/11/26. The Wound Nurse documented the treatment on 06/04/26. On 06/09/2026 at 2:25 PM, an interview was conducted with the Wound Nurse. The Wound Nurse stated she was responsible for providing wound care in accordance with the wound physician's orders. When asked why she had not documented wound treatments on the MAR during April, May, and June 2026, the Wound Nurse stated she performed the wound treatments but often forgot to document them. The Wound Nurse stated Nurse #6 would sometimes sign the MAR on her behalf when she had not completed the documentation. The Wound Nurse explained Nurse #6 would document the treatment so he could continue with his own documentation responsibilities. When asked to identify the specific dates Nurse #6 documented wound treatments on her behalf, the Wound Nurse stated she could not recall the dates; however, she stated the lack of documentation by her occurred beginning around the end of May 2026. The Wound Nurse acknowledged that although she provided the wound care, the MAR documentation reflected Nurse #6 as the individual who completed the treatment. On 06/09/2026 at 2:43 PM, an interview was conducted with Nurse #6. When asked about documentation of wound care on the MAR for April, May, and June 2026, Nurse #6 stated the facility was understaffed and had only one Wound Nurse. Nurse #6 stated the Wound Nurse would sometimes fall behind on documentation. Nurse #6 stated that, as a result, he would sometimes document wound treatments on the MAR after verbally confirming with the Wound Nurse that the wound care had been completed. Nurse #6 stated he would occasionally verify the treatment had been completed by observing the wound or verbally asking the Wound Nurse. Nurse #6 stated there were also times when he personally completed the wound care. Nurse #6 acknowledged it was not best practice to document care performed by another staff member and stated it was the responsibility of the individual providing the wound care to complete their own documentation. b. Review of the Nurse Practitioner (NP) progress note dated 5/4/26 revealed Resident #17 had a history of an enterocutaneous fistula (EC fistula), urostomy, and colostomy. The physical examination documented two ostomies with leakage and a chronic fistula. The NP further documented the fistula was draining stool and that dressing changes were being performed by the wound nurse. However, under the integumentary assessment, the NP documented the exposed skin appeared clean, dry, and intact and indicated no open wounds were noted. On 06/12/2026 at 9:00 AM, an interview was conducted with the Nurse Practitioner (NP) regarding Resident #17's pressure ulcer. The NP stated she became aware of the pressure ulcer upon Resident #17's admission to the facility on 4/20/26 after reviewing the hospital discharge summary. The NP stated she assessed Resident #17 on 5/4/26 and observed the wound at that time. When informed that her progress note dated 5/4/26 documented no wounds, the NP stated the documentation was incorrect. The NP stated she should have completed an addendum to correct the record. The NP stated the addendum was not completed because she could not bill for it. On 06/12/2026 at 4:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation for documentation is that staff document care as it is provided and enter documentation as soon as possible. The DON stated it was unacceptable for staff to delay documentation, including documentation that remained incomplete following a weekend shift. The DON stated staff were not permitted to document care performed by another staff member and that doing so would result in disciplinary action for both employees involved. The DON stated staff could not document care performed by another staff member even if they received a verbal confirmation that the care had been completed. The DON stated he had not been aware that staff were documenting wound care on behalf of the Wound Nurse. Upon review of the information, the DON stated such practice would constitute false documentation and was not consistent with facility expectations. On 06/12/2026 at 4:45 PM, an interview was conducted with the Administrator. The Administrator stated he was unaware that Nurse #6 had documented wound care on the MAR on behalf of the Wound Nurse. The Administrator stated each staff member was responsible for documenting the care and services they personally provided. The Administrator stated staff should not document care performed by another employee, regardless of whether they received verbal confirmation that the care had been completed. The Administrator stated documentation was expected to be accurate and reflect the care actually provided to the resident. Upon review of the information, the Administrator stated documenting care on behalf of another staff member was not consistent with facility expectations. 2. Resident #76 was readmitted to the facility 5/25/26. Review of the physician orders revealed an order dated 5/25/26 for wound care to be completed to the wound on the lower right leg: cleanse with antiseptic wound cleanser, apply Medihoney (a topical medication which creates a moist, acidic environment that promotes healing, naturally debrides dead tissue, and possesses antibacterial properties to combat infections) to the wound, apply a silicone bordered foam, change dressing every 3 days and as needed. a. A skin care assessment completed on 5/25/26 noted a skin tear to the right lower leg with an intact dressing and wound care ordered. Review of the Treatment Administration Record (TAR) for June 2026 revealed the wound care was documented as completed on 6/6/26 by Nurse #9. Resident #76 was observed on 6/8/26 at 11:35 AM in conjunction with an interview with the resident. A wound dressing was noted on her right lower leg. Written on the wound dressing was 6/5/26. Resident #76 reported she had a skin tear on her lower right leg and staff were changing the dressing every couple of days. During a phone interview with Nurse #9 at 6/10/26 at 1:38 PM, she reported she did not change the dressing to Resident #76's right lower leg on 6/6/26 and she did not know why her initials were on the Treatment Administration Record because she did not complete wound care. b. A skin assessment for Resident #76 dated 6/8/26 documented by Nurse #11 under alterations in skin none and under skin treatments none. An interview with Nurse #11 was conducted on 6/12/26 at 3:01 PM. The nurse reported she did not recall documenting none under Resident #76's skin assessment and reported if Resident #76 had a wound dressing, it should have been documented. The Director of Nursing (DON) was interviewed on 6/11/26 at 1:03 PM and she reported she was not certain why the nurse documented the wound care as completed if she did not complete the wound care and did not know why the wound or the dressing was not documented on 6/8/26. An interview was conducted with the Administrator on 6/12/26 at 4:00 PM. The Administrator reported he did not know why the nurse's initials were on the Treatment Administration Record. The Administrator did not know why the wound or wound dressing was not documented on the 6/8/26 assessment. The Administrator reported it was his expectation that staff accurately documented care provided. 3. Resident #4 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #4 was cognitively intact. A review of the hospital Discharge summary dated [DATE] revealed discharge orders for wound care included: Cleanse the wound with wound cleanser. Apply no sting barrier film to protect the periwound skin (skin surrounding the wound edge). Apply Aquacel (silver hydrofiber dressing that absorbs excess moisture and protects from bacteria) to the wound, ensuring it is gently packed into the depth. Palpate for the coccyx, then apply a sacral shaped foam dressing positioned to cover both the sacral wound and the coccyx area. Change every 2 days and as needed for soiling. A review of the physician's orders revealed that there were no wound care orders for Resident #4 during February 2026. On 3/4/26, the Wound Care Nurse added an order for sacral pressure ulcer care. A review of the February 2026 Medication Administration Record (MAR) showed that from February 7 through February 28, 2026, there was no wound care order in place for treatment of Resident #4's sacral wound. The MAR also indicated that wound care was not documented as completed during this period. A review of the March 2026 Medication Administration Record (MAR) revealed that on March 1, 2, and 3, 2026, there was no wound care order in place for treatment of Resident #4's sacral wound. The MAR also showed that wound care was not documented as completed on those same dates. During an interview with Resident #4 on 6/10/26 at 9:33 AM, he stated that facility staff had provided wound care and applied a dressing to his sacral wound daily since his admission on [DATE]. During an interview with the Wound Care Nurse on June 12, 2026, at 8:51 AM, she explained that the Unit Manager typically entered admission orders into the medical record based on the hospital discharge summary. However, if the Unit Manager was assigned to a medication cart, the nurse admitting the resident was responsible for entering the orders. The February 2026 orders were reviewed with the Wound Care Nurse, and she confirmed that there were no treatment orders in the medical record for Resident #4. She also confirmed that the first wound care orders were entered by her on March 4, 2026. She stated that she did not know what happened or why the orders were missing. The Wound Care Nurse further explained that if wound treatment orders were included in the hospital discharge summary, the admitting nurse should have entered them into the medical record. She recalled providing wound care to Resident #4 immediately after admission and throughout February 2026. She added that she must have received a copy of the hospital discharge summary containing the wound care orders and provided care according to those orders, but she did not enter them into the medical record. An interview with the Unit Manager was conducted on June 12, 2026, at 9:38 AM. She stated that she did not enter the admission orders for Resident #4. She also confirmed that if wound care orders were included in the hospital discharge summary, they should have been entered into the medical record. During an interview on June 12, 2026, at 10:12 AM, Nurse #9 stated that she was the nurse who entered Resident #4's admission orders. She explained that she obtained the orders from the hospital discharge summary but could not recall whether wound care orders were included. She acknowledged that she did not enter any wound care orders but stated that she would have notified the Wound Care Nurse that the resident had a wound and needed wound care orders. Nurse #9 added that she knew the Wound Care Nurse would obtain the wound care orders. An interview with the Medical Director was conducted on June 12, 2026, at 11:51 AM. He stated that he was unsure why there was no wound care documentation for Resident #4 until March 4, 2026. He indicated that he would expect the facility to enter any wound care orders provided in the hospital discharge summary into the medical record. He added that if no wound care orders were included, he would expect the facility to contact the physician to obtain appropriate orders. An interview with the Director of Nursing (DON) was conducted on June 12, 2026, at 12:18 PM. She stated that she was unsure why wound care orders were not entered when Resident #4 was admitted on [DATE]. She explained that her expectation was for the admitting nurse to enter any wound care orders listed on the hospital discharge summary into the medical record. If no wound care orders were provided, the admitting nurse should immediately contact the physician to obtain them. The DON added that she expected wound care to be provided as ordered and documented as completed.

Based on record review, Pharmacist, Medical Director and staff interviews, the facility failed to prevent a significant medication error when lacosamide and zonisamide (anticonvulsant medications used to treat epilepsy) were transcribed and administered to Resident #127 incorrectly. This was for 1 of 10 residents (Resident #127) whose medications were reviewed. The findings included: Resident #127 was originally admitted to the facility on [DATE] with diagnoses that included traumatic brain injury and post traumatic seizures. He was readmitted to the facility on [DATE] after a hospitalization for seizure activity.A physician order dated 01/06/25 read; zonisamide suspension (used to treat seizures); 10 milligrams (mg)/milliliter (ml); amount to administer: 4ml (40 mg) via gastric tube at bedtime for seizures. Order discontinued on 10/29/25.Another physician order dated 01/06/25 read; lacosamide solution (used to treat seizures); 10 mg/mL; amount to administer: 5ml (50mg) via gastric tube twice a day at 9:00 AM & 9:00 PM. Order discontinued on 10/29/25.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #127's cognition was severely impaired. Resident #127 received scheduled anticonvulsant medications during the MDS review period.Resident #127's verified Hospital Discharge summary dated [DATE] revealed he was sent to the emergency department (ED) on 10/27/25 due to seizure activity and was discharged back to the facility on [DATE]. The new anticonvulsant medication orders included the following: zonisamide suspension; 20mg/ml; amount to administer: 5ml (100mg) via gastric tube at bedtime, start date: 10/29/25 and lacosamide solution; 10 mg/ml; amount to administer: 10ml (100mg) via gastric tube every 12 hours, start date: 10/29/25.A physician order dated 10/29/25 read: zonisamide suspension; 10mg/ml; amount to administer: 10ml (100 mg) via gastric tube at bedtime for seizures at 9:00 PM.Another physician order dated 10/29/25 read: lacosamide solution; 10 mg/mL; amount to administer: 10ml (100mg) via gastric tube every 12 hours at 9:00 AM & 9:00 PM.Resident #127's October 2025 Medication Administration Record (MAR) revealed the following medication orders were entered into the electronic medical record (EMR): -Order dated 10/29/25 zonisamide suspension; 10mg/ml; amount to administer: 4ml (100mg) via gastric tube at bedtime for seizures at 9:00 PM. Order discontinued on 10/31/25. The correct dose of zonisamide 100 mg was initialed as given on 10/30/25.-Order dated 10/30/25: zonisamide suspension; 10mg/ml; amount to administer: 10ml (100mg) via gastric tube at bedtime for seizures at 9:00 PM. Order discontinued on 10/31/25. The correct dose of zonisamide 100 mg was initialed as given on 10/30/25.-Order dated 10/31/25: zonisamide suspension; 10mg/ml; amount to administer: 4ml (40mg) via gastric tube at bedtime for seizures at 9:00 PM. The MAR was initialed as the incorrect dose was given on 10/31/25.A physician order dated 11/20/25 read; zonisamide oral suspension; 10mg/ml; amount to administer: 10ml (100mg) via gastric tube at bedtime for seizures per neurology.Further review of Resident #127'2 October 2025 MAR revealed the following medication orders were entered into the EMR:- Order dated 10/29/25: lacosamide solution; 10 mg/mL; amount to administer: 10ml (100mg) via gastric tube every 12 hours at 9:00 AM & 9:00 PM. Order discontinued on 10/30/25. The MAR was initialed as the correct dose being given on 10/29/25 and 10/30/25. -Order dated 10/30/25: lacosamide solution; 10 mg/mL; amount to administer: 5ml (50mg) via gastric tube every 12 hours at 9:00 AM & 9:00 PM. Order discontinued on 11/02/25. The MAR was initialed as the incorrect dose being given on 10/31/25.A review of Resident #127's November 2025 MAR revealed the following medication orders were entered into the electronic medical record (EMR):-Order dated 10/31/25: zonisamide suspension; 10mg/ml; amount to administer: 4ml (40mg) via gastric tube at bedtime for seizures at 9:00 PM. The MAR was initialed as the incorrect dose being given 11/01/25 through 11/20/25.-Order dated 11/20/25: zonisamide oral suspension; 10mg/ml; amount to administer: 10ml (100mg) via gastric tube at bedtime for seizures per neurology. The MAR was initialed as the correct dose given 11/21/25 through the end of the month.-Order dated 10/30/25: lacosamide solution; 10 mg/mL; amount to administer: 5ml (50mg) via gastric tube every 12 hours at 9:00 AM & 9:00 PM. Order discontinued on 11/02/25. The MAR was initialed as the incorrect dose was given on 11/01/25 through 11/02/25.-Order dated 11/02/25: lacosamide solution; 10 mg/mL; amount to administer: 10ml via gastric tube Every 12 hours at 9:00 AM & 9:00 PM. The MAR was initialed as the correct dose given 11/02/25 through the end of the month.An interview was conducted on 06/11/26 at 9:47 AM with the Director of Nursing (DON). The DON stated that during a review of Resident #127's admission orders on 10/30/25 she revealed the anticonvulsant medication orders appeared to be incorrect. The DON explained that the orders that the admitting nurse (Assisted Director of Nursing) had entered into the electronic Medication Administration Record (eMAR) on 10/29/25 included zonisamide oral suspension; 10 milligrams (mg)/milliliter (ml); amount to administer: 100 mg via gastric tube at bedtime and lacosamide solution; 10 mg/mL; amount to administer: 10 ml via gastric tube every 12 hours. The DON went on to say that she compared those orders to the 8 page preliminary discharge summary that had been received from the hospital prior to the arrival of Resident #127. The DON then stated the orders listed on the preliminary discharge summary included zonisamide oral suspension; 10mg/ml; amount to administer: 40 mg; via gastric tube at bedtime for seizures (give 4ML) and lacosamide solution; 10 mg/mL; amount to administer: 5 ml; (50 ml) via gastric tube every 12 hours for seizures. The DON indicated she did not realize she was viewing the preliminary discharge summary, not the final verified discharge summary. The DON then stated she changed the two anticonvulsant medication orders for Resident #127 to match the preliminary hospital discharge summary on 10/30/25. During a review of the preliminary discharge summary with the DON, she verified that there was a note that revealed Resident #127 was hospitalized from [DATE] through 10/29/25 due to seizure activity. The DON also verified a note above the medication list read: Changes Made to Medications: increased lacosamide and zonisamide following subtherapeutic levels. The DON explained that although on the preliminary discharge summary had a note that read that Resident #127 was in the hospital for seizure activity and that his zonisamide and lacosamide were increased during the hospital stay due to increased seizures she did not confer with the admitting nurse or call the hospital to clarify the anticonvulsant medication orders. The DON indicated she should have reviewed the verified finale discharge summary for the correct orders.An interview was conducted on 06/11/26 at 10:09 AM with the Assistant Director of Nursing (ADON). The ADON stated she was the admitting nurse for Resident #127 on 10/29/25 and she entered the admission orders per the final verified discharge summary. The ADON obtained Resident #127's discharge summary and demonstrated and explained her steps when transcribing Resident #127's medications. She explained the finale orders were located at the bottom of the discharge summary which had a heading that read Your medication list: START taking these medications: zonisamide 20mg/ml oral suspension; take 5mls (100mg total) by G tube at bedtime. These medications have changed: lacosamide 10mg/ml; take 10mls (100mg total) by G tube every 12 hours. The ADON correctly demonstrated and transcribed the correct orders and was unsure why the DON had changed them back to the orders that Resident #127 was on prior to the hospitalization. A phone interview was conducted on 06/11/26 at 11:30 AM with the Medical Director (MD). He stated he could not recall the exact date but he was made aware of the medication error for Resident #127's lacosamide and zonisamide orders after admission. The MD indicated that although the potential for significant side effects were possible such as increased seizures, Resident #127 did not exhibit any ill effects due to the medications being entered on 10/30/25 for the incorrect amount. The MD did expect the nursing staff to follow the finale verified discharge summary when a resident was admitted . A phone interview was conducted on 06/11/26 at 1:19 PM with Nurse Practitioner (NP) #1. NP #1 reported that she did not know the DON was reviewing Resident #127's preliminary discharge summary when she adjusted his anticonvulsant medication orders on 10/30/25. She explained that she expected all medication orders to be taken from the final, verified discharge summary, and indicated that any questionable medication should have been clarified directly with the prescribing hospital physician. NP #1 reported recalling a phone call from the neurologist on or around 11/20/25 to discuss the resident's medication orders but stated she could not remember the specific details of that conversation.A phone interview was conducted on 06/12/26 at 9:56 AM with the Pharmacist. The Pharmacist explained that Resident #127 was on another anticonvulsant medication and although zonisamide suspension was given at a lower dose than ordered, there was a potential for ill effects, but it was unlikely. The Pharmacist also explained that Resident #127 had been on the medication for a while and it would take time for it to leave the body.An interview was conducted on 06/12/26 at 3:35 PM with the Administrator. The Administrator stated he expected the nursing staff to use the verified finale discharge summary when reviewing and conducting the second check on admissions/readmissions to ensure the correct medication orders were carried out.

Based on observations, record reviews, resident and staff interviews, the facility failed to complete a smoking assessment (Resident #100) and complete a quarterly smoking assessment (Resident #100 and Resident #62). The facility failed to secure smoking material (cigarettes and ignition material) for 3 of 3 residents (Resident #100, Resident #62, and Resident #104) reviewed for safe smoking. The facility also failed to secure one oxygen cylinder stored in a resident's room for 1 of 1 resident (Resident #99) reviewed for accidents. Findings included: A review of the smoke free policy revised on 2/10/26 revealed that, effective 1/1/15, smoking was not allowed on the facility premises by visitors, staff, or residents. The policy encouraged residents to participate in a smoking cessation program. The admission Director or admitting nurse informed residents and/or legal guardians of the smoking policy upon admission. The policy stated that residents should not keep smoking materials in their possession. Staff were to store and secure all smoking and ignition materials. The smoke free policy stated in part, An assessment utilizing The Smoking Observation Form in the Electronic Health Record is completed at least quarterly thereafter only if the answer to either of the first two (2) questions indicates the resident either smokes or has a history of smoking. 1. Resident #100 was admitted to the facility on [DATE] with diagnoses that included gastroparesis, severe protein calorie malnutrition, chronic obstructive pulmonary disease, and tobacco use. A review of the Smoking Observation Form showed a smoking observation date of 12/7/25 and a completion date of 6/8/26 (first day of survey). The form indicated that the resident was a smoker and had a history of smoking. Based on the observation, Resident #100's smoking status was determined to be unsupervised smoker. Review of the medical records revealed Resident #100 did not have a quarterly Smoking Observation Form / assessment. Smoking Observation Form with observation date and completion date 6/8/26 indicated the resident was assessed as unsupervised smoker. During an interview on 6/10/26 at 3:00 PM, the Director of Nursing (DON) stated the facility was smoke free but did admit residents who smoked. Nurses completed smoking observation assessments upon admission for resident who were current smokers and assessed whether the resident was a safe smoker. The DON stated the facility had five residents who smoked and all were assessed as unsupervised smokers. DON stated smoking assessments were completed at admission, when there was change in status and may be quarterly. She was unclear if quarterly smoking observations were completed on residents who smoked. During a re interview on 6/12/26 at 4:17 PM, the DON stated Resident #100's smoking observation was completed on 12/7/25 as indicated in the Smoking Observation Form. DON further stated she did not know why the smoking observation form/ assessment initiated at the time of Resident #100's admission with a smoking observation completed on 12/7/25 was completed/closed on 6/8/26. She reiterated that smoking assessments should be observed and completed on the same day as the scheduled observation date. A review of the Significant Change MDS assessment dated [DATE] showed the resident was cognitively intact and mostly independent with most Activities of Daily Living (ADLs). The assessment indicated no for current tobacco use. A review of the care plan (initiated on 1/14/26 and revised/reviewed on 6/8/26) indicated Resident #100 was care planned for smoking. The care plan indicated that the resident did not need supervision while smoking. The intervention required staff to keep the residents' cigarettes and lighters at the nurse's station. During an observation and interview on 6/8/26 at 1:00 PM, the resident entered the 300 hallway, went to the nurses' station, and signed in. She stated that she left the facility to smoke and kept her cigarettes and lighter with her. Resident #100 pointed to an open bag tied to her walker that contained her cigarettes and lighter. She also stated that she had been assessed as an unsupervised smoker and smoked near the bus stop without staff observation. During an interview on 6/8/26 at 1:10 PM, Nurse #7 stated that Resident #100 was cognitively intact, smoked, and could sign out to leave the facility to smoke. She stated the facility was smoke free and was unsure where the smoking policy was located. She said Resident #100 was assessed as an unsupervised smoker at admission. Nurse #7 was unsure whether the resident could keep her smoking materials, as nursing staff had not received smoking policy instructions. During an interview on 6/9/26 at 8:05 AM, Nurse #8 stated that Resident #100 had signed out to smoke. Nurse #8 indicated he kept the resident's smoking materials locked in the medication cart and provided them upon request. Nurse #8 confirmed that he had given her the smoking materials that morning. On 6/9/26 at 8:10 AM, the resident returned to the 300 hallway. At 8:12 AM, she stated she typically kept smoking materials with her, but last night a nurse (name unknown) instructed her to place her smoking material in a labeled plastic bag to be stored on the medication cart. The resident showed a plastic bag with two cigarette packets and a lighter. The plastic bag had her name on it. Resident #100 stated she had not yet returned the smoking materials to her assigned nurse because the nurse was busy with medications. A continuous observation on 6/9/26 from 2:30 PM to 2:42 PM showed Resident #100 requesting her smoking materials from Nurse #8. Resident used a rolling walker to ambulate. She took the smoking material and left the facility using the far end elevator. At the bus stop, she sat on the bench with her rolling walker in front of her and smoked her cigarette. She ambulated back to the facility with her rolling walker. During an interview on 6/10/26 at 2:25 PM, the admission Director stated the facility was a tobacco free organization and residents and families were informed during admission. The information was also provided in the handbook that was given to the residents and family members. All tobacco products were prohibited inside the building. Nicotine cessation was offered to the residents. The admission Director indicated that there was no smoking agreement in the admission packet, however the information was in the handbook provided to the resident. During an interview on 6/10/26 at 3:00 PM, the Director of Nursing (DON) stated the facility was smoke free but did admit residents who smoked. Nurses completed smoking observation assessments upon admission for resident who were current smokers and assessed whether the resident was a safe smoker. The DON stated the facility had five residents smoked and all were assessed as not requiring supervision. As the facility was smoke free, residents signed out, retrieved their smoking materials from staff, and smoked at the bus stop. Upon return, they signed in and returned the smoking materials to staff. Smoking materials were stored in a locked Tacko box in the medication room. The DON stated no resident should keep smoking materials in their possession. She stated smoking assessments were completed quarterly or with changes in condition and that staff were verbally informed of the policy. Residents received cessation education materials. She reiterated that residents must sign-out before smoking and return materials afterward. During an interview on 6/12/26 at 4:04 PM, the Administrator stated the facility was smoke free and residents and /or resident representatives were informed at admission. Residents who wished to smoke had to sign out and smoke beyond the bus stop. The facility had no designated smoking area and did not supervise residents who smoked. He stated residents sometimes denied smoking during admission but later began smoking. He stated smoking materials must be securely stored by staff and that his expectation was for staff to accurately document smoking status at admission, store materials safely, and ensure residents signed out before smoking. 2. Resident #104 was admitted to the facility 4/6/26. The admission Minimum Data Set assessment dated [DATE] assessed Resident #104 to be cognitively intact. Resident #104 was assessed to use tobacco products. Resident #104 was assessed to have full range of motion of his upper and lower body, he used a walker for ambulation, and he was independent for eating, hygiene, toileting, dressing, and mobility. A smoking assessment dated [DATE] assessed Resident #104 to be a safe smoker. A smoking assessment dated [DATE] assessed Resident #104 to be an unsupervised smoker completed by the Director of Nursing (DON). A care plan that addressed smoking was developed on 6/8/26. Interventions included to educate Resident #104 on the smoking policy and to keep his cigarettes and lighter at the nursing station. During a 6/8/26 interview and observation at 12:15 PM, Resident #104 reported when he wanted to smoke, he signed out and walked to a bus stop a few hundred feet away several times per day. Cigarettes and a lighter were observed in the open drawer of his bedside table, and he stated he kept his smoking materials in his room since his admission to the facility, and no one had told him he could not have the lighter and cigarettes in his room. An interview was conducted with the admission Director on 6/10/26 at 2:25 PM, and she indicated that the facility was a tobacco-free organization and the residents and family were made aware of this during the admissions. The information was also provided in the handbook that was given to the residents and family members. Tobacco and any form of tobacco products were prohibited in the building. Nursing assistant (NA) #7 was interviewed on 6/10/26 at 2:30 PM and she reported she was assigned to Resident #104, but she had not noticed smoking materials in his room. NA #7 further noted that Resident #104 was mostly independent and she did not spend a lot of time providing him care. During a follow up interview and observation on 6/10/26 at 2:35 PM Resident #104 reported he had given staff his cigarettes and lighter for storage, yet three packs of cigarettes, two partially full and one empty, were observed in his open bedside table drawer. He stated the packs were nearly empty and said he did not understand why he could not keep them in his room. He confirmed he had been educated on the smoking policy and stated he could manage his own cigarettes and lighter. An interview was conducted on 6/10/26 at 3:00 PM with the Infection Preventionist Nurse and Nurse #6. When informed Resident #104 had cigarettes in his room, the Infection Preventionist stated, We just took his cigarettes from him, how did he get another pack? Nurse #6 stated, He just came up here and asked for his cigarettes and lighter to go outside to smoke. Nurse #6 noted that he had not observed smoking materials in Resident #104's room when he administered medication to him earlier in the day. During an interview with the Director of Nursing (DON) on 6/10/ 26 at 3:00 PM. The DON stated the facility was a smoke free facility and they do admit residents who smoke. Upon admission the Nurses complete a smoking assessment by observing the resident during smoking and assess if the resident was safe smoker. The DON stated the facility had 5 residents who were smokers and all were assessed as safe smokers. As the facility was a smoke free facility, when the residents want to smoke, they sign themselves out, take their smoking material from the nurses and go out of the facility. The DON explained residents smoke near the bus stop or sit on the bus stop bench and smoke. Upon returning they sign themselves back in and the smoking material are given to the assigned nurse. Smoking materials were stored in a tackle box in the medication room. The DON indicated no resident should be holding the smoking material with them. Smoking assessments were conducted quarterly and when there was change in condition. The DON stated the smokers in the facility were alert and oriented and would report to staff if they had any accidents. The DON reiterated that the facility was a smoke free facility and the staff were verbally notified about the smoking policy. The staff could access the policy through the policy tech platform. Residents were also provided with smoking cessation and education material. The DON was interviewed again on 6/11/26 at 1:30 PM. She reported Resident #104 willingly turned in his cigarettes and lighter for storage at the nursing station on Monday 6/8/26 and she was not aware he had additional cigarettes in his room. The DON reported she completed Resident #104's smoking assessment on 6/8/26. She stated a smoking assessment was completed on admission and a care plan for smoking was developed. She explained residents signed themselves out to smoke off the facility property, usually at the bus stop at the end of the drive, and family members could also sign residents out. She stated she expected all residents to be screened for smoking on admission, have a care plan if they smoke, and store all smoking materials at the nursing station. A phone interview was conducted with the Physician on 6/12/26 at 2:27 PM and he reported that the facility was non-smoking and no residents should have smoking materials in their room. Nurse Practitioner #3 was interviewed by phone on 6/12/26 at 2:48 PM and she reported residents with smoking materials were a safety concern and no residents should have smoking materials in their room. The Administrator was interviewed on 6/12/26 at 4:00 PM. He stated the facility was non smoking and new admissions who smoked required a smoking assessment, a care plan, and storage of all smoking materials at the nursing station. He reported the smoking policy was explained during admission and he expected staff and residents to follow these procedures including the storage of smoking materials. 3. Resident #62 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (paralysis affecting one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body), which affected his dominant right side. A review of the admission assessment dated [DATE] completed by Nurse #11 included an initial smoking assessment and revealed that Resident #62 was a former smoker, vaper, and smokeless tobacco user. The assessment further revealed he had a history of smoking but was not currently using tobacco. During an interview with Nurse #11 on 6/12/26 at 9:12 AM, she stated she could not recall completing Resident #62's initial admission assessment, including the smoking assessment. She explained that she typically asked new admissions whether they had a history of smoking or currently smoked and then documented their response. Nurse #11 reiterated that she did not remember completing Resident #62's assessment but assumed he must have reported that he was not a smoker. She added that she had never observed him, or any other residents, with cigarettes. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #62's cognition was intact and that he did not use tobacco. The assessment further revealed Resident #62 had functional limitation in range of motion on one side of his upper and lower extremities and was independent with propelling himself 150 feet in a wheelchair. A review of the care plan revised 5/25/26 revealed that Resident #62 did not require supervision with smoking due to the facility's non smoking policy. The stated goal was that he abided by the facility's smoking policy. Interventions included keeping cigarettes and lighters at the nurse's station. An observation conducted on 6/8/26 at 12:19 PM revealed that Resident #62 had a pack of cigarettes on his bed. A blue lighter and an orange colored vape device were also on his bedside table. Resident #62 reported that he had been smoking for years and had not stopped after being admitted to the facility. He stated he was not permitted to smoke on the premises and had been told he needed to go to the bus stop to smoke. Resident #62 reported that in the past he would go to the bus stop to smoke, but due to limitations from a previous stroke and the incline leading to the bus stop, it was difficult for him to propel himself there and back. He stated that it was easier for him to propel himself to the edge of the property, in the parking lot, to smoke. Resident #62 also reported that he keeps his smoking materials in a bag in his room. Review of the medical record revealed after 4/23/25 the next smoking assessment was completed by Nurse #12 on 6/8/26 and indicated that Resident #62 was determined to be safe as an unsupervised smoker. The assessment also documented that the facility's smoking policy was reviewed with him on 6/8/26. During an interview with Resident #62 on 6/10/26 at 9:44 AM, he reported that he had continued to smoke cigarettes since his admission to the facility and had always kept his cigarettes and lighter with him. He further stated that staff took his vape on Monday (6/8/26) but told him he could retrieve it when he went outside, provided he returned it afterward. He reported that he forgot to return the vape on Tuesday (6/9/26) and had left it on his bed that morning when a staff member removed it from his room. Resident #62 stated that upon admission, he was informed that the facility was non smoking and that if he wanted to smoke, he needed to go to the bus stop beside the facility to ensure he was off the premises. An observation on 6/10/26 at 11:04 AM revealed Resident #62 sitting in his wheelchair on the left side of the facility at the edge of the parking lot, approximately 150 feet from the facility entrance, smoking. An observation on 6/10/26 at 11:08 AM was made of the bus stop located in front of the facility. The bus stop is approximately 100 feet to the right of the facility entrance. It is situated on the right side of the roadway and was connected to the facility parking lot by a sidewalk. There was a small incline from the parking lot up to the sidewalk. An interview conducted on 6/10/26 at 11:18 AM with Nurse #15 revealed that the facility was a non smoking facility and that any residents who chose to smoke must go off the premises to do so. She stated residents were directed to go to the bus stop beside the facility. Nurse #15 explained that smoking assessments were only completed during the initial admission assessment because the facility was non smoking. She reported she was not aware of any residents who had been grandfathered in as being permitted to smoke. Nurse #15 further stated that although new admissions were informed the facility was non smoking, once they observed other residents going outside to smoke, they would often begin doing the same. An interview conducted on 6/10/26 at 12:34 PM with the Social Services Director revealed that the facility was a non smoking facility and that residents were informed of this at the time of admission. She stated that if residents chose to smoke, they must go off campus to do so. The Social Services Director explained that she assisted in ensuring residents who smoked were included in the care plan but did not participate in smoking observations. She further stated that staff should not be taking residents to smoke and that, if residents were unable to leave the campus independently, their families would need to take them. She added that smoking materials were not permitted in residents' rooms and should be stored at the nurses' station. During an interview with the Admissions Director on 6/10/26 at 2:25PM, she stated that the facility was a tobacco free organization and that residents and their families were informed of this during the admission process. She explained that this information was also included in the handbook provided to residents and family members. An interview conducted on 6/12/26 at 1:23 PM with Nurse #12 revealed that she was from a sister facility and had been assisting in the facility since 6/8/26 when she was asked to create a notebook listing all residents who smoked on each unit, to be kept at the nurses' station. The purpose of the notebook was to ensure staff were aware of which residents were smokers. Nurse #12 stated that Resident #62 was oriented and able to answer the assessment questions and used return demonstration to evaluate his smoking safety. During an interview with the Director of Nursing on 6/12/26 at 12:18 PM, she explained that although the facility was non smoking, a smoking assessment should be completed at the time of admission and whenever the facility became aware that a resident was smoking. She further stated that no residents should have smoking materials in their possession and that such items should be kept at the nurses' desk. An interview with the Administrator was conducted on 6/12/26 at 3:24 PM. He stated that although the facility was a non smoking facility, he expected a smoking assessment to be completed for each resident upon admission and again whenever the facility became aware that a resident was smoking. The Administrator further stated that it was his expectation that smoking materials be kept at the nurses' desk and that no residents should have smoking materials in their rooms. 4. Resident #99 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). A review of Resident #99's quarterly Minimum Data Set (MDS) dated [DATE] revealed that she was cognitively intact and was receiving supplemental oxygen therapy while residing in the facility. A review of Resident #99's physician orders revealed an order dated 6/3/26 for supplemental oxygen at 3 liters per minute, to be administered continuously, for COPD. On 6/10/26 at 2:55 PM, an observation was made of Resident #99 sitting on the side of her bed, wearing continuous oxygen via nasal cannula at a flow rate of 3 liters per minute. Two additional oxygen cylinders were also observed in Resident #99's room. One full cylinder was standing upright in a transport caddy beside the bed. The second full cylinder was stored in a canvas bag designed to secure oxygen tanks to the back of wheelchairs; however, it was leaning against the right side of a stationary chair and was not secured. On 6/10/26 at 3:13 PM, Nurse #10 was notified by the surveyor that an oxygen cylinder in Resident #99's room was unsecured. Nurse #10 confirmed the oxygen cylinder was full. She immediately removed the unsecured cylinder and returned the full cylinder to the designated oxygen storage closet. During an interview on 6/10/26 at 3:15 PM, Nurse #10 confirmed she was Resident #99's assigned nurse that day. Nurse #10 reported that portable oxygen cylinders were stored in a designated locked closet on each floor of the facility. She stated that nurses had keys to the oxygen storage area on each unit. Nurse #10 explained that empty oxygen cylinders were stored upright in individual holders on the left side of the oxygen closet, while full cylinders were stored upright in individual holders on the right side. She further stated that when an oxygen cylinder was taken to a resident's room, it should be transported in an upright position using a secured individual caddy. She added that when oxygen cylinders were stored in canvas bags, the bag should be secured to the wheelchair with the cylinder kept upright. Nurse #10 acknowledged that someone had removed the canvas bag containing an oxygen cylinder from Resident #99's wheelchair and had leaned it against a stationary chair in the room. She stated it was unsafe for an oxygen cylinder to be left leaning on its side and unsecured. Nurse #10 explained that staff had been trained that oxygen cylinders should be stored upright and secured in individual holders. She reported that she had not observed the oxygen cylinder in Resident #99's room when she administered medication earlier that day. On 6/10/26 at 3:20 PM, an interview was conducted with the Unit Manager, who explained that oxygen cylinders should be stored upright in holders within the designated oxygen storage closet. The Unit Manager stated that she had not noticed the oxygen cylinder stored in Resident #99's room on 6/10/26. During an interview with the Director of Nursing (DON) on 6/12/26 at 12:27 PM, she explained that oxygen cylinders should be stored in the designated oxygen storage closet, and if a cylinder was needed in a resident's room, it must be kept in a transport caddy. The DON added that oxygen cylinders should not be left unsecured in a resident's room because it was not safe.

Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for the use of tobacco, indwelling urinary catheter, insulin and dental status for 4 of 20 residents (Resident #100, Resident #62, Resident #76, and Resident #6 ) reviewed for MDS accuracy. Findings included: 1. Resident #100 was admitted to the facility on [DATE] with a diagnosis of tobacco use. The Smoking Observation Form indicated a smoking observation was made on 12/7/25. The form indicated that the resident was a smoker and had a history of smoking. Based on the observation, Resident #100's smoking status was determined to be unsupervised smoker. The significant Change Minimum Date Set (MDS) assessment dated [DATE] revealed the resident was assessed as cognitively intact. Resident #100 assessment indicated no for current tobacco use. During an interview on 6/12/26 at 4:21PM, MDS Nurse #1 stated the facility was a smoke free facility and hence was documenting all residents as nonsmokers. MDS Nurse #1 acknowledged that Resident #100 was a smoker. MDS Nurse #1 indicated she realized only recently that residents who smoked should be marked as smokers and not as nonsmokers even though the facility was a smoke free facility and the residents signed out and went outside the facility to smoke. During an interview on 6/12/26 at 4:30 PM, the Director of Nursing (DON) stated the facility had a smoke free policy, however had some residents who smoked. Smoking observation was completed for these residents upon admission and were assessed as unsupervised smokers. DON stated Resident #100 was smoker and her smoking observation was completed on 12/7/25. DON indicated the MDS should reflect the current smoking status of the residents, and the residents should be marked for tobacco use. 2. Resident #76 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including bladder neck obstruction. A hospital discharge order dated 5/25/26 included use of an indwelling urinary catheter. A nursing readmission note dated 5/25/26 noted an indwelling urinary catheter was in place. A physician order dated 5/25/26 included an order for use of an indwelling urinary catheter. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #76 to be cognitively intact and assessed her to be incontinent of urine. The indwelling urinary catheter was not documented. During an interview with MDS Nurse #1 on 6/11/26 at 9:57 AM, she reported she missed the resident returning from the hospital with an indwelling urinary catheter and should have documented its presence on the MDS assessment for Resident #76. The Administrator was interviewed on 6/12/26 at 4:00 PM and stated he expected the MDS to accurately reflect the care needs of the residents. 3. Resident #62 was admitted to the facility on [DATE]. A review of the nursing admission assessment dated [DATE] revealed Resident #62 had obvious or likely cavities or broken natural teeth. A review of a care plan initiated on 1/14/26 revealed Resident #62 was not identified as needing supervision while smoking. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was not identified for Current Tobacco Use or as having any Oral/Dental Status problems. During an interview and observation with Resident #62 on 6/8/26 at 12:19 PM, he stated that he had smoked cigarettes for years and had continued smoking since his admission to the facility. An observation of Resident #62 noted he had missing upper and lower teeth and his remaining teeth were in poor condition, with evidence of breakage, decay, and discoloration. An interview conducted with MDS Nurse #1 on 6/11/26 at 2:32 PM revealed that Resident #62's Annual MDS Assessment had been completed by MDS Nurse #3, a remote MDS nurse. MDS Nurse #1 stated that MDS Nurse #3 relied solely on the documentation in the medical record to determine whether Resident #62 used tobacco or had any dental problems. She explained that if she had completed the assessment herself, she would have visually observed the resident prior to completing it; however, MDS Nurse #3 had no way to observe Resident #62. An interview with MDS Nurse #3 was conducted on 6/12/26 at 10:46 AM. She explained that she worked remotely for the facility, completing assessments offsite using the electronic medical record. She confirmed that she completed the MDS assessment for Resident #62 dated 3/29/26. MDS Nurse #3 stated that she relied solely on the documentation in the electronic record when determining tobacco use or whether the resident had dental problems. She reported that there was no documentation indicating tobacco use or dental issues for Resident #62. She added that if there was no documentation she had to assume none were present. When asked about the smoking care plan initiated on 1/14/26 she stated that she could not recall why she coded Resident #62 as not using tobacco and acknowledged that she may have overlooked the smoking care plan. During an additional interview with MDS Nurse #1 on 6/12/26 at 11:35 AM, she stated that she had observed that Resident #62 had dental problems. She indicated that the assessment dated [DATE] did not accurately reflect Resident #62's dental status. An interview with the Director of Nursing (DON) was conducted on June 12, 2025, at 12:27 PM. The DON stated that she expected assessments to accurately reflect a resident's dental status and current tobacco use. 4. Resident #6 was admitted to the facility on [DATE], with a diagnosis of diabetes mellitus. A review of Resident #6's May 2026 Medication Administration Record (MAR) revealed that insulin lispro was administered on 7 days during the lookback period. Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE], noted there were 0 days that an injection of any type had been received, and 0 days of insulin injections had been received. On June 11, 2026, at 2:32 PM, an interview with MDS Nurse #1 revealed that Resident #6's quarterly MDS assessment had been completed by MDS Nurse #3, a remote MDS nurse. She stated that MDS Nurse #3 relied solely on documentation in the medical record to determine whether Resident #6 had received insulin. On June 12, 2026, at 10:46 AM, an interview with MDS Nurse #3 revealed that she worked remotely for the facility, completing assessments offsite using the electronic medical record. She confirmed that she completed the MDS assessment for Resident #6 dated May 13, 2026. She explained that she relied solely on documentation in the electronic record when coding the assessment. MDS Nurse #3 acknowledged that Resident #6 did receive insulin during the lookback period and stated that the resident was coded as not receiving injections or insulin injections in error. An interview with the Director of Nursing (DON) was conducted on June 12, 2025, at 12:27 PM. The DON stated that she expected assessments to accurately reflect a resident's medications.

Based on record reviews, resident, responsible party (RP) and staff interviews, the facility failed to assess residents for the eligibility and ensure residents were offered the COVID-19 booster vaccination for 6 of 7 residents reviewed for COVID-19 booster immunizations (Residents #38, #39, #56, #71, #77 and #121). The findings included: The facility's policy and procedure on COVID-19 Vaccination, dated 5/3/24 was reviewed. The policy stated, in part, all partners, residents and patients who had no medical contraindications to the vaccine would be offered the updated COVID-19 vaccine per the Centers for Disease Control and Prevention (CDC) recommendations to encourage and promote the benefits associated with the vaccinations against COVID-19. The policy further indicated that the facility would provide pertinent information about the significant risks and benefits of the vaccine to partners, residents, patients and/or family members. A review of the CDC guidelines, dated 11/19/25, indicated that the CDC recommended a 2025 to 2026 COVID-19 vaccine for individuals that were age [AGE] and older, were at high risk for severe COVID-19, or had never received a COVID-19 vaccine. a. Resident #38 was admitted to the facility on [DATE] and was [AGE] years old. Her diagnoses included type 2 diabetes, coronary artery disease and chronic kidney disease. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #38 had moderately impaired cognition. The COVID-19 question regarding whether Resident #38 was up to date with the vaccine was marked no. Resident #38's immunization record revealed that Resident #38 received a COVID-19 booster at the facility on 11/11/24. There was no documentation that Resident #38 had been offered, given, or refused additional doses of the COVID-19 vaccination. Attempts to contact Resident #38's RP were unsuccessful. b. Resident #39 was admitted to the facility on [DATE] and was [AGE] years old. Her diagnoses included chronic obstructive pulmonary disease, congestive heart failure and dementia. A quarterly MDS assessment dated [DATE] indicated Resident #39 had severely impaired cognition. The COVID-19 question regarding whether Resident #39 was up to date with the vaccine was marked no. Resident #39's immunization record revealed that Resident #39 received a COVID-19 booster at the facility on 10/24/24. There was no documentation that Resident #39 had been offered, given, or refused additional doses of the COVID-19 vaccination. A phone interview occurred with Resident #39's RP on 6/12/26 at 12:29 PM, who stated they could not recall if the facility provided education and an opportunity for Resident #39 to receive a recent COVID-19 booster vaccine. c. Resident #56 was admitted to the facility on [DATE] and was [AGE] years old. Her diagnoses included type 2 diabetes and chronic fatigue syndrome. A quarterly MDS assessment dated [DATE] indicated Resident #56 was cognitively intact. The COVID-19 question regarding whether Resident #56 was up to date with the vaccine was marked no. Resident #56's immunization record revealed that Resident #56 received a COVID-19 booster at the facility on 10/4/24. There was no documentation that Resident #56 had been offered, given, or refused additional doses of the COVID-19 vaccination. A phone interview occurred with Resident #56's RP on 6/12/26 at 12:24 PM, who stated they could not recall being provided with education or an opportunity for Resident #56 to receive a COVID-19 booster recently. An interview was conducted with Resident #56 on 6/12/26 at 1:45 PM and could not recall being provided with education or an opportunity to receive a recent COVID-19 booster. d. Resident #71 was admitted to the facility on [DATE] and was [AGE] years old. His diagnoses included dementia and anemia. A quarterly MDS assessment dated [DATE] indicated Resident #71 had severely impaired cognition. The COVID-19 question regarding whether Resident #71 was up to date with the vaccine was marked no. Resident #71's immunization record revealed that Resident #71 received a COVID-19 booster at the facility on 10/4/24. There was no documentation that Resident #71 had been offered, given, or refused additional doses of the COVID-19 vaccination. A phone interview occurred with Resident #71's RP on 6/12/26 at 12:31 PM and stated he could not recall being provided with education or an opportunity for Resident #71 to receive a recent COVID-19 booster. e. Resident #77 was admitted to the facility on [DATE] and was [AGE] years old. Her diagnoses included chronic obstructive pulmonary disease, type 2 diabetes and chronic respiratory failure. A quarterly MDS assessment dated [DATE] indicated Resident #77 had severely impaired cognition. The COVID-19 question regarding whether Resident #77 was up to date with the vaccine was marked no. Resident #77's immunization record revealed that Resident #77 received a COVID-19 booster at the facility on 11/26/24. There was no documentation that Resident #77 had been offered, given, or refused additional doses of the COVID-19 vaccination. A phone interview occurred with Resident #77's RP on 6/12/26 at 12:37 PM and stated he could not recall being provided with education or an opportunity for Resident #77 to an updated COVID-19 booster. f. Resident #121 was admitted to the facility on [DATE] and was [AGE] years old. Her diagnoses included chronic obstructive pulmonary disease and congestive heart failure. A quarterly MDS assessment dated [DATE] indicated Resident #121 had severely impaired cognition. The COVID-19 question regarding whether Resident #121 was up to date with the vaccine was marked no. Resident #121's immunization record revealed that Resident #121 received a COVID-19 booster at the facility on 10/24/24. There was no documentation that Resident #121 had been offered, given, or refused additional doses of the COVID-19 vaccination. A phone interview occurred with Resident #121's RP on 6/12/26 at 3:40 PM and stated she could not recall being provided education or an opportunity for Resident #121 to receive an updated COVID-19 booster. A comprehensive review was completed of all resident immunization records from 10/1/25 to 3/31/26 and revealed that some residents were provided with the COVID-19 vaccine. An interview was conducted with the Infection Preventionist on 6/12/26 at 12:47 PM. She stated that every resident should be offered the opportunity to receive the COVID-19 booster based on the CDC guidelines. She explained that she utilized the Preventative Health tab in the Electronic Medical Record (EMR) system for tracking who had and who had not received the COVID-19 vaccines rather than a log of some type. She stated it was a random search, and she must have overlooked Residents #38, #39, #56, #71, #77 and #121 for providing them with an opportunity to receive an updated COVID-19 booster. The Infection Preventionist indicated she needed to develop a system so that resident immunizations were not overlooked. The Infection Control nurse added that she had been pulled to work on the medication carts frequently and that she had not been able to dedicate the time needed to ensure residents received their immunizations in a timely manner. The Director of Nursing (DON) was interviewed on 6/12/26 at 2:02 PM and stated that she was unaware that Residents #38, #39, #56, #71, #77 and #121 did not receive education or the opportunity to receive an updated COVID-19 booster. The DON further stated it was her expectation that COVID-19 vaccine education be provided, immunizations to be administered as stated in their policy after consent was obtained, and documentation to be present in the medical record.

Based on record review, Pharmacist, resident, responsible party (RP) and staff interviews, the facility failed to provide education regarding the benefits and potential side effects of the influenza immunization with documentation in the medical record and failed to offer the influenza immunization during the influenza season (October to March) for 6 of 7 residents reviewed for influenza immunization (Residents #38, #39, #56, #71, #77 and #121). The findings included: The facility's policy and procedure on influenza immunizations dated [DATE] was reviewed. The policy stated, in part, all patients who had no medical contraindications to the vaccine would be offered the influenza vaccine annually. The policy further indicated that the facility would provide pertinent information about the significant risks and benefits of the vaccine to patients and/or family members. Additionally, the policy read that current and newly admitted patients would be offered the influenza vaccine beginning on [DATE]st of each year, it would be offered for as long as the influenza viruses were circulating, and unexpired vaccine was available. A. Resident #38 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #38 had moderately impaired cognition. The influenza question regarding whether Resident #38 received the vaccine in the facility was marked no and the reason was coded as not offered. Resident #38's medical record revealed there was no documentation in the Electronic Medical Record (EMR) system or hard chart, to indicate whether Resident #38 or her responsible party (RP) had received education regarding the benefits and the potential side effects of the influenza vaccine for the influenza season of [DATE] to [DATE]. In addition, there was no documentation to indicate whether Resident #38 received or refused the influenza vaccine from [DATE] to [DATE]. Attempts to contact Resident #38's RP were unsuccessful. B. Resident #39 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] indicated Resident #39 had severely impaired cognition. The influenza question regarding whether Resident #39 received the vaccine in the facility was marked no and the reason was coded as not offered. Resident #39's medical record revealed there was no documentation in the EMR system or hard chart, to indicate whether Resident #39 or her RP had received education regarding the benefits and the potential side effects of the influenza vaccine for the influenza season of [DATE] to [DATE]. In addition, there was no documentation to indicate whether Resident #38 received or refused the influenza vaccine from [DATE] to [DATE]. A phone interview occurred with Resident #39's RP on [DATE] at 12:29 PM, who stated they could not recall if the facility provided education and an opportunity for Resident #39 to receive the influenza vaccine for the most recent influenza season. C. Resident #56 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] indicated Resident #56 was cognitively intact. The influenza question regarding whether Resident #56 received the vaccine in the facility was marked no and the reason was coded as not offered. Resident #56's medical record revealed there was no documentation in the EMR system or hard chart, to indicate whether Resident #56 or her RP had received education regarding the benefits and the potential side effects of the influenza vaccine for the influenza season of [DATE] to [DATE]. In addition, there was no documentation to indicate whether Resident #56 received or refused the influenza vaccine from [DATE] to [DATE]. A phone interview occurred with Resident #56's RP on [DATE] at 12:24 PM, who stated they could not recall being provided education or an opportunity for Resident #56 to receive the influenza vaccine for the most recent influenza season. An interview was conducted with Resident #56 on [DATE] at 1:45 PM. The resident could not recall being provided education or an opportunity to receive the influenza vaccine for the most recent influenza season. D. Resident #71 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] indicated Resident #71 had severely impaired cognition. The influenza question regarding whether Resident #71 received the vaccine in the facility was marked no and the reason was coded as not offered. Resident #71's medical record revealed there was no documentation in the EMR system or hard chart, to indicate whether Resident #71 or his RP had received education regarding the benefits and the potential side effects of the influenza vaccine for the influenza season of [DATE] to [DATE]. In addition, there was no documentation to indicate whether Resident #71 received or refused the influenza vaccine from [DATE] to [DATE]. A phone interview occurred with Resident #71's RP on [DATE] at 12:31 PM and stated he could not recall being provided education or an opportunity for Resident #71 to receive the influenza vaccine for the most recent influenza season. E. Resident #77 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] indicated Resident #77 had severely impaired cognition. The influenza question regarding whether Resident #77 received the vaccine in the facility was marked no and the reason was coded as not offered. Resident #77's medical record revealed there was no documentation in the EMR system or hard chart, to indicate whether Resident #77 or her RP had received education regarding the benefits and the potential side effects of the influenza vaccine for the influenza season of [DATE] to [DATE]. In addition, there was no documentation to indicate whether Resident #77 received or refused the influenza vaccine from [DATE] to [DATE]. A phone interview occurred with Resident #77's RP on [DATE] at 12:37 PM and stated he could not recall being provided education or an opportunity for Resident #77 to receive the influenza vaccine for the most recent influenza season. F. Resident #121 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] indicated Resident #121 had severely impaired cognition. The influenza question regarding whether Resident #121 received the vaccine in the facility was marked no and the reason was coded as not offered. Resident #121's medical record revealed there was no documentation in the EMR system or hard chart, to indicate whether Resident #121 or her RP had received education regarding the benefits and the potential side effects of the influenza vaccine for the influenza season of [DATE] to [DATE]. In addition, there was no documentation to indicate whether Resident #121 received or refused the influenza vaccine from [DATE] to [DATE]. A phone interview occurred with Resident #121's RP on [DATE] at 3:40 PM and stated she could not recall being provided education or an opportunity for Resident #121 to receive the influenza vaccine for the most recent influenza season. An interview occurred with the Infection Preventionist on [DATE] at 12:00 PM who stated that influenza education and consents were to be reviewed with the residents and/or RP's yearly. The Infection Preventionist further stated that in [DATE] a batch of influenza vaccines were received but had to be discarded as they were not refrigerated when received. Another batch of influenza vaccines were received but she could not recall how many or when and then stated that there was a delay in obtaining influenza vaccines but couldn't recall when the vaccines were received. A phone interview occurred with the Pharmacist on [DATE] at 11:08 AM. The Pharmacist was able to pull the influenza shipment information for 2025 and stated that the facility received 60 doses of influenza vaccine on [DATE] and on the same date 40 additional influenza vaccines were requested by the facility. The pharmacy was only able to send 27 more doses of influenza vaccines instead of the 40 that had been requested. The Pharmacist stated that additional influenza vaccines were provided in [DATE], but she was unable to retrieve that information. Another interview was conducted with the Infection Preventionist on [DATE] at 12:47 PM. The Infection Preventionist again stated that a shipment of influenza vaccines came to the facility on an unrecalled date in [DATE] but was not refrigerated and had to be discarded. The facility reordered influenza vaccine and received a small amount. She was unable to recall the exact amount of influenza doses received but stated that she randomly provided influenza vaccines after providing education and obtaining consents from the resident and/or RPs. The Infection Preventionist stated she recalled receiving another shipment of influenza vaccines in [DATE] but could not recall the exact amount and when it was received. She stated that again she began providing random influenza vaccines to the residents. The Infection Preventionist reviewed the information for Residents #38, #39, #56, #71, #77 and #121 and explained that she utilized the Preventative Health tab in the EMR system for tracking who had and who had not received the influenza vaccine rather than a log of some type and must have overlooked the referenced residents. The Infection Preventionist added that it was an oversight to have not provided education and an opportunity to receive the influenza vaccine for the most recent influenza season for Residents #38, #39, #56, #71, #77 and #121. The Director of Nursing (DON) was interviewed on [DATE] at 2:02 PM and stated that she was unaware that Residents #38, #39, #56, #71, #77 and #121 did not received education or the opportunity to receive the influenza vaccine during the most recent influenza season. The DON further stated it was her expectation that yearly influenza vaccine education be provided, immunizations to be administered as stated in their policy after consent was obtained, and documentation to be present in the medical record.

Based on record review and interviews with the Registered Dietitian, staff and 5 of 5 residents present in the Resident Council Group Meeting (Resident #17, Resident #4, Resident #85, Resident #91 and Resident #92) the facility failed to serve a nourishing snack to residents at bedtime.Findings included:A review of the scheduled mealtimes provided by the facility revealed the time between dinner (the evening meal) and breakfast the following day was 15 hours.On 06/9/26 at 11:30 AM a Resident Council meeting was conducted with 5 cognitively intact members of the Resident Council (Resident #17, Resident #4, Resident #85, Resident #91 and Resident #92). All 5 members stated they were not regularly offered a snack at bedtime but could get one if they asked. The residents reported they had not approved of a time of greater than 14 hours between the dinner meal and breakfast the next morning.On 06/9/2026 at 7:33 PM Nurse Aide (NA) #1 was observed delivering snacks on the 100 Hall. She reported she had worked at the facility for 15 years on the 3:00 PM to 11:00 PM shift. She stated that the snacks currently present on the snack cart, which were observed to be vanilla and chocolate ice cream, crackers, fig bar cookies, oatmeal pies, vanilla pudding, apple sauce, fruit juice, and zero sugar ginger ale were the usual snacks that were available for the evening. She indicated she normally passed these around to all residents at about 8:00 PM giving them a choice of what was available. She reported although she didn't offer sandwiches, sometimes a resident would ask for one, which were available in the kitchenette on the first floor. She stated sometimes a resident would ask for a sandwich if they didn't eat all of their dinner meal, but tonight everyone had eaten well, and no one had asked. An observation of the 100 Hall kitchenette refrigerator with NA #1 during this interview revealed there were no sandwiches. She reported there was no other place for sandwiches to be kept on the first floor, but if a resident asked for a sandwich and there weren't any in this kitchenette, she had in the past gone down to the kitchen and there were some available there. On 06/9/2026 7:36 PM an interview with Nurse #1 on the 100 Hall indicated she had worked at the facility for 3 years. She stated she was working the 3:00 PM to 11:00 PM and reported that for evening snacks, there were normally cookies, cakes, crackers, and sweets. She reported that if there were currently no sandwiches available, she did not know if the kitchen would be bringing any up. On 06/09/2026 at 7:51 PM Dietary Aide #1 was interviewed in the kitchen. She reported she had been a dietary aide at the facility for about 1 and a half years. She indicated her shift was normally 11:00 AM to 7:00 PM, and she was just finishing up in the kitchen for the day. She reported the NAs would bring the snack cart down for their unit in the mornings, to be stocked with snacks for the day which included cookies, cakes, crackers, and soda including sugar free. She stated the kitchen made turkey and cheese sandwiches for the residents daily which were sent up to the floors around 1:00 PM. She indicated these sandwiches were sent to the 100 Hall as they had a refrigerator, and some extras were sent to 300 Hall, but none were sent to the 200 Hall because that floor did not have a refrigerator. She reported that she thought the NAs were all aware of where the sandwiches were kept. Dietary Aide #1 stated no other snacks were sent up, but if staff needed extra snacks or sandwiches, they could access the reach in cooler after the dietary staff left for the day. An observation of the reach in cooler with Dietary Aide #1 during this interview revealed there were no sandwiches. She stated everything that was going to be sent for the day had already been sent, and the dietary staff would not be making any more sandwiches or sending anything else up to the halls this evening. On 06/9/2026 at 8:07 PM an interview with NA #2 on the 200 Hall indicated she had worked at the facility for about 8 months. She stated she normally worked from 2:00 PM to 10:00 PM. She reported snacks were available in the snack carts on the unit, and when she distributed these, she would go to each resident and offer the snacks. She indicated snacks included zero sugar soda, fruit juices, crispy rice treats, and crackers. NA #2 stated there were no sandwiches available for residents normally. She reported that she had not provided snacks this evening as she had come in early today, so she was on her way out. An observation of the 200 Hall snack cart with NA #2 during this interview revealed of it contained rice crispy treats, oatmeal pies, crackers and fruit juices. In an interview on 06/9/2026 at 8:15 PM NA #3 on the 200 Hall she reported she had been at the facility for 10 months and worked on the 3:00 PM to 11:00 PM shift. She stated she normally passed out evening snacks at about 8:00 PM but had not done so yet on the 200 Hall. She reported there were no sandwiches available on the evening shift. She indicated if a resident asked for a sandwich, she told them there weren't any.On 6/9/26 at 8:28 PM in an interview with NA #4 on the 300 Hall he reported that snacks came from the dietary department on a cart and he went around and offered these to residents in the evening. An observation of the 300 Hall snack cart with NA #4 during the interview revealed it contained crackers, cookies, fruit juice, and sugar free soda. He stated this was the normal evening snack available for residents. He indicated sometimes there were sandwiches in the refrigerator on the 300 Hall, but there weren't any tonight. He stated if a resident asked for a sandwich, and there weren't any available on his floor, sometimes he would go to another floor to see if they had some. He indicated no one had asked for a sandwich this evening. On 06/10/2026 at 10:44 AM in an interview with Resident #91 who resided on the 200 Hall he stated he was not offered a snack last night (06/09/2026) before bed. He reported last year they used to do this, but not this year. He reported got offered snacks in the daytime like rice crispy treats, cookies, and brownies. He indicated at times, he did get hungry between dinner and breakfast the next morning. He stated he could get a snack if he asked, he did not ask for one last night. On 06/10/2026 at 10:54 AM an interview with Resident #4 who resided on the 200 Hall revealed he had not been offered a snack last night (06/09/2026). He reported he had a bag of unsalted chips from his personal supply, and he ate that.On 06/10/2026 at 11:04 AM an interview with Resident #17 who resided on the 100 Hall revealed that he had been offered a snack last night (06/09/2026) at bedtime, it was an applesauce. On 06/10/2026 at 11:09 AM an interview with Resident #92 who resided on the 300 Hall revealed she was offered drinks and cookies last night (06/09/2026) but she usually tried not to eat anything before bed. She reported she did not want a snack last night. She stated sometimes she did get hungry between dinner and breakfast, but she had some candy with nuts in it, and cookies that she kept at her bedside.On 06/10/2026 at 11:19 AM an interview with Resident #85 who resided on the 200 Hall revealed he was not offered a snack last night (06/09/2026) before bed. He reported he got hungry sometimes between supper and breakfast, but he was not hungry last night as he had not been feeling well. He stated there weren't ever any sandwiches available on his hall. He indicated he got tired of crackers for snack.On 06/10/2026 at 10:38 AM in a telephone interview with the facility's Registered Dietitian (RD) she stated that it was hard for her to say whether or not the snacks that were available, which included crackers, cookies, applesauce, fruit juices, and zero sugar soda constituted a nourishing bedtime snack. She reported a nourishing snack would include a combination of fats, protein and complex carbohydrates. On 06/10/2026 at 10:49 AM in a follow up telephone interview the RD reported she knew the facility's mealtime from dinner to breakfast the next morning exceeded 14 hours. She stated based on the snacks that were available, if a resident chose more than one option, it could possibly constitute a nourishing bedtime snack.On 06/10/2026 at 2:30 PM in an interview the Director of Nursing (DON) stated that she would not consider cookies, rice crispy treats, crackers, and soda a nourishing bedtime snack. She reported at one point in time there were sandwiches available for a bedtime snack; she could not say how long ago that was. She indicated she thought the sandwiches were being brought up to the halls for residents, but were all getting eaten before dinner.On 6/10/26 at 4:39 PM an interview with the Administrator revealed he did not think crackers, and cookies were a nourishing bedtime snack. He stated the process was supposed to be that staff should go to either the first floor or to the kitchen where they could obtain sandwiches for residents' bedtime snack because there was more than 14 hours between the dinner meal and breakfast the next morning at the facility. He reported sandwiches would be a nourishing snack, and he thought the facility had sandwiches available. The Administrator stated if no sandwiches were available on 06/09/2026 for the bedtime snack, it was possible that during the day, residents had eaten all the sandwiches that were provided.

Based on observation, record review, and interviews with Resident and staff, the facility failed to honor residents' choices of getting out of bed for 2 of 11 residents reviewed for self determination (Residents #116 and #69). Findings included: 1. Resident #116 was admitted to the facility on [DATE] with diagnoses including incomplete quadriplegia (paralyzed from the neck down with minimal movement of his arms), traumatic brain injury, muscle weakness, spastic hemiplegia (involuntary jerking movements of his arms and legs). Review of the care plan for Resident #116 dated 4/13/26 for Activities of Daily Living (ADL) care due to impaired mobility included interventions to explain procedures prior to touching the resident, to report any rejection of care, and to encourage the resident to get out of bed as part of his long term participation in activities he enjoys. The annual Minimum Data Set, dated [DATE] indicated Resident #116 was cognitively intact and was dependent on staff for bed mobility and activities of daily living, and used a wheelchair. Resident #116 was not coded for behaviors which included rejection of care. On 6/9/26 at 12:55 PM during observation and interview during the lunch meal, Nursing Assistant (NA) #3 was observed handing Resident #116's lunch tray to his Responsible Party. Resident #116 asked NA #3 to get in his wheelchair after lunch. NA #3 walked away from the bed without responding. On 6/9/26 at 1:10 PM NA #3 was interviewed and reported she was passing lunch trays and would notify Resident #116's assigned NA and that the Resident wanted to get out of bed into his wheelchair. On 6/9/26 at 2:45 PM, Resident #116 was observed in bed and reported no one had returned to assist him with getting out of bed, stating staff had only entered to remove his lunch tray. On 6/9/26 at 2:50 PM, NA #3 was interviewed and stated she had forgotten the resident wanted to get up and would inform the assigned NA. NA #3 stated she got busy passing meal trays and forgot to go back around and tell his assigned NA. An interview with NA #12 on 6/9/26 at 3:30 PM revealed she worked 3:00 PM to 11:00 PM that day. She reviewed the staffing assignment and stated that NA #3 had been assigned to Resident #116 from 7:00 AM to 3:00 PM and did not inform her until 3:05 PM that the resident wanted to get out of bed. NA #12 stated she obtained assistance from another staff member on her shift to use the mechanical lift to get the resident up into his chair. On 6/9/26 at 3:45 PM, review of the staff assignment sheet for Resident #116 indicated that NA#3 was assigned to him during the 7:00 AM to 3:00 PM shift on 6/9/26. On 6/10/26 at 3:54 PM, the Director of Nursing (DON) stated that when a resident requested to get up into their chair, staff were expected to work together to honor the request using appropriate assistance, including two person assistance or mechanical lift as needed. She stated she had been unaware the resident made requests on 6/9/26 and Resident #116 was not assisted in getting out of bed until approximately 3:00 PM on 6/9/26, only after the surveyor interviewed staff about his request. The DON stated delays in responding to resident requests were unacceptable and staff were expected to routinely round and follow-up. On 6/10/26 at 2:56 PM, the Administrator stated he was unaware that staff were failing to get Resident #116 into his wheelchair when requested. He stated staff should have gotten Resident #116 up as he asked and confirmed the expectation that resident requests to get out of bed must be honored. 2. The findings included: Resident #69 was admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis of one entire side of the body) and hemiparesis (weakness or partial paralysis affecting only one side of the body) following CVA (cerebral vascular accident/stroke) affecting the left non-dominant side. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 was moderately cognitively impaired. She was assessed as needing substantial assistance with turning in bed and dependent. Resident #69 was not coded for behavioral concerns or rejection of care. A review of Resident #69's care plan last updated 5/18/26 did not reveal behaviors or rejection of care. On 6/11/26 at 2:58 PM an interview was conducted with Resident #69 who stated she had asked multiple staff members at various times throughout the previous week to get her out of bed, but they always told her no. Resident #69 stated it had been several days since she was last out of bed. Nurse Aide (NA) #1, who was assigned to Resident #69 on 6/11/26 3:00 PM to 11:00 PM, was interviewed on 6/11/26 at 3:01PM. NA #1 stated, we do not get Resident #69 out of bed because once we get her up, she complains and wants to go right back to bed. NA #1 could not recall the last time she got Resident #69 out of bed. The Director of Nursing (DON) was interviewed on 6/12/26 at 2:02 PM and stated staff should get Resident #69 out of bed when she asked to get up. According to the DON, even if the resident wanted to go back to bed 30 minutes later, she had the right to get out of bed.

Based on observation, record review, resident, staff and Nurse Practitioner interviews, the facility failed to assess the ability of a resident to safely self-administer medications for 1 of 1 resident reviewed for self-administering medications (Resident #135).The findings included:Resident #135 was admitted to the facility on [DATE] with diagnoses of bipolar disorder and major depressive disorder, single episode, with psychotic features.Review of the annual Minimum Data Set (MDS) dated [DATE] indicated Resident #135 was cognitively intact without behavioral concerns.A review of the active orders revealed an order dated 6/3/26 through 6/9/26 for Cipro 500 milligrams (mg); 1 tablet orally twice daily.A review of the nursing progress notes for Resident #135 revealed the following written by the Director of Nursing: 6/3/26 5:38 PM Resident is refusing to have her blood drawn for a CBC (complete blood count that measures the types and numbers of blood cells in your blood) with diff . She also has her own antibiotics and refuses to give them to the nurse and refuses to take the antibiotics the facility has. Will notify NP (Nurse Practitioner) of the above.A review of the Medication Administration Record for June 2026 revealed Resident #135 refused the Cipro at 5:00 PM on 6/3/26 as signed by Nurse #2, refused at 9:00 AM and 5:00 PM as signed by Nurse #2 on 6/4/26; refused at 9:00 AM and 5:00 PM as signed by Nurse #1 on 6/5/26, 6/6/26 and 6/7/26; refused the 9:00 AM and 5:00 PM doses as signed by Nurse #3.The following nursing progress note regarding Resident #135 was written by Nurse #3:6/8/26 8:26 PM Resident showed to writer her ciprofloxacin 500 mg tablet, the same with facility stock. Resident stated to writer she got it from Walgreens pharmacy when she visited urgent care. Took 9 am ciprofloxacin 500 mg 1 tablet, but resident's stock. Refused the facility medicine packet. Showed to writer her notebook in which she wrote the date she started the medicine, 6-2-26 to 6-9-26. Writer notified Unit Manager. On 6/9/26 at 2:25 PM Resident #135 was interviewed who stated she had the CNA get her ready for the day on 6/2/26 and went out with her friend. According to Resident #135, when she was seen by the urgent care provider, she tested positive for a urinary tract infection (UTI). Resident #135 stated she told the urgent care provider to send her antibiotic order to a local pharmacy where she personally picked the medication up. Resident #135 explained when she returned to the facility later in the day on 6/2/26, she showed the staff her after visit summary and was not trying to hide what she had done. According to the resident, the nurse asked her to give her the bottle of medication, but Resident #135 refused and told the nurse she was going to take it herself. Resident #135 further explained she was in her right mind and capable of taking her own medication. Resident #135 showed a bottle of Cipro to the surveyor and a zippered pouch she kept at her bedside where she stored the medication. The resident denied being formally assessed by staff as being capable of independently taking medications.Nurse #2 was interviewed on 6/9/26 at 2:43 PM and stated she routinely worked with Resident #135. Nurse #2 was assigned to Resident #135 on 6/3/26, 6/4/26, and 6/9/26. According to Nurse #2, she attempted to administer Resident #135's Cipro on 6/3/26 and 6/4/26, but the resident refused each day. Nurse #2 stated the resident told her she had her own bottle of medication and was taking it herself. Nurse #2 specified she did not observe Resident #135 take her medication, and the resident refused to show her the bottle containing the medication until the morning of 6/9/26 when there was only one dose left. Nurse #2 indicated she informed the Unit Manager regarding Resident #135's refusals of medication as well as having a bottle of medication at bedside. She further indicated she wrote a note for the Nurse Practitioner in the provider's notebook kept at the nurse's station for review, but she did not call the provider to inform of the medication at bedside. Nurse #2 further expressed she was unaware if Resident #135 had been formally assessed for the ability to safely self-administer medications.The Unit Manager (UM) was interviewed on 6/9/26 at 2:50 PM who stated Nurse #2 informed her that Resident #135 refused her antibiotic on 6/3/26 and that the resident had obtained her own medications after visiting the local urgent care. The UM stated she spoke with Resident #135 on 6/3/26 who refused to show the bottle of medication to her and refused to allow her to lock the medication in the medication cart. The UM explained she informed the Director of Nursing regarding the refusal and Resident #135 having a bottle of medication at bedside. According to the UM, she did not write a note in the provider's notebook, and she did not call the Nurse Practitioner to inform her about the medication at Resident #135's bedside.On 6/12/26 at 10:29 AM Nurse Practitioner (NP) #2 was interviewed by phone and stated she had been informed about Resident #135 going to the local urgent care as well as the resident's refusal to give her medication to the staff members to place on the cart. According to NP #2, she assessed Resident #135 after the medication refusal was reported to her, and she educated the resident regarding the dangers of taking antibiotics incorrectly. NP #2 indicated she also educated the staff and Director of Nursing about taking antibiotics incorrectly as well. NP #2 stated she was not aware of Resident #135 having been formally assessed as being capable of self-administering medications, and it was beyond her scope of practice to deem her competent or incompetent.The Director of Nursing (DON) was interviewed on 6/12/26 at 2:02 PM who stated she spoke with Resident #135 on 6/3/26 and asked her to let the nurses lock her antibiotics in the medication cart. However, she stated Resident #135 refused to give them to her. According to the DON, she asked the Minimum Data Set (MDS) nurse to observe Resident #135 self-administer her Cipro each day.On 6/12/26 at 2:18 PM an interview was conducted with the MDS nurse who stated she had not been asked to monitor any resident self-administer their medications, and she had not observed Resident #135 take her antibiotic.

Based on record reviews, staff and Health Care Power of Attorney interviews, the facility failed to distribute the funds within 30 days of discharge for 1 of 3 residents reviewed for refund of deposit (Resident #127).Findings included:Resident #127 was admitted to the facility on [DATE].A review of the discharge tracking Minimum Data Set (MDS) dated [DATE] revealed Resident #127 had a planned discharge to another facility on 03/07/26.On 06/09/26 at 1:30 PM a phone interview was conducted with Resident #127's Health Care Power of Attorney (HCPOA). The HCPOA explained Resident #127 was discharged to another skilled nursing facility on 03/07/26 and was owed a refund of approximately $1000. On 06/12/26 at 9:05 AM an interview with the Business Office Manager was conducted. She stated she received an email from the accepting facility in April 2026 indicating that they had not received Resident #127's funds. The Business Office Manager stated she initiated the the refund for Resident #127 on approximately 04/18/26 and the funds were sent to the accepting facility on 04/21/26. The Business Office Manager did verify the transfer took place more than 30 days after Resident #127 was discharged from the facility (03/07/26). The Business Office Manager could not provide the email she received from the accepting facility or the date she received it due to the system automatically deleting the email after 30 days. The Business Office Manager explained that no one communicated to her that Resident #127 was discharged to the other facility. She verified the team had discussed the transfer in the morning meeting prior to Resident #127's discharge and that she did see it on the census report however it did not trigger her to look to see what facility he went to. She went on to say she had been employed with the facility for 6 months and was still learning.An interview was conducted with the Administrator on 06/12/26 at 3:35 PM. The Administrator stated that the refund of funds for Resident #127's account should have occurred per the regulation.

Based on observation, record review, resident and staff interviews the facility failed to maintain a resident's dignity when staff spoke to a resident in an undignified manner. The resident stated she was upset by the way the staff member spoke to her when the staff told her not to hit her call bell (Resident #69). This deficient practice affected 1 of 5 residents reviewed for dignity and respect. The findings included:Resident #69 was admitted to the facility on [DATE] with hemiplegia (paralysis of one entire side of the body) and hemiparesis following CVA (cerebral vascular accident/stroke) affecting the left non-dominant side.A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 was moderately cognitively impaired. She was assessed as needing substantial assistance with turning in bed and dependent.During an observation of Resident #69 on 6/11/26 at 2:58 PM it was noted her call bell was draped across the foot of the bed and lying on the floor. Resident #69 stated the staff put it down there when they had assisted her earlier.An observation and interview of Resident #69 was conducted with Nurse Aide (NA) #1 on 6/11/26 at 3:01 PM. Upon entering the room with NA #1, Resident #69's call bell was observed draped across the bottom of Resident #69's bed lying on the floor. NA #1 stated she must have forgotten to return the call bell to the resident after changing the resident's clothes earlier. NA #1 handed the call bell to Resident #69. As the resident began rubbing the side of the call bell, NA #1 stated in a stern voice, Don't you hit that call bell, I'm standing right here. What do you need? Resident #69 looked away and did not respond. NA #1 then walked away and would not respond to any further questions asked by this surveyor. Resident #69 was interviewed on 6/11/26 at 3:22 PM who stated the way NA #1 spoke to her upset her.Nurse #4 was interviewed on 6/11/26 at 3:30 PM who stated Resident #69 liked to hold the bed control and would often throw other items off the bed trying to find it, such as the call bell. Nurse #4 further stated Resident #69 should not have been discouraged from using her call bell or spoken to her disrespectfully. On 6/12/26 at 2:02 PM the Director of Nursing (DON) was interviewed and stated NA #1 spoke inappropriately to Resident #69 regarding her call bell. According to the DON, it was the resident's right to be spoken to in a dignified manner.

Based on record review, and staff, responsible party (RP), Hospice Nurse, and Physician interviews, the facility failed to notify the provider of a change in condition and x-ray results after a fall for one (Resident #1) of three residents reviewed for notification of falls. Resident #1 fell on 5/17/2025 and the facility failed to notify the provider of pain and a new inability to bear weight. X-ray results obtained midday on 5/19/2025 were not relayed to the on-call provider until after hours on 5/19/2025. Resident #1 sustained an acute impacted left femoral neck fracture (an acute impacted left femoral neck fracture is a break in the upper part of the thigh bone (femur), specifically at the neck, where it connects to the ball of the hip joint). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses of history of cerebral vascular accident, hemiplegia, hemiparesis, and lung cancer. Hemiplegia is paralysis on one side while hemiplegia is weakness on one side of the body. Resident #1 started receiving Hospice services on 3/31/2025. Documentation on a timesheet for Nurse Aide (NA) #1 revealed she worked at the facility from 7:18 AM to 10:53 PM on 5/17/2025. Documentation on the corresponding nursing schedule revealed NA #1 was assigned to care for Resident #1 during that time period. NA #1 was interviewed on 6/10/2025 at 11:54 AM. NA #1 revealed the following information. Resident #1 had a fall on 5/17/2025. NA #1 heard Resident #1 fall, and she told Nurse #4. Nurse #4 was interviewed on 6/10/2025 at 6:41 PM and revealed the following information. Nurse #4 worked the 7:00 AM to 7:00 PM shift on 5/17/2025. Resident #1 fell on 5/17/2025 while trying to go to the bathroom. Nurse #4 did full range of motion assessments of all her limbs and took the vital signs of Resident #1. Nurse #4, with the assistance of NA #1, helped Resident #1 up off the floor and into her wheelchair. Nurse #4 was so busy with a new admission, helping residents eat, changing incontinence briefs, and administering medications that she was not able to document anything in the electronic medical record. Nurse #4 also stated that she forgot to notify anybody about the fall but, Resident #1 was without injury or pain after the fall on 5/17/2025. There was no documentation in Resident #1's electronic medical record of any fall, assessments, or notification of physician or family on 5/17/2025 for the 7:00 AM to 7:00 PM shift. An interview was conducted with the Responsible Party (RP) #1 for Resident #1 on 6/10/2025 at 2:06 PM. RP #1 provided the following information. RP #1, her husband, and her children went to visit Resident #1 on the morning of 5/18/2025. RP #1 barely got down the hallway when she was stopped by NA #1. NA #1 explained that she had not yet assisted Resident #1 out of bed and to get dressed. NA #1 said she knew that RP #1 would like to take Resident #1 outside. NA #1 then told RP #1 that Resident #1 fell yesterday (5/17/2025) but she was fine. RP #1 remarked to NA #1 that nobody had called to tell her about the fall. RP #1 went to see Resident #1 and to ask her about the fall. RP #1 stated that she and her husband were trying to help Resident #1 to get up, but it seemed like she was in pain, and she could not bear any weight. This was a change for Resident #1 because although she was weak on her left side she had always been able to stand. RP #1 revealed she assisted Resident #1 in dressing and then asked her about the fall she had on the previous day. Resident #1 told RP #1 that she was trying to get to the bathroom, and she twisted her left foot and fell. Resident #1 told RP #1 she did not hit her head. Resident #1 told RP #1 that a nurse and a nurse aide put her back into bed. RP #1 indicated Resident #1 seemed very sore and was protecting her left side. RP #1 stated she and her husband took Resident #1 to the bathroom, but Resident #1 was not able to stand or bear any weight. RP #1 indicated Resident #1 required her husband to pick her up and hold her to get on and off the toilet and back into the wheelchair. RP #1 then went to the nurse's desk and spoke to Nurse #4. RP #1 told Nurse #4 that Resident #1 told her she fell last night and she was now in pain. RP #1 said Nurse #4 acted like she didn't know what RP #1 was talking about. Nurse #4 told RP #1 that Resident #1 had not mentioned anything about a fall or pain to her. Nurse #4 stated she would check and see if Resident #1 fell last night and confirmed she did not see anything about a fall in the electronic medical record. Nurse #4 went down to Resident #1's room and gave her pain medication but did not do any assessment or do anything else for Resident #1. RP #1 revealed she told Nurse #4 that Resident #1 was unable to bear weight on her left side and Nurse #4 kept acting like she didn't know what she was talking about or with any concern. Resident #1 told RP #1 that Nurse #4 was the nurse who was in the room last night after the fall. RP #1 did take Resident #1 outside to get some air but Resident #1 seemed very sore anytime they moved her, and she required more assistance than usual. Nurse #4 was interviewed on 6/10/2025 at 6:41 PM. Nurse #4 confirmed she worked the 7:00 AM to 7:00 PM shift on 5/18/2025. Nurse #4 stated that RP #1 came to the desk on the morning of 5/18/2025 and told her Resident #1 was having back pain. Nurse #4 stated that Resident #1's fall that occurred on 5/17/2025 was not discussed at all with RP #1. Nurse #4 stated that Resident #1 was not injured so there was no reason to tell RP #1 about the fall. Nurse #4 confirmed she administered an ordered dose of Oxycodone to Resident #1 on the morning of 5/18/2025. Nurse #4 confirmed she did not do any documentation or notification of a physician on 5/18/2025 because she was too busy with nursing duties. RP #1 was interviewed on 6/10/2025 at 2:06 PM and revealed the following information. On the morning of 5/19/2025 RP #1 had concerns for Resident #1, so she sent a text message to Hospice Nurse #1 first thing in the morning. RP #1 told Hospice Nurse #1 that Resident #1 had a fall on 5/17/2025 and she was in pain. Hospice Nurse #1 told RP #1 that Resident #1 was the first person she would visit that day. RP #1 could see on 5/19/2025 in a video call to Resident #1 that she was in a lot of pain and was guarding her left side. Documentation in a Hospice Nurse as needed visit note dated 5/19/2025 at 1:46 PM revealed, Received message from [RP #1] that [Resident #1] had a fall over the weekend. Arrived [Resident #1's] room, [Resident #1] was sleeping. Called out her name and [Resident #1] woke up without difficulty. Asked [Resident #1] about the fall, [Resident #1] narrated saying, I called for someone to help me to bathroom, but no one came, I did not want to pee on myself, so I got up using my cane, but my left foot got caught and I tripped over and fell on my left side. I lay there until an aide came to help me up. [Resident #1] had an unwitnessed fall on Saturday 5/17/2025, consulted facility nurse for details but [Nurse #3] stated that he had no report of the fall from previous shift. Since then, she has complained of pain of 5 to 8 on numerical scale. [Resident #1] able to assist in turning, but pain prohibits turning to left side of body. [Resident #1] left leg and foot had no bruising, swelling, or hotness. [Resident #1] left side is the weak side from history of [Cerebral Vascular Accident]. Asked the facility provider [MD #1 (Physician)] for further management. Provider did an assessment and ordered STAT (immediate) X-ray of left leg and hip. Called Mobile service for STAT x-ray and collaborated with facility nurse for pain medication, to start with [as needed] acetaminophen. [Resident #1] was slightly tachycardic in 111-113 beats/minute with oximetry, oxygen saturation initially was 88 % on room air then after repositioning it came up to 93 %. (Tachycardia is a medical condition characterized by a rapid heart rate, typically defined as a resting heart rate of over 100 beats per minute.) Called family for update, to call Hospice and not to wait next time there was a concern. Hospice Nurse #1 was interviewed on 6/10/2025 at 5:20 PM. Hospice Nurse #1 revealed she was the case manager for Resident #1. Hospice Nurse #1 stated that on 5/19/2025 RP #1 sent her a text notifying her that Resident #1 had a fall over the weekend on 5/17/2025. Hospice Nurse #1 revealed she went to the facility, assessed Resident #1, and immediately contacted MD #1 (Physician), who was in the building. MD #1 looked at Resident #1 and ordered a STAT x-ray. Hospice Nurse #1 called mobile x-ray. Hospice Nurse #1 confirmed she asked Nurse #3 about Resident #1's fall on 5/17/2025 but he was unaware of the fall and did not see any documentation in the electronic medical record about the fall. MD #1 (Physician) was interviewed on 6/11/2025 at 8:06 AM and revealed the following information. MD #1 was doing his rounds at the facility on 5/19/2025 when a nurse approached him and asked him to look at Resident #1. MD #1 did an assessment of Resident #1 and noted her left leg was shorter and was externally rotated. MD #1 was certain that Resident #1 had a fracture, so he ordered a STAT x-ray of her left hip and made sure that Resident #1 had pain medication ordered and available. MD #1 requested to be contacted when the results of the x-ray came back for further orders. MD #1 expected a provider to be notified of any acute findings at the time they were available. MD #1 explained that Resident #1 was not one of his patients but for any change in condition; including x-ray results of a fracture, a provider should be notified to obtain additional orders. MD #1 confirmed notification was a key piece in the provision of care. Nurse #3 was interviewed on 6/10/2025 at 2:53 PM and provided the following information. Nurse #3 worked from 7:00 AM to 3:00 PM on 5/19/2025. Nurse #3 was told by Hospice Nurse #1 that Resident #1 had a fall on 5/17/2025 and that MD #1 had ordered a STAT x-ray of her left hip. Documentation on the x-ray results dated 5/19/2025 revealed Resident #1 had sustained an acute impacted left femoral neck fracture. The x-ray results were faxed to the facility at 2:50 PM on 5/19/2025. Nurse #2 was interviewed on 6/10/2025 at 2:38 PM and revealed the following information. Nurse #2 worked from 3:00 PM to 11:00 PM on 5/19/2025. Nurse #2 stated she was not aware at the start of her shift that Resident #1 had a fall over the weekend. Nurse #2 explained that she was also the facility wound care nurse and that at some point in her shift, she went to the fax machine to fax wound care orders. Nurse #2 went through all the faxes that were on the fax machine, and she noted the x-ray results for Resident #1. Nurse #2 did not know anything had happened to Resident #1. Nurse #2, at some point in the shift, went to Resident #1 to ask her why she had an x-ray because she was alert and oriented. Resident #1 told Nurse #2 she fell a few days ago. The on-call provider told Nurse #2 to follow up with the regular provider in the morning. Nurse #2 took her vital signs and did a pain assessment. Nurse #2 was alerted by the nurse aides that Resident #1 was in extreme pain when they turned her for incontinence care. Nurse #2 stated she gave pain medication to Resident #1. Nurse #2 explained that when Resident #1 first arrived at the facility she was weak and could not get up to go to the bathroom. Gradually Resident #1 gained strength and confidence and used her cane to go to the bathroom. Resident #1 was continent of bowel and bladder, but staff had to keep reminding her that she needed to ask for help to go to the bathroom so she would not fall. Nurse #2 noted it was a change for Resident #1 to be incontinent and to be provided with incontinent care by the nurse aides. Nurse #2 called the on-call physician with the x-ray results because it was after hours on 5/19/2025. The on-call provider asked if Resident #1 was stable. Nurse #2 told the on-call provider that Resident #1 was stable and was only in pain when she was moved or turned for incontinent care. Documentation in a nursing progress note dated 5/20/2025 at 12:09 AM written by Nurse #2 revealed the following information. Resident #1 fell a few days ago and was in pain when she was turned from side to side. Resident #1 received medication for breakthrough pain in the left hip area. The left hip x-ray results were received, and Resident #1 was noted to have an acute impacted left femoral hip neck fracture. The after-hours provider was contacted. The after-hours provider stated that if the resident was stable, to follow up in the morning with the nurse practitioner. Nurse #2 was interviewed again on 6/11/2025 at 1:31 PM. Nurse #2 conceded that Nurse #3 may have told her Resident #1 had a fall and to watch out for the x-ray results at the change of shift on 5/19/2025. Nurse #2 reiterated that she became aware of the x-ray results at an unknown time and she had many responsibilities that day as the wound care nurse for the facility. An interview was conducted with NA #6 on 6/11/2025 at 8:57 AM and the following information was provided. NA #6 was assigned to care for Resident #1 on 5/19/2025 from 3:00 PM until 7:00 AM on 5/20/2025. Resident #1 told NA #6 that she fell on Saturday. NA #6 asked her what happened because she was alert and oriented. Resident #1 told him she was trying to go to the bathroom and her foot twisted, and she fell. Resident #1 told NA #6 that a nurse and a nurse aide picked her up and put her in bed. NA #6 asked if RP #1 was called and Resident #1 said no. NA #6 called another nurse aide for help to provide incontinent care for her because she was in pain when she was moved. NA #6 stated he left the room to immediately tell Nurse #2 that Resident #1 had a fall over the weekend and she was in pain. Nurse #2 told NA #6 that there was no documentation in the electronic record of a fall sustained by Resident #1 over the weekend. NA #6 returned to Resident #1's room and told her that if she needed a bed pan to call him because he could not help her out of bed to the bathroom like he usually did. NA #6 said Resident #1 was crying in pain and he had to roll her little by little to provide incontinent care for her. NA #6 revealed he told Nurse #5 that Resident #1 had a fall and was in pain when moved. Nurse #5 was interviewed on 6/11/2025 at 7:27 AM and revealed the following information. Nurse #5 worked the 11:00 PM to 7:00 AM shift that ended on 5/20/2025. Nurse #5 revealed she notified the nurse practitioner in the morning on 5/20/2025 that the x-ray results were received by the facility and Resident #1 had an acute impacted left femoral neck fracture. Documentation in the nursing progress notes dated 5/20/2025 at 7:25 AM written by Nurse #5 revealed the nurse practitioner gave a verbal order to send Resident #1 to the emergency room for a left femoral neck fracture. The documentation on Resident #1's hospital Discharge summary dated [DATE] revealed Resident #1 underwent surgery to repair her femur fracture. An interview was conducted on 6/13/2025 at 1:11 PM with the current interim Director of Nursing (DON), who initiated employment with the facility on 5/27/2025. The DON explained she was made aware of the facility investigation for Resident #1 by the previous Administrator at the start of her employment. The DON stated she expected that the nursing staff would assess a resident who fell, and if there was a serious medical issue to contact the provider and herself. The DON elaborated that each nursing station had directions at the desk for what steps needed to be taken when a resident falls, including assessment, notification of provider, and charting. The facility provided a draft plan of correction for past non-compliance that was not acceptable to the state agency due to a lack of measures put into place for audits and monitoring of compliance.

Based on record review, and staff, resident, responsible party (RP), Hospice Nurse, Physician, and Medical Director interviews, the facility failed to provide ongoing assessments after a fall; failed to identify a change in condition that required medical evaluation and treatment; failed to notify a provider of a change in condition; failed to identify one leg shorter than the other and external leg rotation required medical evaluation and treatment; failed to communicate effectively to provide treatment; and failed to notify a provider of fracture x-ray fax results upon receipt for one (Resident #1) of three residents reviewed for abuse and/or neglect. Resident #1 sustained an acute impacted left femoral neck fracture. (an acute impacted left femoral neck fracture is a break in the upper part of the thigh bone (femur), specifically at the neck, where it connects to the ball of the hip joint). Findings included: This tag is cross referred to: F580: Based on record review, and staff, responsible party (RP), Hospice Nurse, and Physician interviews, the facility failed to notify the provider of a change in condition and x-ray results after a fall for one (Resident #1) of three residents reviewed for notification of falls. Resident #1 fell on 5/17/2025 and the facility failed to notify the provider of pain and a new inability to bear weight. X-ray results obtained midday on 5/19/2025 were not relayed to the on-call provider until after hours on 5/19/2025. Resident #1 sustained an acute impacted left femoral neck fracture. (An acute impacted left femoral neck fracture is a break in the upper part of the thigh bone (femur), specifically at the neck, where it connects to the ball of the hip joint.) F684: Based on record review, and staff, responsible party (RP), resident, Hospice Nurse, Physician, and Medical Director interviews the facility failed to provide ongoing assessments after a fall; failed to identify the change in condition required medical evaluation and treatment; failed to identify one leg shorter than the other and external leg rotation required medical evaluation and treatment; and failed to communicate effectively to provide treatment for one (Resident #1) of three residents reviewed for assessment after a fall. Resident #1 sustained an acute impacted left femoral neck fracture (an acute impacted left femoral neck fracture is a break in the upper part of the thigh bone (femur), specifically at the neck, where it connects to the ball of the hip joint). Findings included:

Based on record review, and staff, responsible party (RP), resident, Hospice Nurse, Physician, and Medical Director interviews the facility failed to provide ongoing assessments after a fall; failed to identify the change in condition required medical evaluation and treatment; failed to identify one leg shorter than the other and external leg rotation required medical evaluation and treatment; and failed to communicate effectively to provide treatment for one (Resident #1) of three residents reviewed for assessment after a fall. Resident #1 sustained an acute impacted left femoral neck fracture (an acute impacted left femoral neck fracture is a break in the upper part of the thigh bone (femur), specifically at the neck, where it connects to the ball of the hip joint). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses of history of cerebral vascular accident, hemiplegia, hemiparesis, and lung cancer. Hemiplegia is paralysis on one side while hemiplegia is weakness on one side of the body. Resident #1 started receiving Hospice services on 3/31/2025. Documentation on an admission Minimum Data Set assessment dated [DATE] revealed Resident #1 had moderately impaired cognition with a range of motion impairment on one side of the upper and lower extremities. Resident #1 was also assessed as using a cane or a wheelchair. Resident #1 was evaluated as always incontinent of bowel and bladder. It was unknown if Resident #1 had a history of falls with no falls since her admission. Documentation on a timesheet for Nurse Aide (NA) #1) reveale she worked at the facility from 7:18 AM to 10:53 PM on 5/17/2025. Documentation on the corresponding nursing schedule revealed NA #1 was assigned to care for Resident #1 during that time period. NA #1 was interviewed on 6/10/2025 at 11:54 AM. NA #1 revealed the following information. Resident #1 had a fall on 5/17/2025. NA #1 heard Resident #1 fall, and she told Nurse #4. Any other information would have to be obtained from Nurse #4 and NA #1 declined to make a statement about whether Resident #1 was in pain. NA #1 insinuated she provided the facility with a statement regarding Resident #1's fall on 5/17/2025. The facility provided a statement handwritten by NA #1 on 5/21/2025 regarding the events of 5/17/2025. The documentation on the statement by NA #1 revealed the following information. NA #1 walked into Resident #1's room to collect the evening meal tray. NA #1 noted Resident #1 stood up with her cane. NA #1 requested Resident #1 to wait for her to set the meal tray down before ambulating. NA #1 turned around and she heard Resident #1 fall. NA #1 called for Nurse #4 who stood over Resident #1. NA #1 asked Nurse #4 what to do. Nurse #4 and NA #1 assisted Resident #1 to rise and placed her in bed. Nurse #4 sat in a chair while NA #1 made Resident #1 comfortable in the bed. Nurse #4 then left the room. Nurse #4 was interviewed on 6/10/2025 at 6:41 PM and revealed the following information. Nurse #4 worked the 7:00 AM to 7:00 PM shift on 5/17/2025. Resident #1 fell on 5/17/2025 while trying to go to the bathroom. Nurse #4 did full range of motion assessments of all her limbs and took the vital signs of Resident #1. Nurse #4, with the assistance of NA #1, helped Resident #1 up off the floor and into her wheelchair. NA #1 wheeled Resident #1 to the bathroom. Resident #1 stood up, pivoted, and sat on the commode. After finishing, Resident #1 stood, pivoted, and sat in the wheelchair. NA #1 then helped Resident #1 back to the bed, where Resident #1 stood, pivoted, and sat on the bed. Nurse #4 was adamant that Resident #1 was fine and in no pain. Nurse #4 was so busy with a new admission, helping residents eat, changing incontinence briefs, and administering medications that she was not able to document anything in the electronic medical record. Nurse #4 also stated that she forgot to document or notify anybody about the fall but, Resident #1 was without injury or pain after the fall on 5/17/2025. The facility provided a statement handwritten by Nurse #4 on 5/21/2025 regarding the events of 5/17/2025. The documentation on the statement revealed the following information. Nurse #4 was called to Resident #1's room by NA #1 because the resident had fallen. When Nurse #4 arrived, Resident #1 was sitting up against the nightstand by her bed. Resident #1 stated that she fell while going to the bathroom. Resident #1 had one leg flat, and one leg off the floor. Nurse #4 asked Resident #1 to move her arms and legs and she complied. Nurse #4 took the vital signs of Resident #1. NA #1 assisted Resident #1 into the wheelchair and took her to the bathroom. Resident #1 stood up holding onto the rail in the bathroom and NA #1 put her back into the wheelchair. NA #1 assisted Resident #1 back into bed. Resident #1 did not complain of pain. There was no documentation in Resident #1's electronic medical record of any fall, assessments, or notification of physician or family on 5/17/2025 for the 7:00 AM to 7:00 PM shift. Resident #1 was interviewed over the phone on 6/11/2025 at 3:31 PM. Resident #1 confirmed she remembered what happened when she fell on 5/17/2025 in the evening. Resident #1 stated she was going to the bathroom with her cane when her foot twisted causing her to fall. Resident #1 added that eventually someone came to assist her but not right away. Resident #1 stated she was picked up off the floor and placed back into bed. Resident #1 indicated the nurse did not do any assessment of her arms or legs nor take any vital signs. Resident #1 denied she was taken to the bathroom after the fall. Resident #1 was able to confirm the fall caused her pain but was not able to elaborate on that. Nurse #2 was interviewed on 6/10/2025 at 2:38 PM. Nurse #2 confirmed she worked from 7:00 PM to 11:00 PM on 5/17/2025. Nurse #2 stated she had no knowledge on 5/17/2025 that Resident #1 had fallen on the previous shift. Nurse #2 stated that she did recall that Resident #1 took her nighttime medication, had no complaints, and went to sleep. Documentation on the physician orders revealed Resident #1 had an order initiated on 4/8/2025 for 5 milligrams (mg) of Oxycodone to be administered as one tablet by mouth every 4 hours as needed for moderate pain at a level of 4 to 6 out of 10. Oxycodone is a prescription opioid pain medication used to relieve severe pain. Documentation on a controlled drug record for Resident #1 revealed Nurse #2 removed one dose of the ordered oxycodone at 9:15 PM on 5/17/2025. There was no corresponding documentation on the MAR to confirm the dose was administered to Resident #1. Nurse #2 was interviewed again on 6/11/2025 at 1:31 PM. Nurse #2 revealed the nurse aides came to her to tell her on 5/17/2025 that Resident #1 was in pain when they provided care. Nurse #2 confirmed she gave Resident #1 her ordered oxycodone pain medication at her request. Nurse #5 was interviewed on 6/11/2025 at 7:27 AM. Nurse #5 confirmed she worked the 11:00 PM to 7:00 AM shift beginning on 5/17/2025 and ending on 5/18/2025. Nurse #5 stated she was not informed on 5/17/2025 that Resident #1 had a fall earlier that evening. Nurse #5 indicated Resident #1 slept and had no complaints on her shift ending on the morning of 5/18/2025. Documentation on a timesheet for NA #1 revealed she worked at the facility from 8:31 AM to 3:10 PM on 5/18/2025. Documentation on the corresponding nursing schedule revealed NA #1 was assigned to care for Resident #1 during that time. An interview was conducted with the Responsible Party (RP #1) for Resident #1 on 6/10/2025 at 2:06 PM. RP #1 provided the following information. RP #1, her husband, and her children went to visit Resident #1 on the morning of 5/18/2025. RP #1 barely got down the hallway when she was stopped by NA #1. NA #1 explained that she had not yet assisted Resident #1 out of bed and to get dressed. NA #1 said she knew that RP #1 would like to take Resident #1 outside. NA #1 then told RP #1 that Resident #1 fell yesterday (5/17/2025) but she was fine. RP #1 remarked to NA #1 that nobody had called to tell her about the fall. RP #1 went to see Resident #1 and to ask her about the fall. RP #1 stated that she and her husband were trying to help Resident #1 to get up, but it seemed like she was in pain, and she could not bear any weight. This was a change for Resident #1 because although she was weak on her left side she had always been able to stand. RP #1 revealed she assisted Resident #1 in dressing and then asked her about the fall she had on the previous day. Resident #1 told RP #1 that she was trying to get to the bathroom, and she twisted her left foot and fell. Resident #1 told RP #1 she did not hit her head. Resident #1 told RP #1 that a nurse and a nurse aide put her back into bed. RP #1 indicated Resident #1 seemed very sore and was protecting her left side. RP #1 stated she and her husband took Resident #1 to the bathroom, but Resident #1 was not able to stand or bear any weight. RP #1 indicated Resident #1 required her husband to pick her up and hold her to get on and off the toilet and back into the wheelchair. RP #1 then went to the nurse's desk and spoke to Nurse #4. RP #1 told Nurse #4 that Resident #1 told her she fell last night and she was now in pain. RP #1 said Nurse #4 acted like she didn't know what RP #1 was talking about. Nurse #4 told RP #1 that Resident #1 had not mentioned anything about a fall or pain to her. Nurse #4 stated she would check and see if Resident #1 fell last night and confirmed she did not see anything about a fall in the electronic medical record. Nurse #4 went down to Resident #1's room and gave her pain medication but did not do any assessment or do anything else for Resident #1. RP #1 revealed she told Nurse #4 that Resident #1 was unable to bear weight on her left side and Nurse #4 kept acting like she didn't know what she was talking about or with any concern. Resident #1 told RP #1 that Nurse #4 was the nurse who was in the room last night after the fall. RP #1 did take Resident #1 outside to get some air but Resident #1 seemed very sore anytime they moved her, and she required more assistance than usual. Nurse #4 was interviewed on 6/10/2025 at 6:41 PM. Nurse #4 confirmed she worked the 7:00 AM to 7:00 PM shift on 5/18/2025. Nurse #4 stated that RP #1 came to the desk on the morning of 5/18/2025 and told her Resident #1 was having back pain. Nurse #4 stated that Resident #1's fall that occurred on 5/17/2025 was not discussed at all with RP #1. Nurse #4 stated that Resident #1 was not injured so there was no reason to tell RP #1 about the fall. Nurse #4 confirmed she administered an ordered dose of Oxycodone to Resident #1 on the morning of 5/18/2025. Documentation on the medication administration record (MAR) revealed Nurse #4 administered an ordered dose of Oxycodone to Resident #1 on 5/18/2025 at 10:47 AM for a pain level of 8 out of 10. Nurse #6 was interviewed on 6/11/2025 at 9:07 AM. Nurse #6 confirmed she worked on 5/18/2025 from 7:00 PM to 11:00 PM. Nurse #6 stated she did not know on 5/18/2025 that Resident #1 fell on 5/17/2025. Nurse #6 stated Resident #1 did not complain of any pain, nor did she have any complaints at all on 5/18/2025 on her shift. Nurse #5 was interviewed on 6/11/2025 at 7:27 AM. Nurse #5 confirmed she worked the 11:00 PM to 7:00 AM shift beginning on 5/18/2025 and ending on 5/19/2025. Nurse #5 revealed she was unaware on her shift that began on 5/18/2025 that Resident #1 had a fall the previous day on 5/17/2025. Nurse #5 stated that Resident #5 was sleeping during that shift and did not complain of any pain. RP #1 was interviewed on 6/10/2025 at 2:06 PM and revealed the following information. On the morning of 5/19/2025 RP #1 had concerns for Resident #1, so she sent a text message to Hospice Nurse #1 first thing in the morning. RP #1 told Hospice Nurse #1 that Resident #1 had a fall on 5/17/2025 and she was in pain. Hospice Nurse #1 told RP #1 that Resident #1 was the first person she would visit that day. RP #1 could see on 5/19/2025 in a video call to Resident #1 that she was in a lot of pain and was guarding her left side. Documentation in a Hospice Nurse as needed visit note dated 5/19/2025 at 1:46 PM revealed, Received message from [RP #1] that [Resident #1] had a fall over the weekend. Arrived [Resident #1's] room, [Resident #1] was sleeping. Called out her name and [Resident #1] woke up without difficulty. Asked [Resident #1] about the fall, [Resident #1] narrated saying, I called for someone to help me to bathroom, but no one came, I did not want to pee on myself, so I got up using my cane, but my left foot got caught and I tripped over and fell on my left side. I lay there until an aide came to help me up. [Resident #1] had an unwitnessed fall on Saturday 5/17/2025, consulted facility nurse for details but [Nurse #3] stated that he had no report of the fall from previous shift. Since then, she has complained of pain of 5 to 8 on numerical scale. [Resident #1] able to assist in turning, but pain prohibits turning to left side of body. [Resident #1] left leg and foot had no bruising, swelling, or hotness. [Resident #1] left side is the weak side from history of [Cerebral Vascular Accident]. Asked the facility provider [MD #1 (Physician)] for further management. Provider did an assessment and ordered STAT (immediate) X-ray of left leg and hip. Called Mobile service for STAT x-ray and collaborated with facility nurse for pain medication, to start with [as needed] acetaminophen. [Resident #1] was slightly tachycardic in 111-113 beats/minute with oximetry, oxygen saturation initially was 88 % on room air then after repositioning it came up to 93 %. (Tachycardia is a medical condition characterized by a rapid heart rate, typically defined as a resting heart rate of over 100 beats per minute.) Called family for update, to call Hospice and not to wait next time there was a concern. Hospice Nurse #1 was interviewed on 6/10/2025 at 5:20 PM. Hospice Nurse #1 revealed she was the case manager for Resident #1. Hospice Nurse #1 stated that on 5/19/2025 RP #1 sent her a text notifying her that Resident #1 had a fall over the weekend on 5/17/2025. Hospice Nurse #1 revealed she went to the facility, assessed Resident #1, and immediately contacted MD #1 (Physician), who was in the building. MD #1 looked at Resident #1 and ordered a STAT x-ray. Hospice Nurse #1 called mobile x-ray. MD #1 (Physician) was interviewed on 6/11/2025 at 8:06 AM and revealed the following information. MD #1 was doing his rounds at the facility on 5/19/2025 when a nurse approached him and asked him to look at Resident #1. MD #1 did an assessment of Resident #1 and noted her left leg was shorter and was externally rotated. MD #1 was certain that Resident #1 had a fracture, so he ordered a STAT x-ray of her left hip and made sure that Resident #1 had pain medication ordered and available. MD #1 requested to be contacted when the results of the x-ray came back for further orders. Nurse #3 was interviewed on 6/10/2025 at 2:53 PM and provided the following information. Nurse #3 worked from 7:00 AM to 3:00 PM on 5/19/2025. Nurse #3 was told by Hospice Nurse #1 that Resident #1 had a fall on 5/17/2025 and that MD #1 had ordered a STAT x-ray of her left hip. Nurse #3 stated that Hospice Nurse #1 contacted the mobile x-ray, and the x-ray was taken on his shift on the morning of 5/19/2025. Resident #1 was in pain on his shift, and he gave her pain medication. Nurse #3 stated that he notified Nurse #2, the next shift nurse, that Resident #1 had a fall and the facility was still waiting on the x-ray results. Documentation on a controlled drug record for Resident #1 revealed Nurse #3 removed one dose of the ordered Oxycodone at 9:00 AM on 5/19/2025 and another dose at 2:00 PM on 5/19/2025. There was no corresponding documentation on the MAR to confirm the dose was administered to Resident #1. NA #3 was interviewed on 6/10/2025 at 1:04 PM and revealed the following information. NA #3 was assigned to care for Resident #1 on 5/19/2025 for the 7:00 AM to 3:00 PM shift. NA #3 had not worked that weekend, but when he came back to work on 5/19/2025 he had heard Resident #1 had a fall. NA #3 stated Resident #1 was in pain, and he told Nurse #3 she was in pain. NA #3 stated that every time he turned Resident #1 for incontinent care, she was in pain, and it was hard. NA #3 stated he had to talk Resident #1 through it. Resident #1 didn't want to turn because she was in pain. Documentation on the x-ray results dated 5/19/2025 revealed Resident #1 had sustained an acute impacted left femoral neck fracture. The x-ray results were faxed to the facility at 2:50 PM on 5/19/2025. Nurse #2 was interviewed on 6/10/2025 at 2:38 PM and revealed the following information. Nurse #2 worked from 3:00 PM to 11:00 PM on 5/19/2025. Nurse #2 stated she was not aware at the start of her shift that Resident #1 had a fall over the weekend. Nurse #2 explained that she was also the facility wound care nurse and that at some point in her shift she went to the fax machine to fax wound care orders. Nurse #2 went through all the faxes that were on the fax machine, and she noted the x-ray results for Resident #1. Nurse #2 did not know anything had happened to Resident #1. Nurse #2, at some point in the shift, went to Resident #1 to ask her why she had an x-ray because she was alert and oriented. Resident #1 told Nurse #2 she fell a few days ago. Nurse #2 took her vital signs and did a pain assessment. Nurse #2 was alerted by the nurse aides that Resident #1 was in extreme pain when they turned her for incontinence care. Nurse #2 stated she gave pain medication to Resident #1. Nurse #2 explained that when Resident #1 first arrived at the facility she was weak and could not get up to go to the bathroom. Gradually Resident #1 gained strength and confidence and used her cane to go to the bathroom. Resident #1 was continent of bowel and bladder, but staff had to keep reminding her that she needed to ask for help to go to the bathroom so she would not fall. Nurse #2 noted it was a change for Resident #1 to be incontinent and to be provided with incontinent care by the nurse aides. Nurse #2 called the on-call physician with the x-ray results because it was after hours on 5/19/2025. The on-call provider asked if Resident #1 was stable. Nurse #2 told the on-call provider that Resident #1 was stable and was only in pain when she was moved or turned for incontinent care. The on-call provider told Nurse #2 to follow up with the regular provider in the morning. Nurse #2 was interviewed again on 6/11/2025 at 1:31 PM. Nurse #2 conceded that Nurse #3 may have told her Resident #1 had a fall and to watch out for the x-ray results at the change of shift on 5/19/2025. Nurse #2 reiterated that she became aware of the x-ray results at an unknown time and she had many responsibilities that day as the wound care nurse for the facility. Documentation in a nursing progress note dated 5/20/2025 at 12:09 AM written by Nurse #2 revealed the following information. Resident #1 fell a few days ago and was in pain when she was turned from side to side. Resident #1 received medication for breakthrough pain in the left hip area. The left hip x-ray results were received, and Resident #1 was noted to have an acute impacted left femoral hip neck fracture. The after-hours provider was contacted. The after-hours provider stated that if the resident was stable, to follow up in the morning with the nurse practitioner. Documentation on a controlled drug record for Resident #1 revealed Nurse #2 removed one dose of the ordered Oxycodone at 9:15 PM on 5/19/2025. There was no corresponding documentation on the MAR to confirm the dose was administered to Resident #1. An interview was conducted with NA #6 on 6/11/2025 at 8:57 AM and the following information was provided. NA #6 was assigned to care for Resident #1 on 5/19/2025 from 3:00 PM until 7:00 AM on 5/20/2025. Resident #1 told NA #6 that she fell on Saturday. NA #6 asked her what happened because she was alert and oriented. Resident #1 told him she was trying to go to the bathroom and her foot twisted, and she fell. Resident #1 told NA #6 that a nurse and a nurse aide picked her up and put her in bed. NA #6 asked if RP #1 was called and Resident #1 said no. NA #6 called another nurse aide for help to provide incontinent care for her because she was in pain when she was moved. NA #6 stated he left the room to immediately tell Nurse #2 that Resident #1 had a fall over the weekend and she was in pain. Nurse #2 told NA #6 that there was no documentation in the electronic record of a fall sustained by Resident #1 over the weekend. NA #6 returned to Resident #1's room and told her that if she needed a bed pan to call him because he could not help her out of bed to the bathroom like he usually did. NA #6 said Resident #1 was crying in pain and he had to roll her little by little to provide incontinent care for her. NA #6 revealed he told Nurse #5 that Resident #1 had a fall and was in pain when moved. Nurse #5 was interviewed on 6/11/2025 at 7:27 AM and revealed the following information. Nurse #5 worked the 11:00 PM to 7:00 AM shift that ended on 5/20/2025. On the last rounds where the nurse aides provided incontinence care to the residents, one of the nurse aides came to Nurse #5 and told her Resident #1 was grimacing when she was moved during care. Nurse #5 stated she knew Resident #1 had an order for Oxycodone because she was receiving Hospice services. Nurse #5 revealed she offered a dose of Oxycodone to Resident #1, but she refused. The dose of Oxycodone was not administered to Resident #1, and it was wasted. Documentation on the MAR revealed Nurse #5 administered a dose of Oxycodone to Resident #1 on 5/20/2025 at 5:49 AM for a pain level of 10 out of 10. Documentation on the controlled drug record for ordered Oxycodone for Resident #1 dated 5/20/2025 revealed the Oxycodone dose offered by Nurse #5 was refused. Documentation in the nursing progress notes dated 5/20/2025 at 7:25 AM written by Nurse #5 revealed the nurse practitioner gave a verbal order to send Resident #1 to the emergency room for a left femoral neck fracture. The nurse practitioner, whose employment ended on 5/30/2025, did not respond to requests for an interview. Documentation in the nursing progress notes written as a late entry on 5/20/2025 at 7:43 AM by Nurse #3 for 5/19/2025 revealed Resident #1 had an x-ray completed due to complaints of increased pain in the left thigh. Documentation on an Emergency Medical Services record dated 5/20/2025 at 7:54 PM revealed Resident #1 received non-emergent transport to the hospital. Resident #1 was noted to only be in pain when moved and declined pain medication during transport. The documentation on Resident #1's hospital Discharge summary dated [DATE] revealed Resident #1 underwent surgery to repair her femur fracture. It was noted that a non-operative femur fracture would have led to significant pain in the long term. Resident #1 was to return to the facility. An interview was conducted with RP #2 on 6/10/2025 at 11:31 AM. RP #2 stated that when Resident #1 was released from the hospital and she returned to the facility the resident cried every day because she was scared. RP #2 explained that the hospital was not able to secure another bed in another facility prior to her discharge. An interview was conducted with RP #1 on 6/10/2025 at 2:06 PM. RP #1 stated that x-ray results revealing Resident #1 had a fracture were not conveyed to her until 5/20/2025. RP #1 had the concern that Resident #1 was in pain until a transfer to the hospital. RP #1 revealed on 5/23/2025 she contacted the facility to express her opinion that Nurse #4 was neglectful. RP #1 confirmed that Resident #1 was not happy about returning to the facility, but the hospital was unable to find another facility at the time of her discharge from the hospital. Documentation in a care plan for Resident #1 updated on 5/28/2025 revealed a focus area for a risk for falls related to disease process, generalized weakness, contractures, history of cerebral vascular accident, incontinence, and medication side effects with an actual fall on 5/19/2025. The approach added on 5/28/2025 was for Resident #1 to be reminded to call for assistance with transfers. Documentation in the electronic medical record revealed Resident #1 was transferred to another facility on 6/6/2025. The previous Administrator, whose employment at the facility ended on 6/6/2025, did not respond to requests for an interview. The facility Medical Director, was interviewed on 6/11/2025 at 8:06 AM via telephone. The Medical Director revealed that after looking at the electronic medical record he was able to see that Resident #1 had no complaints of pain and received very little pain medication from 5/17/2025 to 5/19/2025. The Medical Director conceded that the documentation for the fall on 5/17/2025 was poor. The Medical Director stated that perhaps Resident #1 had an underlying issue due to paralysis on her left side that delayed her expressing pain and required treatment. The Medical Director also indicated that he was aware the family had transferred Resident #1 to the bathroom on the morning of 5/18/2025 and may have caused injury to the resident. The Medical Director felt the x-ray being completed by 5/19/2025 and Resident #1 being sent to the hospital for treatment of the fracture on 5/20/2025 was an appropriate time frame for a resident on Hospice who was not expressing any pain. The Medical Director praised the Hospice services for assuring Resident #1 received assessment and treatment. An interview was conducted on 6/13/2025 at 1:11 PM with the current interim Director of Nursing (DON), who initiated employment with the facility on 5/27/2025. The DON explained she was made aware of the facility investigation for Resident #1 by the previous Administrator at the start of her employment. The DON stated she expected that the nursing staff would assess a resident who has had a fall and if there was a serious medical issue to contact the provider and herself. In addition, the DON had the expectation that an attempt would be made to contact the family of a resident who had fallen. The DON elaborated that each nursing station had directions at the desk for what steps needed to be taken when a resident falls, including assessment, notification of provider, and charting. The DON also stated that she expected communication to occur between nurses to make sure x-ray results were conveyed to a provider as soon as received. The facility provided a draft plan of correction for past non-compliance that was not acceptable to the state agency due to a lack of measures put into place for communication between nursing shifts, education of expectations for nurse aides, audits, and monitoring of compliance.

Based on record review and interviews with staff and the Physician Assistant, the facility to protect Resident #1's right to be from a suspicious injury for 1 of 1 resident sampled for abuse (Resident #1). Resident #1 told staff he was hit in the eye and was later discovered with a bruise around the left eye. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance and Alzheimer's disease. A review of a quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1's cognition was severely impaired for daily decision making and required total assistance with activities of daily living. There were no behaviors documented on the behavior monitoring sheet on 1/7/23. An interview was conducted on 2/1/23 at 8:45 AM. The Transportation Staff stated Resident #1 returned from his appointment between 1:00 PM-1:30 PM on 1/7/23. Resident #1 was placed in bed after the completion of his lunch meal. Resident #1 did not exhibit any behaviors, nor did he have any injuries when he returned from his appointment. An interview was conducted on 1/31/23 at 3:17 PM, Nurse #3 stated she had worked the 3-11 PM shift on 1/7/23. She recalled she had observed Nurse Aide #4 using a lift with Resident #1. Nurse #3 did not state she observed Resident #1 combative in the lift when she walked by the room to go to her car. She said Resident #1 did not require transfer by a mechanical lift. The resident had already been placed in bed. She spoke with Nurse Aide #4 about not using the lift with Resident #1. Nurse #3 indicated she was notified by Nurse Aide #4 that Resident #1 was combative and fighting to get out of the lift. She checked on the resident between 6:00 PM-7:00 PM. She saw Resident #1's left eye was red and swollen at the bottom of the eye. She stated she asked the resident several questions about what happened. Initially, the resident did not respond. When asked if he was hit, he said, Yes. He was asked if it was a female, he said, Yes, she hit me in the eye. Nurse #3 stated she did not ask Resident #1 any other questions because she wanted to speak with the staff who worked with him on the previous shift (7AM-3PM). Nurse #3 did not state why Res #1 was agitated and wanted to be alone. Nurse #3 further stated she did not discuss the observation or incident with Nurse Aide #4 or the supervisor on duty. When asked was a head-to-toe assessment, incident report, nursing note about her observation or the statement made by the resident statement, the response was it was not done until 1/8/23. There was no nursing documentation in the nursing notes or on any other form that Resident #1 had any concerns. There was no notation of observation of Resident #1's face on 1/7/23. The 24-hour shift report for 1/7/23 revealed there was no documentation of Resident #1's condition or behaviors on the 3-11 PM or 11-7AM shifts. An interview was conducted on 1/31/23 at 1:22PM. Nurse Aide #3 stated she had worked with Resident #1 on first shift, Saturday, 1/7/23 and he did not have any injuries. When she arrived on Sunday morning 1/8/23 to provide care to the resident around 7:30 AM, she noticed the Resident #1 had a left black eye. Nurse Aide #3 stated Resident #1 told her he had been punched in the eye by staff. She stated she was unsure what happened, so she went to Nurse #3 and reported what she had found. Resident #1 had no injuries when he returned from his dialysis appointment on 1/7/23 around 1:00-1:30 PM and when she left her shift. A nursing note dated 1/08/2023 at 11:37 PM was reviewed. Nurse #3 documented Resident #1 was observed with a left black eye. Resident #1 told her he was hit in the eye. The Director of Nursing (DON) was made aware and 911 was called. Nurse #3 was in room when a police officer questioned the resident. Resident #1 had no complaint of pain or discomfort. Resident #1 was very agitated and wanted to be left alone. The facility 24-hour shift report for 1/8/23 on the 7AM-3 PM shift indicated there was documentation Resident #1 had a left black eye. The body audit form dated 1/8/23, revealed discoloration of left eye. There was no timeframe for when the assessment was done or a description of the discoloration by Nurse #3. An interview was conducted on 1/31/23 at 3:30 PM, Nurse #5 stated she received a call from Nurse #3 the morning of 1/8/23, she could not recall exact time. Nurse #3 stated that Resident #1 had a black eye and the resident had reported being hit in the face by staff on 1/7/23. Nurse #3 also reported Resident #1 had been combative during the evening shift per Nurse Aide #4. Nurse Aide #4 was using a mechanical lift alone on Resident #1 that should not have been used. Nurse #5 stated Nurse #3 stated Resident #1's eye was red and swollen during her observation on 1/7/23. A telephone interview was conducted on 1/31/23 at 3:55 PM, Nurse #4 stated he was the supervisor on the 3-11 PM shift on 1/7/23 on a different floor. He was unaware Resident #1 reported he had been hit by staff and that Resident #1's eye had been injured. Nurse #3 did not inform him of the situation. A telephone interview was conducted on 1/31/23 at 3:45 PM, the Nurse Aide #4 stated she received a call from Nurse #4 and Nurse #5 asking questions about Resident #1's black eye. Nurse Aide #4 stated when she left the shift, Resident #1 did not have any injuries. Nurse Aide #4 stated she was using the mechanical lift when the resident became combative as she was putting the resident to bed. Nurse Aide #4 stated Nurse #3 was informed of the behaviors and Nurse #3 proceeded to informed her that the lift should not have been used for this resident. Nurse Aide #4 stated there might have been a possibility the strap from the lift could have hit the resident in the face during his combativeness, but she was not certain this was the case. When she left her shift, the resident was asleep and there was nothing on the resident's face. An interview was conducted on 1/31/23 at 4:42 PM. The Director of Nursing (DON) stated she had not received a call from the 3- 11 PM nursing staff on 1/7/23 when Nurse #3 observed the condition of Resident #1's eye. She further stated Nurse #3 spoke with her around 9:00 AM on 1/8/23 and informed her that Resident #1 reported he had been hit in the eye by staff on 1/7/23 and the left eye discoloration was red/dark and swollen. An interview was conducted on 1/31/23 at 4:50 PM. The Administrator stated she was unaware the incident occurred on 1/7/23. She was informed on 1/8/23 that the resident reported being hit by staff resulting in a black eye. An interview was conducted on 2/1/23 at 11:19 AM. The Physician Assistant (PA) stated she assessed Resident #1 on 1/9/23. Resident #1 was unable to state what happened. There was a circular bruise around the left eye, she was unable to determine if it was trauma related or abuse due to the lapse of time from the initial injury. The Administrator was notified of the Immediate Jeopardy on 2/15/23 at 7:09 AM. The facility provided the following corrective action plan with a completion date of 1/16/23. Problem identified: On 1/7/23 Resident # 1 sustained an injury of unknown origin, a red and swollen left eye. Immediate Action: Resident # 1 sustained an injury of unknown origin, a red and swollen left eye on 1/7/2023. The Certified Nursing Assistant assigned to Resident #1 was suspended on 1/8/2023 and terminated on 1/16/23, she did not work between 1/8/23 and 1/16/23. 2.Other residents with potential to be affected. All residents have the potential to be free from injures of unknown origin. On 1/8/23 the Unit Coordinator completed skin observations on four non-interviewable residents on the C.N.A assignment and did not identify any new skin impairments of the residents. On 1/8/23 Nineteen Residents assigned to the Certified Nursing Assistant (C.N.A) were interviewed by the Unit Coordinator on 1/8/2023 regarding abuse, the questions asked of the resident included Do you feel safe, have you ever been abuse, have you seen anyone else be abused, and do you have any concerns. Eighteen of the residents stated they had no concerns, and one resident stated the alleged C.N.A was rough during care. The week of 1/8/2023 the Director of Nursing and/or the Licensed Nurses completed skin observation on all residents residing in the facility with no other injury of unknown origins noted. Systemic Changes: On 1/8/23 the Director of Health Services and/or Nurse Managers began education to all staff on Prevention of Abuse and Neglect with focus on no tolerance for injuries of unknown origin. This education has been added (enhanced) in the general orientation of all staff newly hired. Employees not educated by 1/16/23 will be educated prior to their next scheduled shift. All newly hired employees continue to be educated in general orientation by the Director of Nursing / Clinical Competency Coordinator or Human Resource Director regarding all residents have the right to be free of injuries of unknown origin and the facility has a zero tolerance for abuse. Beginning 1/8/23 this education is now completed quarterly versus annually within the facility for all staff members. The Director of Nursing reviews of the Skin Observations will be completed weekly for four weeks them monthly thereafter until three months of sustained compliance is maintained, then quarterly thereafter. On 1/8/23 the Director of Nursing and /or Nurse Managers notified the Licensed Nurses that as they complete the weekly skin observation and a new skin impairment is identified (injury of unknown origin), the Director of Health Services is notified at the time of identification. The Director of Nursing is reviewing the skin observations for completion weekly to ensure all resident's skin observation has been completed. The Director of Nursing reviews of the Skin Observations will be completed weekly for four weeks them monthly thereafter until three months of sustained compliance is maintained, then quarterly thereafter. Quality Assurance The Director of Nursing presented an analysis of the Resident Abuse questionnaire to the Quality Assurance and Performance Improvement Committee on 1/25/23 and monthly thereafter until three months of sustained compliance then quarterly thereafter. The Director of Health Services presented an analysis of the skin observation review to the Quality Assurance and Performance Improvement Committee on 1/25/23 and monthly thereafter until three months of sustained compliance then quarterly thereafter. The Clinical Competency Coordinator will present the analysis of the prevention of injuries of unknown education / employee to the Quality Assurance and Performance Improvement Committee monthly until three months of sustained compliance then quarterly thereafter. The Administrator decided to address the F 600 citation in the Ad Hoc Quality Assurance and Performance Improvement was made on 1/16/23 after the investigation related to the event was completed. Completion dated 1/16/23. The Credible Allegation was validated on 2/17/23 when staff interviews, revealed that they had received recent education on the Abuse policy and procedures, resident rights to be free from injuries of unknown origin. The education included documentation and reporting to management immediately when they become aware of reported, suspected abuse and/or injury. Staff were also educated on the assessment and daily checks of resident skin impairments during personal care, using the body audit form. The body audit form would provide the location of the skin impairment with staff circling the area on the diagram. The body audits for include measurements and description of the noted area. Nurse Aide must submit the report daily to the Nurse/Unit Manager immediately. The Nurse would review the body audit daily to be placed in the physician and wound care notebook for further evaluation. The Unit Manager would review the body audit forms weekly to ensure all skin impairments and/or injuries were reviewed by the physician and/or wound care nurse. The report would be submitted to the Director of Nursing and the Administrator. Facility documentation revealed staff were trained on the following topics: Abuse policy and procedures, resident right education and interviewing for abuse, nurse notification and assessment, body audit forms and physician notification of injury unknown origin Attestations were signed by trained staff for the verbal education that was provided. Staff indicated they were trained prior to working in the facility for their next shifts. Newly hired staff received an in-service packet prior to working and this was verified by the facility trainers and orientation form. The facility deficiency was corrected on 1/16/23.

Based on record review and interviews with staff and the Physician Assistant (PA), the facility failed to report an allegation of abuse to the administrator immediately per policy, assess Resident #1 when the left eye was observed to be red and swollen, assess other residents who were under the care of Nurse Aide #4, and protect all residents from physical abuse by allowing Nurse Aide #4 to continue working the entire shift. This deficient practice was discovered for one of one resident sampled for abuse, however the deficient practice had the high likelihood to impact multiple residents. The findings included: Review of the abuse policy dated 9/2022 revealed, in part, under procedure, anyone witnessing, suspecting, or hearing an allegation of mental, physical, verbal, or sexual abuse, neglect or exploitation of any resident will immediately report this to the Administrator whether the Administrator is on the premises or not. The Administrator will immediately begin an investigation and implement measures necessary to assure the safety and protection of the resident from the actual or alleged perpetrator. Under procedure: 8. If the alleged perpetrator(s) is a staff member of the home, the Administrator will place them on administrative leave until a determination of the allegation is made. Confirmed allegation shall result in termination with notification to appropriate boards, registries and agencies and the police as appropriate. Resident #1 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance and Alzheimer's disease. A quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #1's cognition was severely impaired for daily decision making and required total assistance with activities of daily living. There were no behaviors documented on the behavior monitoring sheet on 1/7/23. There was no documentation on the facility's 24-hour shift report dated 1/7/23 that Resident #1 reported an allegation that he had been hit in the face by staff on the 3-11 PM or 11-7 AM shifts to Nurse #3. The nursing notes dated 1/7/23 did not included documentation, that Resident #1 reported to Nurse #3 he was hit in the face or a description of the condition of Resident #1's eye. There was no documentation of the time Resident #1 reported the allegation to Nurse #3. There was no documentation in the nursing noted that Nurse #3 reported the allegation to the shift supervisor or contact the Director of Nursing and Administrator. The 24-hour report to the State Agency dated 1/8/23 documented under allegation description, Resident #1 had discoloration to the eye and stated nurse aide from previous day hit him. The report was submitted as an injury of unknown origin. The 5-day report was submitted for an injury of unknown on 1/13/23, not for an abuse allegation. An interview was conducted on 1/31/23 at 3:17 PM. Nurse #3 stated she had worked the 3-11 PM shift on 1/7/23. She recalled she had observed Nurse Aide #4 using a lift with Resident #1. Nurse #3 had not observed Resident #1 combative in the lift when she walked by the room to go to her car. She said Resident #1 did not require transfer by a mechanical lift. The resident had already been placed in bed. She spoke with Nurse Aide #4 about not using the lift with Resident #1. Nurse Aide #4 notified Nurse #3 that Resident #1 was combative and fighting to get out of the lift. She checked on the resident between 6:00 PM-7:00 PM. She saw Resident #1's left eye was red and swollen at the bottom of the eye. She asked the resident several questions about what happened. Initially, the resident did not respond. When asked if he was hit, he said, Yes. He was asked if it was a female. He said, Yes, she hit me in the eye. Nurse #3 stated she did not ask Resident #1 any other questions because she wanted to speak with the staff who worked with him on the previous shift (7AM-3PM). Nurse #3 did not state why Resident #1 was agitated and wanted to be alone. Nurse #3 did not discuss the observation or incident with Nurse Aide #4 or the supervisor on duty. When asked was a head-to-toe assessment, incident report, nursing note about her observation or a statement made by the resident, the response was, it was not done until 1/8/23. When asked why she had not notified the Supervisor-on-Duty, contacted the Director of Nursing or the Administrator, Nurse #3 stated she did not want to put herself or the resident in danger. A nursing note written by Nurse #3 and dated 1/08/2023 at 11:37 PM revealed Nurse #3 observed Resident #1 with a left black eye. Resident #1 told Nurse #3 that he was hit in the eye. The Director of Nursing (DON) was made aware and 911 was called. Nurse #3 was in the room when the police officer questioned the resident. Resident #1 had no complaint of pain or discomfort. Resident #1 was very agitated and wanted to be left alone. An interview was conducted on 1/31/23 at 3:30 PM. Nurse #5 stated she received a written statement from Nurse #3 on 1/8/23 stating Resident #1's left eye was red, and the resident was hit by staff. Nurse #3 did not say anything to Nurse Aide #4. She did not want to put herself and resident in danger. Nurse #3 spoke with Nurse Aide #3 at 7:40 AM who worked with Resident #1 on previous shift and stated Resident #1 did not have any injury when he returned from his appointment. Nurse #3 proceeded to call the Director of Nursing, 911 and the Responsible Person. Nurse #5 stated she had contacted Nurse #4 the shift supervisor who worked on 1/7/23. He was asked if he was aware of Resident #1's black eye. Nurse #5 and Nurse #4 obtained a telephone interview on 1/8/23 from Nurse Aide #4. Nurse Aide #4 reported Resident #1 was fighting/combative and she was not sure Resident #1 was scratched. This was the first time she had used the lift on the resident and did not know the lift should not have been used. Nurse Aide #4 further stated the lift strap may have hit the resident in the face as he pulled it toward himself. A telephone interview was conducted on 1/31/23 at 3:45 PM. Nurse Aide #4 stated she received a call on 2/1/23, no time was reported. Nurse #4 and Nurse #5 asked questions about Resident #1's black eye. Nurse Aide #4 stated when she left the shift Resident #1 did not have any injuries. Nurse Aide #4 stated she was using the mechanical lift when the resident became combative as she was putting the resident to bed. Nurse Aide #4 stated Nurse #3 was informed of the behaviors and Nurse #3 proceeded to inform her that the lift should not have been used for this resident. Nurse Aide #4 stated there might have been a possibility the strap from the lift could have hit the resident in the face during his combativeness, but she was not certain this was the case. When she left her shift the resident was asleep and there were no marks on the resident's face. A telephone interview was conducted on 1/31/23 at 3:55 PM, Nurse #4 stated he was the Supervisor on the 3-11PM shift on 1/7/23 on a different floor. He was unaware Resident #1 reported he had been hit by staff and that Resident #1's eye had been injured. Nurse #3 did not inform him of the situation. Nurse #4 stated he assisted Nurse #5 with obtaining statements. An interview was conducted on 1/31/23 at 4:42 PM. The Director of Nursing (DON) was asked why Nurse #3 had not let the shift supervisor know about the resident's eye, the allegation, or called the Director of Nursing and the Administrator during the shift. Nurse #3 stated she wanted to verify with first shift staff that the resident did not have any injuries or reported being hit by staff. The DON stated Nurse #3 should have called the Administrator and Director of Nursing immediately per policy on 1/7/23. Nurse #3 should have done a head-to-toe assessment, documented her observations on 1/7/23 in the nursing notes, performed a skin assessment form and completed an assessment form. The physician and responsible person should also have been called on 1/7/23. The alleged perpetrator should have been sent home until the investigation was completed. An interview was conducted on 1/31/23 at 4: 50 PM. The Administrator stated she was unaware the incident occurred on 1/7/23. She was informed on 1/8/23 that the resident reported being hit by staff resulting in a black eye. Nurse #3 should have performed a head-to-toe assessment on 1/7/23, documented her observation and spoken with the shift supervisor. The nursing staff were trained how to conduct abuse investigations, report allegations of abuse and injuries of unknown origin. Staff were also trained how to contact the Administrator and Director of Nursing when there was an allegation of abuse and injury of unknown origin per policy. The Administrator stated the alleged staff should have been sent home to protect Resident #1 and any other resident who had been under Nurse Aide #4's care. An interview was conducted on 2/1/23 at 11:19 AM. The Physician Assistant stated she was not informed Resident #1 had been hit by staff or the resident had been agitated over the weekend. She was told on 1/8/23 the resident had a black eye and needed to be assessed. The PA further stated staff should have notified the on-call physician of any injuries to any part of a resident's head so the physician could determine if the resident needed to be evaluated outside of the facility. The Administrator was notified of the immediate jeopardy for F610 on February 15, 2023 at 7:09 AM. The facility provided the following corrective action plan with a completion date of 1/16/23. Problem identified: Nurse #3 failed to notify the Administrator of allegation of abuse per facility policy. Resident # 1 reported to Nurse #3 he was hit in the face by staff and Nurse #3 observed Resident #1's eye red and swollen on 1/7/23. Immediate Action: Nurse #3 did not report Resident #1 red and swollen left eye to the Director of Health Services and/or Administrator per policy on 1/7/23. Nurse #3 reported the discoloration of the left eye to the Director of Health Services on 1/8/23. The Director of Nursing / Administrator reported the injury of unknown origin to the Health Care Personnel Registry within a 2-hour time frame of their notification, with police and Adult protective services notification also. Nurse #3 interviewed Resident #1 on 1/7/2023 he stated, she knocked the hell out of me. Nurse #3 did not remove the Certified Nursing Assistant assigned to Resident #1. The Administrator and Director of Nursing investigated the allegation when notified on 1/8/23 by Nurse #3. Certified Nursing Assistant was suspended on 1/8/2023 when the Administrator and Director of Nursing were notified on the event and terminated on 1/16/23, she did not work between 1/8/23 and 1/16/23. The Director of Health Services verbally counseled Nurse #3 on immediate reporting of alleged abuse including injuries of unknown origin, and immediate removal of the alleged abuser from the facility. Identification of others potentially affected. Nineteen Residents assigned to the Certified Nursing Assistant (C.N.A) were interviewed by the Unit Coordinator on 1/8/2023 regarding abuse, the questions asked of the resident included do you feel safe, have you ever been abuse, have you seen anyone else be abused, and do you have any concerns. Eighteen of the residents stated they had no concerns, and one resident stated the C.N.A was rough during care. The Unit Coordinator completed skin observations on 1/8/2023 of the Four non-interviewable residents on the C.N.A assignment and did not identify any new skin impairments of the residents. The week of 1/8/2023 the Director of Nursing and/or the Licensed Nurses completed skin observation on all residents residing in the facility with no other injury of unknown origins noted. When the Licensed Nurses complete the skin observation and a new skin impairment and/or injury of unknown origin is identified, the Director of Health Services is notified at the time of identification. The facility Administrator and Department managers completed a sample of 20 residents interview throughout the facility from 1/8/23 through 1/27/23 for any indicators of abuse. 0 of 20 resident identified any issues of abuse during this time frame. Systemic Changes: On 1/8/23 the Director of Health Services and/or Nurse Managers provided re- education to all staff in all departments on Prevention and Protecting Residents from Abuse and Neglect, Reporting of Abuse, removal of any suspected / alleged abuser and immediate Notification and assessment of any allegation of abuse, neglect, and injuries of unknown origin to the Director of Health Services and/or Administrator. Facility staff members were educated prior to their next scheduled shift. Employees not educated by 1/16/23 will be removed from the schedule until education is completed. The Clinical Competency Coordinator/Human Resources Director/ Director of Nursing continues to educated newly hired employees on Prevention and Protecting Residents from Abuse and Neglect, Reporting of Abuse, removal of any suspected / alleged abuser and immediate Notification and assessment of any allegation of abuse, neglect, and injuries of unknown origin to the License nurse / Supervisor for completion of assessment of area of unknown injury and notification to the Director of Health Services and/or Administrator during general orientation of newly hired employees, however on 1/8/2023 this education was given emphasis and newly hired employees are required to complete the education prior to working with Residents. The Clinical Competency Coordinator/ Director of Nursing is tracking the compliance of completion during general orientation of the Staff who have completed the education. Beginning on 1/8/2023 the Administrator / Director of Health Services and/or Department Managers are interviewing 20 alert and oriented residents monthly to identify if 1. Have you ever been physically, verbally, sexually, mentally abused or exploited; and 2. Have you ever witnessed any abuse. The Administrator / Director of Health Services and/or Department Managers Resident will continue the monthly Resident interviews for six months then quarterly thereafter. Beginning on 1/8/2023 the Director of Nursing and/or the Licensed Nurses will complete skin observation on all residents residing in the facility weekly and ongoing weekly. When the Licensed Nurses complete the skin observation, and a new skin impairment (injury of unknown origin) is identified the Director of Health Services is notified at the time of identification. When any staff member identifies an injury of unknown origin at any time, the staff member immediately notifies the License nurse / Supervisor for completion of assessment of area of unknown injury and the Director of Health Services and/or facility Administrator, for reporting to the Health Care Personnel Registry. Beginning on 1/8/2023 the Facility Administrator and/or Director of Health Services will notify the Area [NAME] President and/or the Senior Nurse Consultant for [NAME] Health - [NAME] of all allegations of abuse including injuries of unknown origin. The Area [NAME] President and/or Senior Nurse Consultant will review the allegation of abuse including injuries of unknown origin to validate a thorough investigation was completed, including assessing the resident injuries, protecting the resident from abuse, and reporting resident alleged abuse was completed timely. This process of notification will be ongoing. Monitoring: The Director of Nursing presented an analysis of the Resident Abuse questionnaire to the Quality Assurance and Performance Improvement Committee on 1/25/23 and monthly thereafter until three months of sustained compliance then quarterly thereafter. The Director of Health Services presented an analysis of the skin observation review to the Quality Assurance and Performance Improvement Committee on 1/25/23 and monthly thereafter until three months of sustained compliance then quarterly thereafter. The Administrator decided to address the F 610 citation in the Ad Hoc Quality Assurance and Performance Improvement was made on 1/16/23 after the investigation related to the event was completed. The credible allegation was validated on 2/17/23 when staff interviews, revealed that they had received recent education on the Abuse policy and procedures, and resident rights to be free from injuries of unknown origin. The education included documentation and reporting to management immediately when they become aware of reported or suspected injury. The Administrator and the Director of Nursing were the designated staff to complete the state agency required reports within 24-hour and 5 days. Newly hired staff were required to complete the computer-based training on abuse before the start of the shift. New hire orientation packets for the past two months were reviewed to ensure abuse policy and procedures were reviewed. The Unit Manager would submit the completed the weekly skin observations and monthly audit of the resident skin assessments to the Director of Nursing and the Administrator. The Unit Managers completed the abuse questionnaire with residents and documented any concerns the resident reported. Attestations were signed by trained staff for the verbal education that was provided. Staff indicated they were trained prior to working in the facility for their next shifts. An interview was conducted on 2/17/23 at 3:30 PM, the Administrator stated that the Facility Administrator and/or Director of Health Services will notify the Area [NAME] President and/or the Senior Nurse Consultant for [NAME] Health - [NAME] of all allegations of abuse including injuries of unknown origin. The Area [NAME] President and/or Senior Nurse Consultant reviewed the allegation of abuse including injuries of unknown origin to validate a thorough investigation was completed, including assessing the resident injuries, protecting the resident from abuse, and reporting resident alleged abuse was completed timely. This process of notification will be ongoing. The Administrator reviewed all the audit and monitoring tools and assessment for all residents and address areas of concern monthly. The facility deficiency was corrected on 1/16/23.

Based on record review, staff interviews, physician assistant and physician interviews, the facility failed to identify/assess a wound for 1 of 3 residents (Resident #293). Nurse #11 identified a wound on Resident's right leg on 7/27/22. There were no orders for wound care. From 7/27/22 to 8/12/22 Nurses failed to complete the weekly body observations that included wound observations and measurements. On 8/12/22 Nurse # 7 noted an open wound to posterior right leg with foul smelling odor with some bleeding and, Nurse #7 failed to address/communicate/report/document the condition/status/size/appearance of the wound. On 8/13/22 Resident #293's condition changed, and Resident #293 was hospitalized . Resident #293 required treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy began on 7/27/22 when Nurse #11 identified a wound to Resident's posterior right leg, and necessary care and services were not provided. The Immediate Jeopardy was removed on 10/22/22 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity E (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and all staff have been in-serviced. Findings included: Resident #293 admitted to the facility on [DATE]. A review of admission observation for Resident #293 dated 6/8/22 revealed no skin alterations. A review of Resident #293's June electronic medication record (EMAR) revealed no order for skin observations for the month of June. A review of the medical record revealed no documented weekly skin observations from July 2022 to August 2022. A review of Resident #293's July EMAR revealed an order dated for 7/15/22 to observe and examine Resident's skin from head to toe and complete accompanying observations. It was noted on the EMAR for 7/15/22 it was initialed by Nurse #7, on 7/22/22 by Nurse #10, and on 7/29/22 by Nurse #7, however there was no documentation to verify they were complete. During an interview with Nurse #10 on 10/13/22 at 12:45 pm, it was indicated she did not remember doing a skin observation on Resident #293 on 7/22/22. She indicated the skin observations should be documented in the computer. An interview with Nurse #7 was conducted on 10/13/22 at 1:43 pm, it was indicated she did not recall doing skin observations on Resident # 293 on 7/15/22 and 7/29/22. She further indicated when she did skin observations, she would sign off she completed the skin observation on the EMAR and document the skin observation in the computer. A review of Nursing progress note dated 7/27/22 at 7:24 pm by Nurse #11 read in part Resident #293 had an open wound to his right leg. No treatment orders were found. Wound was packed with normal saline, damp to dry sterile gauze, and covered with sterile gauze secured by kerlix. Resident tolerated well. Repositioned off right side following cleaning and linen change after bowel movement. An interview was made on 10/11/22 at 4:33 pm with NA #4, and she indicated she recalled working one night, (however could not recall the exact date) with Nurse #11 and reported to her about the wound to Resident's right leg and Nurse #11 put a bandage on it. During a telephone interview on 10/11/22 at 5:48 pm with Nurse #11 it was indicated on 7/27/22 she assisted NA #4 provide activities of daily living (ADL) care on Resident #293 and when they went to turn the Resident, she observed an open wound on Resident's right leg that was about 1/2 inch in diameter and 2 inches long. She indicated she cleaned the wound and put a dressing on it. She indicated she observed Resident's skin and did not see any other wounds on Resident. Nurse #11 indicated she reported the wound to Nurse #1 who was in the facility at the time, and Nurse #1 stated she would let the wound Physician know about the wound the next morning. Nurse #11 indicated she asked Nurse #1 if she wanted her to measure the wound or get orders and she stated Nurse #1 informed her she would take care of it and instructed her to put a dressing on the wound. On 10/11/22 at 3:21 pm an interview was conducted with Nurse #1, and she indicated Resident #293 had no skin concerns on admission. She indicated the floor nurses were responsible for performing skin assessments weekly on the residents and to document any abnormal findings in the wound communication books located at each nurse's desk. Nurse #1 indicated she did not recall the conversation with Nurse #11. Resident #293's Quarterly minimum data set (MDS) dated [DATE] revealed cognition assessment was not assessed. Further review of the MDS revealed Resident #293 was able to make needs known and required extensive assistance with 1-person physical assist with bed mobility, toilet use, personal hygiene, bathing, and supervision with setup help with eating. Resident #293 had no wounds identified on this assessment. A review of August EMAR for Resident #293 revealed on 8/5/22 it was initialed by Nurse #2 Resident's skin observation was completed; however, no documentation was found to verify it was complete. On 10/13/22 at 3:30 pm an interview was conducted with Nurse #2, and it was indicated he did not remember doing a skin observation on Resident #293 on 8/5/22. He indicated he did not recall Resident having a wound. A review of care plan last revised on 8/12/22 revealed Resident #293 had a potential for impaired skin integrity related to decreased mobility, incontinence, and obesity. A goal was for Resident to remain free from development of pressure injury. The interventions included observe skin with daily care, report open, reddened, excoriated, sore areas to nurse, diet as ordered, report meal refusals to nurse, moisture barrier cream if indicated, provide peri care following incontinent episodes, provide turning/positioning assistance with care rounds and as needed, use pillows as tolerated/indicated for offloading. An interview was made on 10/11/22 at 4:33 pm with NA #4 and she indicated she was assigned to Resident # 293 on 8/12/22. She indicated when she came to work on the 11pm shift on 8/12/22 and while doing her rounds she went to check Resident and saw drainage on his sheets and noted a bandage on his right leg. She indicated she reported her findings to Nurse #7. A review of Nursing progress note dated 8/12/22 at 10:00 pm by Nurse #7 read in part Resident # 293 was found to have an open wound on right leg (calf) with a foul-smelling odor, and some bleeding noted. Observations left in wound care and Physician book for further evaluation. On 10/11/22 at 4:10 pm an interview was conducted with Nurse #7, and she indicated she was the Nurse that worked on 8/12/22. She indicated it was reported by the NA #4 assigned to Resident # 293 that he had blood on his sheets. She indicated she went to check Resident and observed a bandage wrapped on his right leg. Nurse #7 indicated the bandage had no date on it and when she removed the bandage, she observed wound to right calf that had bloody, greenish drainage. She indicated she observed the wound to be to the bone. Nurse #7 indicated it was the end of her shift and she had to leave. During a follow up interview with Nurse #7 it was clarified that on 8/12/22 she found Resident #293 with a dressing on Resident's right calf area, and it had no date, the dressing was soiled, and a foul smelling bloody greenish colored drainage was on the sheet. Review of electronic medical record revealed on 8/12/22 a SBAR (situation, background, assessment, resident evaluation) completed by Nurse #7 communication form read in part a change in condition symptoms or signs observed was wound to right leg, and it started on 8/12/22. Wound was evaluated to have drainage and foul smell. The responsible party (RP) was notified on 8/13/22 at 4:50 pm, and Physician notified. A review of Nursing progress note dated 8/13/22 at 1:28 pm by Nurse #7 read in part, Spoke to Physician, and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders were transcribed for [MEDICATION(S)] (an antibiotic to treat bacterial infections) 200 milligrams (mg) by mouth twice a day for 7 days, and wound care orders for Dakin's solution and Santyl ointment daily. Also received lab orders for a Complete blood count and basic metabolic panel for Monday 8/15/22. The RP was notified. A review of Nursing progress note dated 8/13/22 at 6:37 pm by Nurse #7 read in part Resident #293 sent to emergency department for further evaluation due to wound on right leg and uncontrolled pain per Physician request. Director of Nursing (DON) and RP notified. Temperature (T) was 97.3, pulse (P) was 134, respirations (R) was 18, blood pressure (B/P) was 120/72, and oxygen level was 100% on room air. X-ray was done and results of right leg findings suggest further assessment with a computerized tomography (CT)/magnetic resonance imaging (MRI). The results were left in the Physician book and reported to floor nurse. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/11/22 at 3:21 pm an interview was conducted with Nurse #1, and she indicated she was called on 8/13/22 and Nurse #7 informed her of Resident #293's wound to right leg. She indicated she informed Nurse #7 to call the Physician. On 10/11/22 at 4:10 pm an interview was conducted with Nurse #7, and she indicated she returned to work on 8/13/22 and went to check on the Resident and then went and called the Physician. She indicated she received orders for x-ray of right leg, antibiotics, and blood work. She stated she went back into Resident's room later in the shift and Resident was in pain despite receiving pain medication and she called the Physician back and received orders to send Resident to hospital for evaluation of wound to rule out [CONDITION(S)]. She further indicated she called the DON and RP to inform them of the above information. During an interview on 10/12/22 at 1:38 pm with Nurse #9, it was indicated she was the Nurse assigned to Resident #293 on 8/13/22 and helped Nurse #7 send Resident #293 to the hospital. Nurse #9 also indicated she was assigned to Resident #293 on 8/12/22. She indicated she received report of the wound from Nurse #7 and Nurse #7 stated she had worked with the Resident the night before and she was going to notify the Physician because she had found the wound the evening before. She indicated she was informed by Nurse #7 she had received an order on 8/13/22 to send Resident to the hospital for evaluation. Nurse # 9 indicated she had not seen a wound on the Resident prior to 8/13/22 and had only observed the wound on 8/13/22 with Nurse #7 while she did the treatment to the wound. She indicated she observed the wound on Residents right calf, and she could see the muscle. She indicated it had a small amount of bloody drainage on the bandage. She indicated she did not recall doing a skin observation on Resident #293. She indicated the skin observation was on the EMAR and was to be completed weekly. She also indicated they were supposed to sign off on the EMAR once the observation of the skin was completed and document in the observation section in the computer. Nurse #9 indicated she did not recall Resident #293 having any wounds. On 10/12/22 at 10:28 am a telephone interview was conducted with the primary Physician of Resident #293, and he indicated as of 9/17/22, he no longer worked at the facility and no longer had access to Resident #293' s records. He indicated he recalled the call from Nurse #7 on 8/13/22 concerning Resident's wound. He indicated he gave Nurse #7 orders, (however did not remember exactly what orders), and eventually sent Resident to the hospital for further evaluation. He indicated he did not recall anything further about Resident #293. During an interview on 10/11/22 at 4:04 pm with NA #10 it was indicated she worked with Resident #293 on occasion and last worked with Resident in July. She indicated Resident would barely let anyone touch him, was difficult to turn, would often refuse to be turned, bathed, or touched. She indicated she notified the nurses when Resident refused care. NA #10 indicated Resident #293 had a bandage on back of his leg and buttocks. She indicated she did not know what was under the bandages. A telephone interview was conducted on 10/12/22 at 10:15 am with the Physician Assistant (PA) and it was indicated she longer worked in the facility and did not have access to her notes. She indicated she did not recall personally seeing any wounds on Resident #293. During an interview on 10/13/22 at 1:06 pm with the DON she indicated the process for when a wound was identified was to notify the Physician and RP, get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She also indicated the Nursing staff should put any new wounds identified in the wound communication book to notify the wound nurse. She indicated she reviews the activity report in the computer and 24-hour report to see if anything was reported of any abnormal findings. She indicated she was not aware of this incident until 8/13/22 and after this occurred, she did a performance improvement plan (PIP) which included education to Nursing staff on completing body audits, skin assessments in a timely manner, to ensure residents are provided quality care to promote optimum outcomes and decrease the occurrence of new acquired wounds, education of doing skin observations, and they did wound checks on the residents on 8/24/22 as part of the PIP. During an interview on 10/13/22 at 5:10 pm with the Administrator it was indicated it was her expectation when a new wound was identified was to notify the Physician, get orders to treat the wound, and notify the family. She further indicated it was her expectation skin observations were to be done weekly and documented in the computer. A review of hospital emergency department records read in part Resident #293 presented to hospital on 8/13/22 ill-appearing, in acute distress, had diffuse pain, and had a wound to the right lower leg, that was covered. Resident's vital signs were as follows T-99.6, P-119, R-20, B/P-105/63. On exam it was noted Resident meet systemic [CONDITION(S)] response (SIRS)criteria and was started on intravenous fluids and antibiotics. On 8/15/22 MRI of Resident #293's right lower leg was done, and results revealed MRI along posterolateral upper leg with sinus tract to bone with [CONDITION(S)]. The Administrator was notified of immediate jeopardy on 10/20/22 at 6:07 pm. On 10/22/22 the facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance. Resident #293 no longer resides in the facility. On 7/27/22 Nurse #11 noted wound to posterior right lower leg, applied dressing but failed to notify physician, her supervisor and did not report off to on-coming nursing staff. From 7/27/22 to 8/12/22 Nurses failed to complete the weekly body observations that included wound observation and measurements of the resident's skin integrity status for this same period of time. On 8/12/22 Nurse noted an open wound to posterior right lower leg with foul smelling odor with some bleeding noted, the Nurse placed a written communication in the Physician and Wound Care book for further evaluation and failed to address/communicate/report/document the condition/status/size/appearance of the wound. On 8/13/22 nurse spoke with physician and new orders were obtained for antibiotics and wound care orders with an x-ray to right leg. X-ray dated 8/13/22 identified lytic lesion, and resident #293 was transferred to the Hospital emergency room . The Residents admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #11 is no longer employed by this facility. The Director of Health Services initiated 100% body audits on all residents within the facility on 10/20/22. There were no new skin integrity issues identified by comparing the known (current) skin integrity (wounds) on the wound manager report, in the electric medical record, currently in house to the body audits completed by the nurses on 10/20-21/2022. All residents have the potential to suffer a serious adverse outcome as a result of the failure to address/communicate/report/document the identification/condition/status/size/appearance of the wound on a weekly basis. Actions taken by the facility to alter to alter the process or system failure to prevent a serious adverse outcome from reoccurring and when the action will be completed. The Director of Health Services and/or Nurse Managers have reviewed the wound audit conducted on 10/20-21/22 and reviewed the documentation to ensure residents with skin impairments had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Health Services and/or Nurse Managers began education to the Nurses on 10/20/22 regarding weekly skin observations and documentation in the electronic health record of same. When a new skin impairment is noted, the Nurse will complete the wound documentation in the electronic medical record that includes description and measurement of area and contact the physician/physician extender for orders, regarding newly identified skin impairments and/or worsening skin impairments for wound treatment orders. This includes the observations and measurements are necessary as a monitoring tool to determine if there are any changes in the wound that would require a change in the treatment plan. The Clinical Competency Coordinator was notified on 10/21/22 by the Licensed Nursing Home Administrator to add the skin observations and documentation in the electronic health record education to the Nurse general orientation upon hire with emphasis that the nurse who identifies the skin integrity issue completes the wound documentation, physician notification, initiates treatment per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Any Nurse will not be allowed to work after 10/21/22 until they receive the education. On 10/21/22 The Director of Health Services notified the Wound Nurse and the Nurse Practitioner to meet weekly to discuss and review all residents with wounds. On 10/20/22 and 10/21/22 the Director of Health Services and Nurse Managers educated the Certified Nursing Assistants on daily skin checks during personal care. This education includes notification to the nurse of any skin impairment and/or new dressing noted on resident's skin. The Certified Nursing Assistant will obtain a paper body diagram at the beginning of their shift from the nursing station on each unit and maintain in their possession throughout the day. The Nursing assistant will utilize a body diagram for each resident daily during resident care, for nurse notification of skin integrity issues. The Certified Nursing Assistant will circle the area of the body, on the body diagram, with the skin integrity issue with a pen / pencil and notify nurse regarding skin integrity issue. The Nurse will complete body observation on residents the certified nursing assistants have identified with new skin integrity issues and notify physician for treatment orders. The Clinical Competency Coordinator was notified on 10/21/2022 by the Licensed Nursing Home Administrator, to add the education regarding the Body diagrams and utilization of a body diagram for each resident daily for nurse notification of skin integrity issues to the general orientation of the Certified Nursing Assistant. Any Certified Nursing Assistant will not be allowed to work after 10/21/22 until they receive the education regarding the Body diagrams and utilization of a body diagram for each resident daily for nurse notification of skin integrity issues. The Clinical Competency Coordinator/RN was notified by the Licensed Nursing Home Administrator on 10/21/22, that they are responsible for ensuring education is completed prior to the start of any Licensed Nurse and/or Certified Nursing Assistant working the floor after 10/21/22. On 10/21/22 The Licensed Nursing Home Administrator notified the Director of Health Services and/or Nursing Leadership to review the weekly skin observations (weekly focus observation), in the electronic medical record under observation section, to validate all areas identified have physician notification, treatments orders are written, wound is monitored for changes weekly for four weeks then monthly thereafter. Date when corrective action will be completed: 10/22/22. On 10/27/22 the credible allegation of immediate jeopardy was validated by onsite verification. Record reviews and interviews were conducted which verified the audits were completed. Interview with the Minimum data set (MDS) Nurse revealed skin assessments were completed daily. Nurse Assistants (NA) complete a skin audit daily and if there is an issue with a resident's skin, the NA notifies the charge nurse who then documents, notifies the Physician, and obtains order if needed. MDS Nurse also indicated they notify the responsible party (RP)/family. A review of the audits revealed all residents' orders were reviewed and any discrepancies were corrected. A review of the education training revealed education was provided to staff as stated in the credible allegation. Interview was conducted with staff on 10/27/2022 at 10:18 am who indicated they had been educated by facility that NAs are to report any issues with skin to charge nurse. The Nurse then assesses resident's skin and documents, notifies wound nurse, Physician and RP/family. Interview was conducted with staff on 10/27/2022 at 10:22 am who indicated knowledge of completing a daily body audit sheet for any issues with a resident's skin and notifying the charge nurse if observes any skin issues. Interview was conducted with Wound Nurse on 10/27/2022 at 11:12 am who indicated NAs had to do full skin audits on every shift. If identified any areas, including redness, they notify the nurse and audits were turned into the nurse who reviews and signs off the skin audit and skin audit given to DON. Nurses review audit sheets and if anything observed, they are to do a SBAR, assess wound, inform Physician and RP, and transcribe any order in computer. Nurses put information in wound communication book and treatment nurse checks the book every day for any new areas on skin that were identified. Interviews with staff revealed that education was provided. The immediate jeopardy removal date of 10/22/2022 was validated on 10/27/22.

Based on record review, staff interviews, physician assistant and physician interview, the facility failed to notify the physician of the development of an open wound to a resident's right leg on 7/27/22 that deteriorated in condition through 8/13/22 for 1 of 3 residents (Resident #293) reviewed for notification of change. This failure resulted in no physician evaluation of the wound and no physician ordered treatments to the wound. On 8/12/22 the wound was assessed by Nurse #7 with a foul odor and on 8/13/22 Nurse #7 notified the physician of the wound, a change in the resident's condition, and the physician ordered for the resident to be transferred to the hospital. Resident #293 was treated in the hospital for [CONDITION(S)] (blood poisoning, especially caused by bacteria or their toxins) and [CONDITION(S)] (inflammation of the bone caused by infection) related to right leg wound. Immediate Jeopardy began on 7/27/22 when the facility failed to notify the physician of the open wound found on Resident #293's right leg. The Immediate Jeopardy was removed on 10/22/22 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems implemented are effective and to complete staff education. Findings included: Resident #293 was admitted to the facility on [DATE]. A review of a nursing progress note dated 7/27/22 at 7:24 pm made by Nurse # 11 read in part Resident #293 had an open wound to his right leg. No treatment orders were found. Wound was packed with normal saline, damp to dry sterile gauze, and covered with sterile gauze secured by kerlix (white gauze dressing). Resident tolerated well. During a telephone interview on 10/11/22 at 5:48 pm with Nurse #11 she indicated, on 7/27/22 she recalled Nursing Assistant (NA) #4 asked for assistance to provide care to Resident #293. She indicated when they went to turn the Resident, she observed an open area on the Resident's right leg that was about 1/2 inch in diameter and 2 inches long. She indicated she cleaned the wound and put a dressing on it and looked at the Resident's skin and did not see any other areas on the Resident's body. She indicated she reported the wound to Nurse #1 who was in the facility at the time, and Nurse #1 informed her she would let the wound Physician know about the wound the next morning. Nurse #11 indicated she asked Nurse #1 if she wanted her to measure the wound or get orders and she stated Nurse #1 informed her she would take care of it and instructed her to put a dressing on the wound. On 10/13/22 at 3:45 pm an interview was conducted with Nurse #1. She denied being notified by Nurse #11 of Resident #293 having any wounds on 7/27/22. She indicated she had no knowledge of the Resident having any wounds in July. Record review from 7/27/22 through 8/12/22 revealed no evidence the physician was notified of Resident #293's right leg wound first identified on 7/27/22, no treatment orders were in place, and no wound assessments or physician evaluations of the wound were completed. A review of Nursing progress note dated 8/12/22 at 10:00 pm by Nurse #7 read in part, Resident # 293 was found to have an open wound on right leg (calf) with a foul-smelling odor, and some bleeding noted. Observations left in wound care and Physician book for evaluation. On 10/11/22 at 4:10 pm an interview was conducted with Nurse #7, and she indicated she was the Nurse that worked on 8/12/22. She indicated it was reported by NA #4 who was assigned to Resident #293 that he had blood on his sheets. She indicated she went to check the Resident and observed a bandage wrapped on his right leg. Nurse #7 indicated the bandage had no date on it and when she removed the bandage, she observed wound to right calf that had bloody, greenish drainage. She indicated she observed the wound to be to the bone. Nurse #7 indicated it was the end of her shift and she had to leave and left a written note in Physician book that is left at the nurse's station for further evaluation when Physician returned to facility, and she notified Physician verbally on the phone on 8/13/22. Review of electronic medical record revealed on 8/12/22 a SBAR (situation, background, assessment, resident evaluation) communication form was completed by Nurse #7. The communication form read in part a change in condition identified on 8/12/22 was a wound to right leg. Wound was evaluated to have drainage and foul smell. The responsible party (RP) was notified on 8/13/22 at 4:50 pm, and Physician notified. A review of hospital records read, in part, Resident #293 presented to hospital on 8/13/22 ill-appearing, in acute distress, had diffuse pain, and had a wound to the right lower leg that was covered. On exam it was noted Resident meet SIRS (Systemic [CONDITION(S)] Response, an exaggerated defense response of the body to a noxious stressor like infection and/or inflammation) criteria and was started on intravenous fluids and antibiotics. On 8/15/22 MRI (magnetic resonance imaging) of Resident #293's right lower leg was done, and results revealed MRI along posterolateral (situated on the side and toward the posterior aspect) upper leg with sinus tract to bone with [CONDITION(S)]. A telephone interview was conducted on 10/12/22 at 10:15 am with the Physician Assistant (PA) and it was indicated she no longer worked in the facility and did not have access to her notes. She indicated she did not recall personally seeing any wounds on Resident #293 or being informed of any. On 10/12/22 at 10:28 am a telephone interview was conducted with the primary Physician of Resident #293, and he indicated as of 9/17/22, he no longer worked at the facility and no longer had access to Resident #293's records. He indicated he was not aware of Resident #293 having any wounds in July and was not able to access the records for the Resident. During an interview on 10/13/22 at 1:06 pm with the Director of Nursing (DON) she indicated the process to be followed when a wound was identified was to notify the Physician and Responsible party (RP), get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She also indicated the nursing staff should put any new wounds identified in the wound communication book to notify the wound nurse. She indicated she reviewed the activity report in the computer and 24-hour report to see if any report included abnormal findings. She indicated she was not aware Resident #293 had any wounds in July. During an interview on 10/13/22 at 5:10 pm with the Administrator it was indicated her expectation when a new wound was identified was to notify the Physician, get orders to treat the wound, and notify the family. She further indicated it was her expectation skin observations were to be done weekly and documented in the computer. The Administrator was notified of immediate jeopardy on 10/21/22 at 11:11 am. On 10/21/22 the facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance. Resident #293 no longer resides in the facility. On 7/27/22 Nurse #11 noted wound to posterior right lower leg, applied dressing but failed to notify physician. On 8/12/22 Nurse noted open wound to posterior right lower leg with foul odor and placed in physician and wound care notification books without verbal notification to the physician. On 8/13/22 nurse spoke with physician and new orders were obtained for antibiotics, wound care orders and an x-ray to right lower leg. X-ray dated 8/13/22 identified lytic lesion to distal femoral shaft. Upon the Nurse's notification to the Physician regarding the Right leg X-ray results the Physician transferred the resident #293 to the emergency room . The Residents admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #11 is no longer employed by this facility. The Director of Health Services initiated 100% body audits on all residents within the facility on 10/20/22 to be done by the Nurses. There were no new skin integrity issues identified by comparing the known (current) skin integrity (wounds) on the wound manager report, in the electric medical record, currently in house to the body audits completed on 10/20/2022. Actions taken by the facility to alter to alter the process or system failure to prevent a serious adverse outcome from reoccurring and when the action will be completed. The Director of Health Services and/or Nurse Managers have reviewed the wound body audit completed by the Nurses, conducted on 10/20-21/22, and reviewed the documentation to ensure residents with skin impairments had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Health Services and/or Nurse Managers began education to the Nurses, on 10/20/22 regarding weekly skin observations and documentation in the electronic health record of same. When a new skin impairment is noted, the nurse will complete the wound documentation in the electronic medical record that includes description and measurement of area and contact the physician/physician extender for orders, regarding newly identified skin impairments and/or worsening skin impairments for wound treatment orders. This includes the observations and measurements are necessary as a monitoring tool to determine if there are any changes in the wound that would require a change in the treatment plan. The Clinical Competency Coordinator was notified on 10/21/22 by the Licensed Nursing Home Administrator to add the skin observations and documentation in the electronic health record education to the Nurse general orientation upon hire with emphasis that the nurse who identifies the skin integrity issue completes the wound documentation, physician notification, initiates treatment per physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Health Services and Nurse Managers educated the Certified Nursing Assistants on daily skin checks during personal care. This education includes notification to the nurse of any skin impairment and/or new dressing noted on resident's skin. On 10/20/22 and 10/21/22 the Director of Health Services and Nurse Managers educated the Certified Nursing Assistants on daily skin checks during personal care. This education includes notification to the nurse of any skin impairment and/or new dressing noted on resident's skin. The Certified Nursing Assistant will obtain a paper body diagram at the beginning of their shift from the nursing station on each unit and maintain in their possession throughout the day. The Nursing assistant will utilize a body diagram for each resident daily during resident care, for nurse notification of skin integrity issues. The Certified Nursing Assistant will circle the area of the body, on the body diagram, with the skin integrity issue with a pen / pencil and notify nurse regarding skin integrity issue. The Nurse will complete body observation on residents the certified nursing assistance have identified with new skin integrity issues and notify physician for treatment orders. The Clinical Competency Coordinator was notified on 10/21/2022 by the Licensed Nursing Home Administrator, to add the education regarding the Body diagrams and utilization of a body diagram for each resident daily for nurse notification of skin integrity issues to the general orientation of the Certified Nursing Assistant. Any Certified Nursing Assistant will not be allowed to work after 10/21/22 until they receive the education regarding the Body diagrams and utilization of a body diagram for each resident daily for nurse notification of skin integrity issues. The Clinical Competency Coordinator/RN was notified by the Licensed Nursing Home Administrator on 10/21/22, that they are responsible for ensuring education is completed prior to the start of any Licensed Nurse and/or Certified Nursing Assistant working the floor after 10/21/22. On 10/21/22 The Licensed Nursing Home Administrator notified the Director of Health Services and/or Nursing Leadership to review the weekly skin observations (weekly focus observation), in the electronic medical record under observation section, to validate all areas identified have physician notification, treatments orders are written, wound is monitored for changes weekly for four weeks then monthly thereafter. Alleged date of immediate jeopardy removal: 10/22/22 On 10/27/22 the credible allegation of immediate jeopardy was validated by onsite verification. Record reviews and interviews were conducted which verified the audits were completed. Interview with the Minimum data set (MDS) Nurse revealed skin assessments were completed daily. Nurse Assistants (NA) complete a skin audit daily and if there is an issue with a resident's skin, the NA notifies the charge nurse who then documents, notifies the Physician, and obtains order if needed. MDS Nurse also indicated they notify the responsible party (RP)/family. A review of the audits revealed all residents' orders were reviewed and any discrepancies were corrected. A review of the education training revealed education was provided to staff as stated in the credible allegation. Interviews with staff indicated they had been educated by facility that NAs are to report any issues with skin to charge nurse. The Nurse then assesses resident's skin and documents, notifies wound nurse, Physician and RP/family. Interviews further indicated knowledge of completing a daily body audit sheet for any issues with a resident's skin and notifying the charge nurse if observes any skin issues. Interview was conducted with Wound Nurse on 10/27/2022 at 11:12 am who indicated NAs had to do full skin audits on every shift. If identified any areas, including redness, they notify the nurse and audits were turned into the nurse who reviews and signs off the skin audit and skin audit given to DON. Nurses review audit sheets and if anything observed, they are to do a SBAR, assess wound, inform Physician and RP, and transcribe any order in computer. Nurses put information in wound communication book and treatment nurse checks the book every day for any new areas on skin that were identified. Interviews with staff revealed that education was provided. The immediate jeopardy removal date of 10/22/2022 was validated on 10/27/22.

Based on observations, staff interviews, Nurse Practitioner interview, and record review, the facility failed to provide the necessary care and services for a pressure ulcer including failure to complete weekly skin assessments and treatments as ordered. The facility failed to identify a pressure ulcer before it was significant enough to have depth (7/10/22). Three days later the wound was with slough, debris, and necrosis. On 8/3/22, the wound was assessed to be deteriorated and a stage three. The wound continued to deteriorate. On 10/11/22, a nurse detected odor in the wound and did not seek medical attention. This was for 1 of 3 residents reviewed for pressure ulcer prevention and treatment (Resident #83). The findings included: Resident #83 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly minimum data set (MDS) dated [DATE] revealed Resident #83 was at risk for pressure ulcer development. She had no pressure ulcers at the time of assessment. Weekly skin assessment documentation was not provided. A wound note by Nurse #1 dated 7/10/22 revealed Resident #83 had a new sacral wound, and she was started on supplements to promote wound healing. The wound had a light amount of exudate (drainage) and was noted to have the following measurements: length 2.5 centimeters (cm), width 4.5 cm, and depth 0.3 cm. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply Medi honey to the wound bed and cover with a dry dressing once daily. Review of a wound note by Nurse Practitioner (NP) #1 dated 7/13/22 revealed Resident #83 was assessed for a new sacral wound. Resident #83 required extensive staff assistance with mobility, followed some commands, and was not combative. NP #1 indicated the wound exhibited some yellow slough and debris. Therefore, depth of the wound was estimated to be 0.4 cm. The length was measured to be 2.2 cm and the width was 5.8 cm. There was a presence of necrotic tissue (tissue death) and a mild amount of drainage noted. The plan was to apply topical Medi honey gel that would promote debridement. NP #1 recommended use of an air mattress to promote optimal offloading of the resident's weight on her sacrum, as well as repositioning. The NP indicated the origin of the pressure ulcer as in-house and marked no for unavoidable. Review of a wound note by NP #1 dated 8/3/22 indicated the sacral wound had a slight deterioration in appearance. It was noted to be a stage three pressure injury and measured length 1.5 cm, width 3.5 cm, and depth 0.2 cm. There was a mild amount of exudate, and a debridement was performed. It was noted that offloading weight should continue as well as nutritional support measures. Resident #83's care plan, revised on 8/4/22, revealed a focus area for pressure ulcers. The goal was for Resident #83's pressure ulcer to heal without complications. Interventions included monitored pressure ulcer for signs and symptoms of infection, informed the physician or nurse practitioner of any changes, and provided treatments as ordered. A wound note by NP #1 dated 8/10/22 indicated Resident #83's wound was deteriorating. The was a mild amount of exudate and measurements were as follows: length 6cm, width 5 cm, and depth 0.2 cm. The resident was noted to be dependent for transfers and urinary diversion with catheter placement was addressed. A wound note by NP #1 dated 8/24/22 indicated Resident #83's wound healing demonstrated slight deterioration from previous assessments. There was a mild amount of exudate, and the wound measurements were as follows: length 6.5 cm, width 5 cm, and depth 0.2 cm. NP #1 indicated Resident #83 remained dependent for positioning and transfers. Review of MDS documentation revealed Resident #83 was hospitalized from 9/1/22 - 9/5/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] revealed Resident #83 was severely cognitively impaired. She required extensive staff assistance with bed mobility and had a stage three unhealed pressure ulcer. She was noted to receive pressure ulcer care and a pressure reducing device for the bed. The resident weighed 179 pounds. Review of a wound note by NP #1 dated 9/14/22 indicated the wound was again deteriorating, but stable in appearance. There was a mild amount of exudate, and the measurements were as follows: length 6.5 cm, width 7 cm, and depth 0.2 cm. It was noted that there was a lack of significant improvement and treatments were changed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound note by Nurse #1 dated 9/21/22 revealed Resident #83 had a stage three pressure ulcer, and treatments would be continued. There was a moderate amount of drainage and measurements were as follows: length 4.5 cm, width 3 cm, and depth 0.3 cm. A Physical Therapy (PT) progress note dated 9/26/22 revealed Resident #83 was noted to be supine in bed. She participated in rolling to her side and was repositioned with pillows to promote offloading of weight. There was a large red patch surrounding the sacral wound and the resident had a soiled brief. The area was assessed by applying pressure with the nail tip to surrounding tissues with no response from the resident. It was unable to be determined if this was due to confusion or poor sensitivity. A PT progress note dated 9/27/22 revealed Resident #83 was noted to be supine in bed. The resident participated in rolling to her side and was repositioned with pillows to promote offloading of weight. There was increased redness around the sacral wound and the therapist questioned Resident #83's sensation. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order further indicated to cleanse the wound with wound cleanser, pat dry, and pack the cavity with Dakin's solution moist gauze. The wound was to be covered with a dry dressing. There was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a wound note by NP #1 dated 9/28/22 indicated the sacral wound was larger when assessed and it was deteriorating. It was evaluated to have changed from a stage three to stage four pressure ulcer. NP #1 suggested nurses utilized a wedge pillow to optimize offloading considering Resident #83's immobility and body habitus. There was a mild amount of drainage and an increase in necrotic tissue was present. A debridement was performed, and the wound measurements were as follows: length 5 cm, width 4cm, and depth 1 cm. A PT progress note dated 9/28/22 revealed Resident #83 was noted to be supine in bed. She complained of back pain and participated in the PT session. Resident #83 stated she felt better after she was repositioned with a pillow to promote offloading of weight. A wound note by Nurse #1 dated 9/28/22 revealed Resident #83 had a stage four pressure ulcer with moderate drainage. There was necrotic tissue present, and the following measurements were documented: length 5cm, width 4 cm, and depth 1 cm. Treatment orders included Dakin's solution daily. A PT note dated 9/29/22 revealed Resident #83 was repositioned to her side at the end of the session for optimal wound pressure relief. Skin around the wound was noted to be red. Review of documentation revealed Resident #83 was hospitalized from 10/1/22 - 10/6/22. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound care was not documented on 10/8/22. An observation on 10/10/22 11:42 AM revealed Resident #83 was in bed lying on her back. An observation on 10/10/22 1:20 PM revealed Resident #83 was in bed with a pillow under her right hip. An observation on 10/10/22 at 4:00 PM revealed the resident was in bed lying on her back. An interview was conducted with Nurse #8 on 10/11/22 at 3:17 PM. Nurse #8 stated Resident #83 developed a pressure ulcer in July 2022 and received dressing changes daily, unless she refused care. The treatment nurse typically performed wound care, but nurses were responsible when the treatment nurse was absent. During an observation on 10/11/22 at 3:55 PM, Nurse #7 was observed providing pressure ulcer care for Resident #83. The resident had a pillow under her right hip. Dressing supplies and cleansing solution were placed on the resident's bedside table. Resident #83's sacral dressing had an unreadable (smeared) date and was wet with brown exudate. Nurse #7 removed the dressing and commented on the strong presence of an odor from the wound. Nurse #7 cleansed the wound with Dakin's solution-soaked gauze, packed the wound with calcium alginate, and applied a foam dressing. Resident #83's air mattress was set to normal pressure for a weight of 350 pounds. Resident #83 did not have a catheter at the time of the observation. During an interview with Nurse #7 on 10/11/22 at 3:55 PM, she stated she checked physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no odor when she last performed wound care. An interview was conducted with NA#9 on 10/11/22 at 3:55 PM. He stated Resident #83 was mostly calm. She received incontinence care as needed. If the resident's dressing was loose or soiled, he would notify the nurse. An interview was conducted with Nurse #1 on 10/11/22 at 4:03 PM. She stated Resident #83 developed a pressure ulcer in July 2022 after going to the hospital. At the time of the resident's return, she had a small red area on her back. About a week later, the area was open, it was assessed, and treatments were ordered including dressing changes and an air mattress. Nurse #1 further explained nurses should adjust the settings on the air mattress. Nurse #1 indicated the air mattress should not be set at 350 pounds for Resident #83. Resident #83 has been hospitalized several times causing interruptions in treatments. Nurse #1 last saw Resident #83 two weeks ago. During an interview with NA #4 on 10/11/22 at 4:32 PM, she stated Resident #83 did not like to lie flat. The NA stated Resident #83 was turned and repositioned every 2 hours. An observation on 10/12/22 at 7:34 AM revealed Resident #83 was in bed lying on her back. Appeared calm when staff were engaging with her. The air mattress was set to 160/200-pound setting, normal pressure. An interview and observation of care were conducted with NP #1 on 10/12/22 at 8:05 AM. NP #1 stated Resident #83 had recently been hospitalized . She indicated pressure settings on the air mattress should reflect the resident's weight to promote optimal wound healing. NP #1 assessed the wound and determined the treatment with Dakin's solution should continue. Nurse #1 was present and noted there was some odor when the dressing was removed. NP #1 had not been notified of an odor from the previous day. The NP was unsure if the wound had deteriorated and stated she would need to review previous notes. NP #1 indicated physical therapy would see the resident to help keep her off her back and to reduce pressure. Resident # 83 was cooperative with the care that was provided and positioned on her back after the pressure ulcer assessment and treatment was completed. An observation on 10/12/22 at 10:50 AM revealed Resident #83 was in bed lying on her back with the head of the bed slightly elevated. During a follow up interview on 10/12/22 at 12:45 PM, NP #1 stated she was unsure if the wound had deteriorated since her last assessment, and she would need to review previous notes. NP #1 indicated Resident #83's pressure ulcer had been assessed by the hospital's general surgeon and infection preventionist during her recent hospitalization (10/1/22 - 10/6/22). It was not infected at the time of that assessment and surgical debridement was not needed. An observation on 10/12/22 at 1:17 PM revealed Resident #83 was in bed lying on her back with the head of the bed slightly elevated. An observation on 10/12/22 at 3:00 PM revealed Resident #83 was in bed lying on her back with the head of the bed slightly elevated. During an interview with nurse aide (NA) #2 on 10/12/22 at 3:00 PM, she stated she turned resident #83 during a bath before lunch and returned her to her back. NA #2 stated Resident #83 did not want a pillow under her. An observation on 10/13/22 at 9:58 AM revealed Resident #83 was lying on her back with the head of the bed slightly elevated. An interview was conducted with Physical Therapist (PT) #1 on 10/13/22 at 11:30 AM. She stated she received a referral to evaluate Resident #83's stage four pressure ulcer. She would assess the resident for wound healing modalities and bed mobility for optimal relief of pressure area. PT #1 indicated she had seen the pressure ulcer earlier in the day and stated it appeared worse than the last time she saw it. Resident #83 had not rejected any treatments that were provided in the past. An observation on 10/13/22 at 12:15 PM revealed Resident #83 was lying in bed on her back. During an interview with the Director of Nursing (DON) and a follow up interview with Nurse #1 on 10/13/22 at 12:23 PM, the DON stated nurses should provide pressure ulcer care as ordered. The DON and Nurse #1 confirmed nurses should verify settings on air mattress beds. During an interview with the Administrator on 10/13/22 at 5:07 PM, she stated wound care should be provided as ordered and bed settings should be correct and accurate.

Based on record review and staff interviews, Nurse Practitioner interview and Laboratory Manager, the facility failed to identify a tourniquet that was left on after morning lab draw for 1 of 3 residents (Resident #5), resulting in a bruise, blister and swelling to Resident #5's right wrist. The findings included: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #5 was severely cognitively impaired, total care of 1 to 2 staff assistance with all Activities of Daily Living (ADL) and at risk for pressure injury. A review of the most recent care plan dated 08/19/19 and revised on 07/2/20 revealed goals of assistance with ADL care and risk of pressure injury. Interventions included repositioning every 2 hours and monitor for signs of skin breakdown. A review of physician's orders [REDACTED]. A review of the Point of Care ADL record dated 08/04/20 indicated Resident #5 was provided incontinent care every two to four hours and she received a partial bed bath on 08/04/20. A review of the laboratory requisition form revealed a Phlebotomist (person obtaining blood sample) obtained a blood sample from Resident #5 on 08/04/20 at 3:55am with results reported to the facility on [DATE] at 2:09pm. A review of the nursing note dated 08/05/20 at 2:53pm revealed Resident #5 had a new right wrist bruise. A review of the nursing note dated 08/05/20 at 3:35pm revealed Resident #5 was assessed by the wound team after being informed by Nurse #8 that Resident #5 had right hand swelling and a blister. The note further revealed Resident #5 was unable to verbalize pain and was non-verbal, blisters were observed around Resident #5's right wrist with some swelling. The note revealed an order for [REDACTED]. A review of physician's orders [REDACTED].#5's right wrist blisters with normal saline or wound cleanser and pat dry. The order continued stating to apply Silver [MEDICATION NAME] to affected blisters and cover with dry gauze once daily. This order was discontinued on 08/27/20. A review of Resident #5's x-ray results dated 08/05/20 at 1:53pm showed no evidence of [MEDICAL CONDITIONS] to the right upper arm. A review of the Nurse Practitioner (NP) note dated 08/06/20 at 3:30pm showed an assessment of Resident #5's right wrist and arm, appearing to be healing well. The NP note further revealed the nurse will apply an ice pack to the inflamed area for 15 minutes four times a day while awake for 72 hours. During an interview with the Nurse Aide #15 (NA#15) on 10/13/20 at 3:15pm indicated she worked 11:00pm to 7:00am on 08/4/20 to 08/5/20, she did not recall observing laboratory staff. NA#15 further revealed Resident#5 would have been provided care between the hours of 4:00am to 6:30am to ensure all residents were clean. The NA#15 stated she did not observe a tourniquet on Residents #5's right wrist while providing care. During an interview with the Nurse Aide #17 (NA#17) on 10/12/20 at 12:25pm indicated the she worked with Resident #5 on 08/04/20 and 08/05/20 from 7:00am to 3:00pm. She stated Resident #5 was a total care resident, frequently incontinent, required two-hour repositioning and was non-verbal. The NA #17 stated she gave Resident #5 a partial bed bath on 08/04/20 and did not observe a tourniquet on Resident #5's right wrist during care, the NA #13 further stated Resident #5 usually had blankets over her arms and that it was not always necessary to remove the blankets when providing care. During an interview with the Nurse #8 on 10/15/20 at 1:29pm revealed on 08/05/20, during mid-morning to early afternoon care she noticed Resident #5's right hand to be slightly swollen and there was a tourniquet around Resident #5 right wrist. Nurse #8 stated the tourniquet was tight when she removed it and that she observed three blisters and a small bruise to Resident #5's right wrist. Nurse #8 indicated she had informed the Director of Nursing (DON), NP, Wound consultant Nurse Practitioner (WCNP) and Resident #5's Responsible Party (RP) of the incident and that the NP gave verbal orders for Silver [MEDICATION NAME] and an ice pack to be applied to the right wrist every four hours for 72 hours. During an interview with the WCNP on 10/13/20 at 9:40am revealed she assessed Resident #5 right wrist after being informed by Nurse #8. The WCNP stated Resident #5 had three blisters, small bruise and appropriate pulse in the right wrist. The WCNP further stated she evaluated Resident #5's right wrist as a friction injury. She stated she assessed Resident #5 right wrist once a week for two weeks and the area was resolved by the 3rd week. The WCNP stated if a tourniquet was left in place for 24 hours it would be expected that the Resident's extremity would be cold to touch, pulseless and painful. During an interview with the Laboratory Manager (LM) on 10/15/20 at 3:59pm indicated the DON informed the LM of the incident regarding a tourniquet being left on Resident #5's right wrist. The LM stated the phlebotomist involved was reeducated and provided corrective action. The LM further stated that it was included in the annual competency and new employee orientation not to leave the tourniquet on for longer than one minute as this can affect the laboratory results. During an interview with the NP on 10/15/20 at 10:23am indicated she assessed Resident #5 two times a month or more if necessary. The NP stated the nurse informed her that a tourniquet was discovered on Resident #5 right wrist resulting in 3 blisters a small bruise and slight swelling. The NP stated she gave the facility verbal orders for standard treatment and would assess the resident the following day. The NP further revealed on 08/06/20 Resident #5's right wrist assessment showed no swelling, one small bruise and what appeared to be dry blisters. The NP stated if a tourniquet was left in place for 24 hours it would be expected that the Resident ' s extremity would be cold to touch, pulseless and painful.

Based on record review and physician, staff, and responsible party interviews, the facility failed to prevent elopement from the facility for one of three residents who had cognitive impairment, Resident #1. The facility was unable to account for Resident #1's location for a period of approximately 7 hours until he was found by police at the downtown bus terminal. The immediate jeopardy began on [DATE] when Resident #1 left the facility unobserved. Resident #1 was transported by emergency medical services (EMS) at 8:27 PM to a hospital emergency department after being found by at a bus terminal by police. Resident #1 was admitted to the hospital after the emergency department evaluation revealed acute on chronic congestive heart failure, acute kidney injury, elevated liver function tests, and major neurocognitive disorder. The Immediate Jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential of no more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full corrective action at that time. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Elopement Risk Observation Form competed upon admission to the facility on [DATE] revealed Resident #1 had a total score of 11. The top of the form indicated that a resident with a score of 11 or greater was to have interventions immediately put into place. Some of the interventions on the form were Weekly Behavior Management and Wanderguard Program. (A Wanderguard is a monitoring system to prevent a resident from exiting the facility unsupervised.) This form was not signed by the staff member who completed it. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #1 had severe cognitive impairment and that he exhibited no signs of wandering or rejection of care behaviors. Supervision of one person was required for a walk in his room and for locomotion on and off the unit. The same MDS assessment indicated Resident #1 was not steady while walking or turning around, but was able to stabilize without staff assistance. In addition, he had functional limitation of his upper extremity on one side and that he used no mobility devices. The nursing care plan for Resident #1 which was last updated on [DATE] revealed there were goals and interventions in place for the potential for injury from falls related to general weakness, cognitive deficits, and the use of psychotropic medications. An additional goal with interventions was in place for the potential for side effects and/or adverse reactions related to the use of antidepressants for depression. The care plan did not address Resident #1's risk for elopement. Review of the facility's incident report for the elopement of Resident #1 dated [DATE] at 7:30 PM was reviewed. The report indicated Resident #1 left the faciity on his own and could not be located. The immediate action listed on the report read, Res. (Resident) in ER (emergency room .) The incident report form noted Resident #1 was taken to hospital: (Hospital #1) and that the Interim Director of Health Services prepared the report. In an interview with a responsible party (RP) #1 on [DATE] at 5:45 PM, she stated that she and 2 other RPs called the facility on [DATE] during the evening hours (not certain of the time) to notify the staff that she had talked with Resident #1 on the phone and he stated he was at the bus stop. RP #2 explained she didn't know whether to believe him, and she wanted the staff to check his room to see if he was in the facility. She stated she waited while the staff observed his room, and the staff returned to the phone and reported he was not there. RP #2 added that she and the 2 other RPs came to the facility at that point to help find him. She stated she called the police and that the facility also called the police, and that the police called the facility back later that evening to say that Resident #1 had been found at the hospital's emergency department. In an interview with Nursing Assistant (NA) #1 on [DATE] at 10:50 AM, he stated he was working 7:00 AM to 3:00 PM on [DATE], but Resident #1 was not on his assignment. He stated he received a call from a facility staff member after he left work that day (not sure of the time) to ask him if he had seen Resident #1. He stated he told the staff member he had last seen Resident #1 around 1:00 PM on [DATE] as he passed by his room. On [DATE] at 10:59 AM, an interview was conducted with NA #2, who was assigned to care for Resident #1 on the 3:00 PM to11:00 PM shift on [DATE]. NA #2 stated she arrived about 3:30 PM for her shift and that she did not see Resident #1 in his room at that time. She explained she saw his lunch tray sitting on the over bed table and it still had the cover over the plate as though it had not been eaten. NA #2 explained she thought he was probably out with family members, as he did this from time to time. She added that she did not check the sign out book at the nurse's station and took no other action to locate Resident #1. The interview with NA #2 continued, and NA #2 stated she then assisted other residents with their supper meals around 5:00 PM in the dining room. NA #2 did not pass out dinner trays on the hall. She explained that sometime after dinner, Nurse #1 informed her that Resident #1 could not be found, so she started to search for him in his room, the bathroom, the rest of the hall, and the other floors in the facility. NA #2 further clarified that Resident #1 was ambulatory, did not have a Wanderguard and was free to walk to other areas of the facility and go outside. She added there was no code needed for the residents to access the elevator to go to other areas of the facility, and since Resident #1 had no Wanderguard, there was no alarm that would sound if he boarded the elevator or exited the facility. In an interview with the MDS Nurse on [DATE] at 2:37 PM, she stated the Elopement Risk Observation Form was typically completed by the nurse who admitted the resident and she acknowledged the form dated [DATE] with the total score of 11 was not signed. The MDS Nurse stated that the nursing department, would initiate a Wanderguard for residents who were at a high risk for elopement based on Resident #1's score of 11. In a telephone interview with the Interim Director of Health Services (IDHS) on [DATE] at 11:32 AM, she stated she received a call from Nurse #1 on Sunday night, [DATE], (was not certain of the time) to inform her that Resident #1 was missing from the facility. She explained she did not come in to the facility at that time because she did not live in the area. In an interview with NA #3 on [DATE] at 12:50 PM, she stated she was on duty on the 3:00 PM to 11:00 PM shift when Resident #1 wandered away from the facility. She indicated she first became aware that Resident #1 was not in his room on [DATE] when she was picking up dinner trays around 7:00 PM. NA #3 explained that she and another nursing assistant were asked to search for him, so they drove through nearby apartment complexes, gas stations, and the bus terminal and they were unable to find him. She stated they continued looking for him until it got too dark and then they returned to the facility. NA #3 added that typically, the resident was quiet and did not socialize much, but he did come out of his room and was ambulatory. On [DATE] at 2:10 PM, and interview was conducted with Nurse #1 who was on duty on [DATE] on the 3:00 PM to 11:00 PM shift. Nurse #1 stated the Resident #1 had free access to the building, so when he was not in his room, it was possible he was elsewhere on the campus. She explained he did not have a Wanderguard and at times, he would sit outside the facility. Nurse #1 stated on [DATE], Resident #1's family member had called the facility (could not recall what time it was) and asked her if Resident #1 was in the facility, so she went to check his room and noted he was not there. Nurse #1 returned to the phone and informed the family member he was not in his room, and she would check other areas of the facility and call her back. At that time, she asked two nursing assistants to search other floors of the facility, including the basement level. Nurse #1 stated she called the family member back and reported he was not in the facility, and the family member responded she had called his cell phone, and that Resident #1 stated he was at the bus the bus terminal. Nurse #1 stated she then asked the two nursing assistants to go to the bus station to search for him. She added that she called the police and notified the IDON and the Administrator. In addition, Nurse #1 confirmed she was the nurse who filled out the Elopement Observation Risk Form upon his admission on [DATE]. She stated she was told she should have notified the IDHS and initiated behavior monitoring and the Wanderguard Program. She did not specifically remember who told her this, but said she had received in-service education after Resident #1 eloped from the facility. In a follow up interview with Nurse #1 on [DATE] at 11:25 AM, she stated the police notified her around 9:00 PM on [DATE] that Resident #1 was found at the bus terminal by a bystander who called EMS. In an interview with the Administrator and the current Director of Health Services (DHS) on [DATE] at 4:11 PM, the DHS explained she was not involved with the elopement incident for Resident #1 because she was not the DHS at that time. She stated that her role at that time was as a Nurse Navigator, a type of case manager for residents. The Administrator stated the last time the facility could confirm that Resident #1 was seen on [DATE] was at 1:00 PM. The Administrator stated he was called about 7:30 or 7:45 PM on [DATE] by Nurse #1 who reported Resident #1 was not in the facility. He added that he asked Nurse #1 to notify all staff in the building and to assign nursing assistants to search outside. He further stated that Nurse #1 contacted him between 8:00 PM and 9:00 PM to report he was found by the police and that the police reported Resident #1 was taken to the hospital by an emergency medical service (EMS.) The Administrator said that he was never able to confirm who called the EMS, but that police reported he was found at the bus station. The DHS stated Nurse #1, the admitting nurse who filled out the Elopement Risk Observation Form, should have contacted a supervising nurse to initiate behavior monitoring and a Wanderguard program. During the interview on [DATE] at 4:11 PM with the Administrator and the DHS, they provided a corrective action plan the facility had initiated on [DATE] which included educating the nursing staff about the use of the Wanderguard for all residents who had a risk score of 11 or greater with a Brief Interview for Mental Status (BIMS) score of below 13. (A BIMS score below 13 indicates impaired cognition.) On [DATE] through [DATE], Elopement Risk Observation Forms and BIMS assessments were completed for all residents in the facility and Wanderguards were initiated for those who were assessed as needing one. Follow up with 10% of the staff each week was being completed to test staff on knowledge of information provided in in-service education. Care plans were being updated for those residents who were found to be at risk for elopement and behavior monitoring was being completed weekly in the medication administration records. There was no root cause analysis included in the corrective action plan. A review of the EMS report dated [DATE] revealed EMS was dispatched to assist the police department for a sick person call. Upon initial assessment at 8:17 PM, Resident #1 had an altered level of consciousness with confusion and disorientation and a heart rate of 95. The report further indicated the resident had bilateral swelling in his feet and that he was transferred to the hospital at 8:27 PM. The hospital discharge summary dated [DATE] from Hospital #2 indicated Resident #1 was disoriented upon evaluation in the emergency department and was admitted to the coronary intensive care unit on [DATE] with [DIAGNOSES REDACTED]. Upon discharge from the hospital, the [DIAGNOSES REDACTED]. (Cardiogenic shock is a condition in which your heart suddenly can't pump enough blood to meet your body's needs.) In an interview with Resident #1's physician on [DATE] at 1:17 PM, he stated he had end stage congestive heart failure and was experiencing a slow decline in health and that he felt there was no long term effect on the resident's health due to the elopement. He added that Resident #1 was capable of walking and that it would have been possible for him to ambulate a distance of 3 miles. Per the google maps revealed the distance between the facility and the bus terminal was 3.0 to 4.5 miles, depending on which route was used. The weather conditions per AccuWeather on [DATE] for the facility's city was 81 degrees Fahrenheit. The Administrator and DHS were notified of Immediate Jeopardy on [DATE] at 6:50 PM. On [DATE] at 6:35 PM, the facility provided an acceptable credible allegation as follows: Process that lead to the Deficiency: Resident was admitted to the facility on [DATE], Root Cause Analysis: Failure to provide supervision to prevent elopement. His elopement risk assessment score was 11 (high risk). The facility did not initiate interventions to prevent elopement at that time. Elopement Observation was not completed appropriately. Admitting Nurse was not properly trained on completing the elopement risk observation form. Nurse Management change specific to Director Health Services and Clinical Competency Coordinator, caused a gap in orientation and education for licensed staff. Resignation of positions. On [DATE] resident was last observed on third floor at approximately 1300. Facility was made aware that he was not on the premises when the resident's mother called the facility at approximately 1930 and asked the charge nurse to establish if the resident was in the room. The charge nurse quickly checked the room and informed the mother that the resident was not in his room. The mother at this point informed the charge nurse that the resident had called his sister and said he was trying to get home but had missed the bus. At around 7:54pm, charge nurse notified Administrator and Director of Health Services. At around 8:17pm, the charge nurse called 911 to report the resident missing. The Nurse described the last location the resident was seen, third floor at approximately 1300, description of clothing (tan pants, dark shirt and black lace up shoes) that he was wearing as well as the physical description of resident including height and weight of resident. Around 8:30pm, the police officer arrived to gather more information about the resident (physical description again). At approximately 9:00pm, the police officer informed the charge nurse that the resident had been located in Duke Hospital ER. The Resident was readmitted [DATE] at 4:00pm and was reassessed for elopement by the Licensed Nurse; a wander guard was then put into place. The Resident's description and picture was placed in the wander guard book by the Medical Records Director. Resident expired in the facility on [DATE] of CHF. Process for implementing the acceptable plan of correction for specific deficiency. On [DATE], all other residents were accounted for in the facility. 100% elopement assessments were initiated on [DATE] and completed on [DATE] by the Director of Health Services and Nurse Management team. Residents with a score of 11 or above, indicating a high-risk for elopement and that have a BIMS score of less than 13, and/or not alert and oriented, had a wander guard placed immediately. The residents were assessed by the Interdisciplinary Team for further intervention recommendations. Three-day behavior logs were initiated for residents who are able to move self throughout the facility with a score of ,[DATE], identified medium risk on elopement observation form, and were kept on behavior management for 4 weeks. Care plan interventions were implemented, reviewed and / or revised as needed based on the assessment. Education was initiated on [DATE] by the Administrator, Director Health Services, Clinical Competency Coordinator, Nursing Management team and Department managers for all staff on elopement including assessment of risk, signs of exit seeking behavior, location of the elopement risk book and, who to report signs of exit seeking behavior to 100% education was completed by [DATE]. Staff members who have not completed the education will not be allowed to work until they are educated. All newly hired staff will be educated on elopement during new hire orientation by the Director of Health Services and/or the Clinical Competency Coordinator. Elopement Risk Observation forms will be completed on admission/readmission, quarterly and change of condition. Care plans will be updated with assessment/observation as needed to ensure compliance. Licensed nurses will place immediate intervention to include but not limited to placing the resident on 1:1, complete an elopement observation form, a picture will be placed in the wander guard notebook/elopement risk book with description of the resident; a wander guard will be placed on the resident as needed. The Maintenance Supervisor and/or Housekeeping Supervisor will check doors for wander guard compliance using the wander guard tester every day. The Maintenance Director will educate all department heads and weekend supervisors on checking doors for wander guard compliance. On the weekend, the supervisor and/or the Manager on Duty will check the doors for wander guard compliance. Monitoring procedure to ensure that the plan of correction is effective. As of [DATE], an elopement observation audit tool is being utilized by licensed nurse and reviewed by the Director of Health Services, Assistant Director of Health Services and/or Nurse Managers daily for 1 week, then 2x weekly for 3 weeks, then weekly for 4 weeks and, monthly for 1 month. The results of the data collected and interventions implemented of the elopement risk observation audit with tracking and trending by the Director of Health Services will be taken to the Quality Assurance / Performance Improvement Committee by the Director of Health Services until 6 months of continued compliance has been sustained. A questionnaire on elopement is being completed with 10% of all staff by the Administrator, Director of Health Services, Clinical Competency Coordinator and, Department Managers weekly for 4 weeks then monthly for 2 months to ensure compliance is maintained. The results of the elopement questionnaire will be correlated by the Administrator and reported in the Quality Assurance / Performance Improvement Committee until 6 months of continued compliance has been sustained Title of Person Responsible for implementing the acceptable plan of correction. The Administrator is responsible for implementing the acceptable plan of correction. On ,[DATE] at/2017 at 7:45 PM, validation of the credible allegation was evidenced via interviews with nurses, nursing assistants, residents, and unit supervisors who stated they received in-service education regarding the importance of observing for signs of elopement. Nurses stated they understood the need for completing elopement risk assessments accurately upon admission and after a significant change in condition especially for residents who had severe cognitive impairment. Staff also stated that residents who had a risk of elopement had pictures with their names in an elopement book kept at the nurse's stations for ready reference. An observation of the facility's two exit doors were observed for Wanderguard function, and each door's alarms and locks engaged upon activation by the Wanderguard. There were no residents observed in the outside area at the time of validation.

Based on record review and physician, staff, and responsible party interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to identify how a cognitively impaired resident exited the facility without supervision in order to prevent future elopement. This was evident in one of three cognitively impaired resident with exit seeking behaviors. (Resident #1). The facility was unable to account for Resident #1's location for a period of approximately 7 hours until he was found by police at the downtown bus terminal. The immediate jeopardy began on [DATE] when the facility failed to do a root cause analysis in an attempt to determine how Resident #1 left the facility unobserved. Resident #1 was transported by emergency medical services (EMS) at 8:27 PM to a hospital emergency department after being found at a bus terminal by police. Resident #1 was admitted to the hospital after the emergency department evaluation revealed acute on chronic [MEDICAL CONDITION], acute kidney injury, elevated liver function tests, and major neurocognitive disorder. The Immediate Jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential of no more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full corrective action at that time. Findings included: This tag is cross referenced to F323: Based on record review and physician, staff, and responsible party interviews, the facility failed to prevent elopement from the facility for one of three residents who had cognitive impairment, Resident #1. The facility was unable to account for Resident #1's location for a period of approximately 7 hours until he was found by police at the downtown bus terminal. An interview was conducted with the administrator on [DATE] at 1:52 PM regarding the Quality Assurance (QA) program. The administrator said the facility has a QA committee consisting of the medical director, director of nursing, administrator, pharmacy consult, staff development coordinator, case manager, and department heads. The committee met monthly and quarterly. All quarterly meetings were attended by the medical director and the pharmacy consultant. The administrator stated the facility identified concern or issues for QA activity by: The clinical meeting was conducted daily Monday through Friday to discuss issues documented in the 24 hour report identified by nursing, new admissions and any other issues that were brought up. The QA identified concerns through grievances from residents and families. The facility department heads did daily compliance rounds Monday through Friday to identify any concerns also. The QA addressed non-compliance identified during surveys and the facility by putting a plan of correction in place containing the four components of a plan of corrections as required by the federal regulations. The administrator said the facility did not differentiate in the plan of correction between a federal tag or a concerns identified by the facility during QA activity. If non-compliance continued then the monitoring will be extended until compliance is achieved. The administrator stated there were two doors in the facility and both were equipped with wander guard system. The resident could have got out from either one of these doors since he did not have a wanderguard. The Administrator was notified of Immediate Jeopardy on [DATE] at 6:50 PM. On [DATE] at 6:35 PM, the facility provided an acceptable credible allegation as follows: Process that lead to the Deficiency: Root Cause Analysis: The Quality Assurance process was ineffective to address supervision, MDS assessment and care plan. QA process was not properly implemented. Director of Nursing was not properly trained on QA process. DON was new to her position and new to being a DON. Resignation of positions. On [DATE] Resident #1 was last observed on third floor at approximately 1 PM. The facility was made aware that he was not on the premises when the resident's mother called the facility at approximately 8:30 PM and asked the charge nurse to establish if the resident was in the room. The charge nurse quickly checked the room and informed the mother that the resident was not in his room. The mother at this point informed the charge nurse that the resident had called his sister and said he was trying to get home but had missed the bus. At around 7:54pm, charge nurse notified Administrator and Director of Health Services. At around 8:17pm, the charge nurse called 911 to report the resident missing. The Nurse described the last location the resident was seen, third floor at approximately 1 PM, description of clothing (tan pants, dark shirt and black lace up shoes) that he was wearing as well as the physical description of resident including height and weight of resident. Around 8:30pm, the police officer arrived to gather more information about the resident (physical description again). At approximately 9:00pm, the police officer informed the charge nurse that the resident had been located in Duke Hospital ER. The Resident was readmitted [DATE] at 5 PM and reassessed for elopement by the Licensed Nurse; a wander guard was then put into place. The Resident's description and picture were placed in the wander guard book by the Medical Records Director. Resident expired at the facility on [DATE] of [MEDICAL CONDITION]. Process for implementing the acceptable plan of correction for specific deficiency. QA process will be reviewed to put emphasis and focus on root cause analysis to drill down to underlying cause of issues related to supervision to prevent accidents, MDS assessments and care plans related to resident wandering and elopement risk. MDS assessments are being reviewed upon admission and significant change for accuracy according to RAI manual, for wandering and supervision, by the IDT during daily risk meeting. Based on the elopement observation scores in conjunction with the BIMS scores the Care plans will be updated to reflect interventions put in place. The Administrator and the Director of Health Services will educate all staff with emphasis and focus on the root cause of what led to the deficiency. Monitoring procedure to ensure that the plan of correction is effective. Administrator will lead QA meetings with emphasis and focus on root cause analysis in order to assure that basis of issue is addressed to prevent further deficient practices related to MDS assessment, Care Plans and supervision to prevent elopement. Members of the regional team to include senior nurse consultant, clinical reimbursement consultant or area vice president will attend QA meetings for the next six months to ensure that root cause analysis is an integral part of QA process. Title of Person Responsible for implementing the acceptable plan of correction. The Administrator is responsible for implementing the acceptable plan of correction. Validation of the credible allegation of removal of the immediate jeopardy was conducted on [DATE] at 5:15 PM. The administrator was interviewed and verbalized understanding of the need for a root cause analysis of how the resident left the building. The Administrator could not determine for sure how the resident left the building. Record review revealed that elopement risk observation forms were completed on all residents on [DATE]. Record review of the inservice education records sign in sheet revealed facility staff were inserviced regarding elopement policy and Code Pink on [DATE], [DATE] and [DATE]. Nurses and nursing assistants were interviewed on the 100, 200 and 300 Halls. The nurses and nursing assistant acknowledged that they received inservices few weeks ago regarding residents at risk for elopement. The nurses and nursing assistants were able to verbalize the process as described in the facility credible allegation of removal. A sample of residents with wander guard were checked for placement and functionality of the wander guard placement.

Based on record review, observation and staff, family and eyewitness interviews the facility failed to lock the wheelchair and failed to place a resident on a level surface during a scheduled appointment to an outlying medical clinic in which a resident fell from the wheelchair and sustained a left orbital (bone of the eye socket) fracture and laceration of the scalp for 1 of 1 sampled residents (Res # 205) that required staff supervision for outside appointments. Findings included: Review of the medical record revealed resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was moderately cognitively impaired, needed a wheelchair for mobility and was only able to stabilize from sitting to standing with human assistance. Resident #1 's care plan initiated on 2/5/2016 and updated on 2/14/16 and 3/12/2016 indicated the potential for injury from falls related to recent history of fall, impaired mobility, general weakness, and seizure disorder. The goal was resident would have no fall related injuries through the next review. Interventions included to keep pathways clear and free of obstacles and to maintain safety with transfers. Review of the clinical medical record revealed the resident was transported to a local clinic appointment via wheelchair by a transport company on 3/22/2016. The resident was accompanied by a facility nursing assistant (NA) #1. In an interview with NA#1 on 3/30/16 at 3:10 PM, NA#1 indicated she accompanied the resident to the appointment on 3/22/2016. NA#1 reported the appointment was completed at approximately 11:30 AM and she notified the transport company via telephone they were ready to go back to the facility. NA#1 reported within 15 minutes of the call, the van arrived and NA#1 propelled the resident in his wheelchair to meet the van outside the clinic. NA#1 reported she propelled the resident in his wheelchair to the sidewalk to wait for the van to back up. NA#1 reported she looked over her left shoulder and noticed a clinic employee walking toward the sidewalk. NA#1 reported she recalled her hands were not on the resident 's wheelchair at that time. NA#1 indicated when she looked back toward the resident, his wheelchair had rolled down the sidewalk. NA#1 indicated she did not lock the wheelchair. The NA#1 stated I don't know why I didn't lock the wheels, I knew I was supposed to. NA#1 reported she saw the resident going forward out of the wheelchair and could not stop him and the resident fell from the wheelchair and onto the pavement with the left side of his face on the pavement. NA#1 revealed resident's eyes were open and he was bleeding from a cut over his left eye. NA#1 further revealed an employee from the clinic immediately assessed the resident and ran back in the clinic to call for assist. NA#1 indicated the clinic employee returned within just a few seconds and stayed with the resident until the ambulance arrived. NA#1 reported she made a call to the facility and spoke with the Director of Nursing (DON) to inform her of the incident. NA#1 was unsure what time the call was made but recalled the DON instructed NA#1 to take a picture of the resident (with her cell phone), to stay with the resident and to keep the DON updated on the resident's condition. NA#1 stated the DON notified her around 5:00PM to return to the facility. NA#1 indicated she returned to the facility, wrote a statement on the incident and went home. NA#1 reported the DON called her at home later that evening and told her she was suspended for 3 days. NA#1 indicated she returned to work on 3/28/2016. An interview was conducted on 3/31/16 at 11:40 AM with the clinic employee who witnessed the incident on 3/22/2016. The employee stated she witnessed the entire incident. The employee reported she walked out of the building around noon and noticed the resident in the wheelchair close to the curb. The employee reported the NA was standing beside the resident's wheelchair. The employee stated NA#1 left the resident unassisted and walked toward the employee. The employee looked over the NA#1 ' s shoulder and saw the resident's wheelchair as it rolled down and over the curb. The employee reported she ran to the resident and he had fallen down the curb in his wheelchair and the wheelchair was on top of him. The employee reported the resident's right foot was caught in the wheel of the chair and she had to get his foot out before the chair could be removed. The employee reported the resident was lying on the pavement with the left side of his face on the pavement. He was bleeding from the left side of his face. The employee indicated she assessed him briefly to make sure he was breathing and the resident took a deep breath and coughed a little. The employee noted the resident had a pulse and was attempting to verbally respond. The employee reported the resident didn't respond to her commands initially although his eyes were opened, but when she talked louder it was evident he was hard of hearing. The employee indicated when she talked louder the resident responded and moved his eyes on command. The employee reported she instructed NA#1 to stay with the resident and she ran to the clinic to call Emergency Medical Services (EMS). The employee indicated being gone for only a couple of minutes and returned to stay with the resident until EMS arrived. The resident was transported to the emergency room . On 4/1/2016 at 9:00 AM the area where the incident occurred was observed. NA#1 and the facility DON were present. The area was observed to be the designated pick up area for patients from the clinic and was located directly in front of the clinic/office building. The area was covered by a stationary canopy. There was ample room for transport vehicles to drive through. There was a curb along the flat concrete surface and a sloped area leading to a wheelchair access. There was approximately a 20-25 degree incline which was the wheelchair access from the flat concrete surface to the drive through area. NA#1 stood in the area where she placed the resident in his wheelchair on the day of the incident. The placement was approximately 12 to 18 inches from the curb and at the beginning of the incline. NA#1 reported the right side of the resident's wheelchair rolled on the incline and the left side went over the curb which caused the resident to fall from the wheelchair to the drive through area. NA#1 indicated the resident landed on his left side with the left side of his face on the drive through area. NA#1 stated she did not lock the wheelchair and did not know why. Review of the emergency room hospital records dated 3/22/2016 revealed the resident sustained [REDACTED]. A physician note dated 3/23/2016 at 1:40 AM revealed the resident was admitted to the hospital after completion of initial emergency department evaluation and it was determined that resident required further evaluation and treatment in a hospital setting. The resident's hospital admitting [DIAGNOSES REDACTED]. -Urinary Tract Infection -Laceration of scalp -Fracture of lateral wall of orbit -Dementia An interview was conducted with the DON and Administrator (ADM) on 4/1/2016 at 2:00 PM. The DON reported NA#1 had called the facility and reported the incident at approximately noon on 3/22/2016. The DON stated she instructed NA#1 to take a picture of the accident scene and to stay with the resident. The DON reported she also instructed NA#1 to call with the resident's condition when updated. The DON reported she called the resident's responsible party to inform him of the incident and transfer to the emergency room . The DON indicated later in the evening on 3/22/2016 she notified NA#1 and instructed her to return to the facility. The DON also reported she sent another NA to sit with the resident but at that time the family was present and requested for the NA to leave. The DON revealed NA#1 returned to the facility and was require to recall the incident before any more time had passed to ensure the recollection was correct. NA#1 indicated to the DON the wheelchair was not locked and NA #1 had let go of the wheelchair for just a few seconds and the incident occurred. The DON stated NA#1 was suspended on the evening of 3/22/2016 pending the investigation results. In the interview with the DON, the DON stated it was her expectation for facility staff to ensure the safety of all residents. The DON also stated her expectation when a resident required facility staff to accompany for outside appointments, was for the staff member to provide the necessary supervision to prevent accidents. During the interview, the ADM revealed his expectation was the same as the DON.

Based on record review, physician, and staff interviews, the facility failed to immediately notify the physician when 1 of 1 sampled residents (Resident # 3) was found arousable only to sternal rub. Findings included. Resident # 3 was admitted to the facility on [DATE] with re-admissions on 1/2/2014, 1/6/2014, and 1/10/2014. [DIAGNOSES REDACTED]. Hospital records reviewed documented that in November 2013 Resident # 3 had a Transjugular intrahepatic portosystemic shunt (TIPS) which was a procedure to create new connections between two blood vessels in the liver due to severe liver problems. The Nurses' notes for 1/6/2014 documented that Resident #3 arrived at the facility around 6 pm, was alert and responsive with no complaints of pain or discomfort. On the Admission physician's orders [REDACTED]. Also noted was [MEDICATION NAME] (20 gm/30 ml) po q 4 hrs as needed titrate to 3-4 bowel movements) per day The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Rifaximin 550 mg po bid had no initial for 5 pm on 1/6/2014 and a circled initial for 9am on 1/7/2014. The back of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 1/7/14 at 2 am the Nurses' notes indicated no distress was observed for Resident #3. At 8 am Resident #3 was assessed by the nurse manager and aroused enough to open eyes with sternal rub being done and moaned a little. Will continue to monitor and have MD (physician) to see patient today. The 12pm note indicated the nurse manager assessed Resident #3 and found no changes. A review of the Physician's 1/7/2014 Transition into care note revealed the following. After hospitalization the [MEDICATION NAME] was titrated up to q 6 hrs. He was transferred back to the facility on [DATE] and it is not clear whether he tolerated his oral medications. Today on my exam he was not responding to stimulation, painful stimulation, or sternal rub. Staff stated resident not able to take medications due to somnolence, decreased level of consciousness. Patient will be transferred to the hospital via EMS (emergency medical services). The Nurses' note for 2:30 pm documented the MD was with the patient and orders given to send the resident to the hospital. At 3:50 pm 911 was called and at 4:15 pm Resident #3 was transported to the hospital On 1/17/2014 at 8:45 am Nurse #5 stated that on 1/7/2014 when she went to give Resident #3 his morning medications he was so lethargic that he could not take his medications. His medications at 1pm on 1/7/2014 were also held due to the lethargy and then he was sent to the hospital. Nurse #5 said the MD or NP was there on the morning of 1/7/2013 and assessed Resident #3 and said if he wasn ' t more alert by afternoon to send him to the hospital. During an interview on 1/17/2014 at 10:10 am the physician (also the Medical Director for the facility) who sent Resident #3 to the hospital on [DATE] stated that she saw him on 1/7/13 for a re-admission note. She was not sure what time she saw Resident #3, but thought it was around noon and the nurse reported that he had not taken his scheduled [MEDICATION NAME] for her due to his lethargy. The physician said when she examined Resident #3, he was limp and very lethargic. She indicated he did not respond at all for her sternal rub. She added that with his advanced liver disease missing 1 or 2 doses of [MEDICATION NAME] would lead to the same effect. Asked when he missed his doses what were her expectations of the nurse, she responded that she expected the nurse to call right away. When Resident #3 was arousable only to sternal rub, she would have expected someone to call the physician service or the physician herself. If she had known he had missed his medications and had lethargy, she would have sent him to the hospital right away. During an interview on 1/17/2014 at 2:33 pm, the nurse manager stated that if she knew the physician was coming to the facility that day, she waited for the physician to come to the floor to see the patient to inform them about changes. She added that when the nurse told her Resident #3 was lethargic on 1/7/2014 and she assessed the resident she was not aware that he had missed any doses of his [MEDICATION NAME]. The nurse manager further stated that she didn't check the MAR indicated [REDACTED]. She added that none of the nurses told her Resident #3 had missed any medications. On 1/17/2014 at 4:49 pm the Director of Nurses (DON) was asked what her expectations were of her nurses if a resident had altered mental status such as arousing only to sternal rub. The DON said she expected the nurse to notify the physician.

Based on observation, record review, physician, and staff interviews, the facility failed to administer physician ordered medications resulting in two hospitalization s for one of five residents sampled for medication administration (Resident #3). Findings included: Resident # 3 was admitted to the facility on [DATE] with re-admissions on 1/2/2014, 1/6/2014, and 1/10/2014. [DIAGNOSES REDACTED]. Hospital records reviewed documented that in November 2013 Resident # 3 had a Transjugular intrahepatic portosystemic shunt (TIPS) which was a procedure to create new connections between two blood vessels in the liver due to severe liver problems. Record review found no completed Minimum Data Set (MDS). The MDS nurse stated on 1/16/2014 at 10:27 am that Resident # 3 had not been in the facility enough consecutive days to complete the MDS which was in progress. The Interim Care Plans for 1/2/2014, 1/6/2014, and 1/10/2014 were reviewed with diabetes, abdominal pain, and skin impairment being addressed. Physician orders [REDACTED]. The Medication Administration Record (MAR) for December 23-27, 2013 documented that Resident #3 received each ordered dose of [MEDICATION NAME] 30 ml po (by mouth) and Rifaximin 500 mg po starting the night of 12/23/2014 and ending with the last dose the morning of 12/27/2014 before going to the hospital. physician progress notes [REDACTED]. Initially resident was able to sit up in bed and communicate with staff. Today it was reported that he had been presenting with increased lethargy and somnolence since 2 days ago. His ammonia level yesterday was 177 (normal 20-70). On eval very lethargic. Will transfer to the hospital for further management. Review of a hospital Discharge Summary dated 1/2/2014 found that Resident #3 had been admitted on [DATE] with altered mental status secondary to hepatic [MEDICAL CONDITION]. Resident #3's ammonia level checked at the facility was 177. The summary noted that the [MEDICAL CONDITION] gradually occurred despite receiving the ordered doses of [MEDICATION NAME] 20 gm in 30 ml bid and Rifaximin 550 mg bid. On discharge the [MEDICATION NAME] was increased from bid to three times a day (tid) and Resident #3 was counseled on the importance of taking the [MEDICATION NAME] titrated to 2-3 bowel movements per day. (The liver normally breaks down ammonia, but in liver disease such as [MEDICAL CONDITION] the blood may bypass the liver, allowing this poisonous substance to pass to the brain. Here it can impair brain function, causing confusion, drowsiness and finally coma. Per the 2013 Lippincotts Nursing Drug Handbook [MEDICATION NAME] causes the migration of blood ammonia into the colon trapping and expelling it in the feces. Rifaximin is used for reduction of recurrence of hepatic [MEDICAL CONDITION] in patients with advanced liver disease.) A review of Nurses' notes found that Resident # 3 arrived at the facility on 1/2/2014 around 5:45 pm, was able to verbalize needs, had no pain or distress. Medications were verified by the nurse practitioner (NP) and faxed to the pharmacy. On the Admission physician's orders [REDACTED]. The MAR for 1/2-1/31/2014 was reviewed. For 1/2/2014 the MAR had no initials indicating administration of [MEDICATION NAME] 30 ml po at 5 pm and the initials were circled at 9am and 1pm on 1/3/2014. Rifaximin 550 mg po bid had no initials on 1/2/2014 at 5 pm and the initials were circled for 9am on 1/3/2014. There was no documentation on the back to indicate the reason for missed doses. Circled initials indicated the medication was not given. On 1/3/2014 the notes indicated that at 2 am Resident # 3 was alert and oriented, able to make needs known. At 8 am the nurse manager noted that during rounds Resident #3 was found to be very lethargic and unable to arouse. "Will have Dr. to see this am." At 9 am the note indicated the physician was there to see the patient and new orders were written. At 2 pm the note indicated there was an order to send Resident #3 to the hospital and at 3 pm 911 was there to transport. A physician order [REDACTED]. Physician's Progress Note of 1/3/2014 Transition into care was reviewed for the following information. [MEDICATION NAME] was increased to tid ...On eval today pt (patient) was resting in bed, asleep, difficult to arouse, unable to keep eyes open or answer simple questions. According to daytime nurse, he had been like this all morning today and was not able to eat lunch due to AMS (altered mental status). Nighttime nurse reported he was awake and alert .... "Since he failed to wake up and become more interactive as was his baseline and requested blood work won't be available today, will transfer back to the hospital." A review of the hospital Discharge Summary dated 1/6/2014 noted that Resident # 3 was admitted to the hospital on [DATE] with hepatic [MEDICAL CONDITION] with altered mental status and somnolence. His ammonia level on admission was 181. The summary indicated that it was thought the cause was possibly due to missed doses of [MEDICATION NAME]. After being given [MEDICATION NAME] in the hospital by a nasal gastric (ng) tube over 12 hours, Resident # 3 was back to his baseline. On discharge the [MEDICATION NAME] was being given by mouth and was to be given q (every) 6 hours. The patient was instructed to continue his scheduled [MEDICATION NAME] as prescribed to avoid altered mental status again. Instructions noted the [MEDICATION NAME] was to be given for a goal of 3-4 bowel movements a day. If the scheduled dose was not sufficient to achieve 3-4 bowel movements a day extra doses could be given q 4 hours. The Nurses' notes for 1/6/2014 documented that Resident #3 arrived at the facility around 6 pm, was alert and responsive with no complaints of pain or discomfort. On the Admission physician's orders [REDACTED]. Also noted was [MEDICATION NAME] (20 gm/30 ml) po q 4 hrs as needed titrate to 3-4 bowel movements per day The MAR for January 6-31, 2014 in review revealed that on 1/6/2014 [MEDICATION NAME] 30 ml po was initialed given at 6 pm, had no initials for 12 midnight or 6 am and had circled initials for 12 noon. The Rifaximin 550 mg po bid had no initial for 5 pm on 1/6/2014 and a circled initial for 9am on 1/7/2014. The back of the MAR documented that at 9 am and 12 noon all meds were held due to resident very drowsy at 9am and unable to rouse at noon. The MAR had not documented any PRN (as needed) doses of [MEDICATION NAME] given. On 1/7/14 at 2 am the notes indicated no distress was observed for Resident #3. At 8 am Resident #3 was assessed by the nurse manager and aroused enough to open eyes with sternal rub being done and moaned a little. Will continue to monitor and have MD (physician) to see patient today. The 12pm note indicated the nurse manager assessed Resident #3 and found no changes. A review of the Physician's 1/7/2014 Transition into care note revealed the following. After hospitalization the [MEDICATION NAME] was titrated up to q 6 hrs. He was transferred back to the facility on [DATE] and it is not clear whether he tolerated his oral medications. Today on my exam he was not responding to stimulation, painful stimulation, or sternal rub. Staff stated resident not able to take medications due to somnolence, decreased level of consciousness. Patient will be transferred to the hospital via EMS (emergency medical services). The Nurses' note for 2:30 pm documented the MD was with the patient and orders given to send the resident to the hospital. At 3:50 pm 911 was called and at 4:15 pm Resident #3 was transported to the hospital The hospital Discharge Summary dated 1/10/2014 for an admission on 1/7/2014 was reviewed. The Summary indicated that Resident # 3 was again admitted for portosystemic [MEDICAL CONDITION]. His ammonia level was 163. Search for the cause of the recurrent hepatic [MEDICAL CONDITION] "revealed medication noncompliance by the facility." The Summary added that the physician spoke with the 7 am to 3 pm nurse and had her read the Medication Administration Record (MAR) revealing that Resident # 3 went 24 hours without receiving any [MEDICATION NAME] resulting in the [MEDICAL CONDITION]. The physician noted that he had spoken with Resident # 3's regular care nurse and again emphasized the importance of not missing any doses of [MEDICATION NAME] given his TIPS procedure and his high tendency to develop hepatic [MEDICAL CONDITION]. The physician added that attempts had been made to contact the medical director of the facility to express the concerns and avoid recurrent facility caused hepatic [MEDICAL CONDITION]. The Admission Physicians Order sheet dated January 10, 2014 included [MEDICATION NAME] (20 gm/30 ml) po q 6 hrs at 6 am, 12 noon, 6 pm, 12 midnight start per order at 12 midnight, Rifaximin 550 mg po daily at 9am, [MEDICATION NAME] 20 gm po q 4 hrs as needed for titrate 3-4 BMs/day. The MAR for 1/10-1/31/2014 documented that Resident #3 had received each ordered dose of [MEDICATION NAME] 30 ml po and Rifaximin 550 mg po since his return on 1/10/2014. An observation was made of Resident # 3 on 1/15/2014 at 3:31 pm lying in his bed awake and alert. When asked if he was doing all right, he replied "I am trying to." On 1/15/2014 at 3:36 pm the nurse manager stated in an interview that Resident #3 had been to the hospital 3 times for end stage liver disease with high ammonia levels. She added that Resident #3 was on [MEDICATION NAME] for the ammonia and had refused a couple of doses. With missing doses she said his ammonia levels go up. She educated him and he had been taking it since he came back. Resident #3 was now on the [MEDICATION NAME] q 6 hours and PRN Resident # 3 was observed during Medication Administration observation on 1/15/2014 at 4:10 pm. He was alert and aware of each medication he received. He kept asking if it was time for his [MEDICATION NAME]. Nurse # 3 explained that his [MEDICATION NAME] was due at 6 pm so it was too early to give it at this time. Asked if he knew why he received the [MEDICATION NAME], Resident # 3 said yes he did At 9 am on 1/16/2014 Nurse #5 stated in an interview that Resident #3 knows he gets [MEDICATION NAME] and that it is very important for him to get it. If he misses even one dose his ammonia levels go up. On 1/17/2014 at 8:45 am Nurse #5 stated that Resident #3 had never refused his medications when alert. When he got confused that could change. The nurse revealed that on 1/3/2014 and 1/7/2014 when she went to give Resident #3 his morning medications he was so lethargic that he could not take his medications. His medications at 12 noon on 1/3/2014 and at 1pm on 1/7/2014 were also held due to the lethargy and then he was sent to the hospital. Nurse #5 said the MD or NP was there both mornings and assessed Resident #3 and said if he wasn't more alert by afternoon to send him to the hospital. The nurse added that before his last hospitalization they didn't know that missing even one dose of [MEDICATION NAME] would cause an increase in Resident #3's lethargy. They know now and make sure he takes it. Asked what circled initials on a MAR indicated she replied that the medication was not given and they usually noted on the back of the MAR the reason. During an interview on 1/17/2014 at 10:10 am the physician (also the Medical Director for the facility) who sent Resident #3 to the hospital on [DATE] stated that she saw him on 1/7/13 for a re-admission note. She was not sure what time she saw Resident #3, but thought it was around noon and the nurse reported that he had not taken his scheduled [MEDICATION NAME] for her due to his lethargy. The physician said when she examined Resident #3, he was limp and very lethargic. She indicated he did not respond at all for her sternal rub. She added that with his advanced liver disease missing 1 or 2 doses of [MEDICATION NAME] would lead to the same effect. Asked when he missed his doses what were her expectations of the nurse, she responded that she expected the nurse to call right away. When Resident #3 was arousable only to sternal rub, she would have expected someone to call the physician service or the physician herself. If she had known he had missed his medications and had lethargy, she would have sent him to the hospital right away. On 1/17/2014 at 11:59 am the physician who sent Resident #3 to the hospital on [DATE] stated in an interview that when she saw him on the morning of 1/7 around 9am, the resident was hard to keep awake. The nurse informed her that the resident had been unable to take his 9 am medications because he was too lethargic. The physician added that she ordered a STAT (immediate) ammonia level with the hopes of getting it back that day. In 2-3 hours when he was still difficult to arouse and she was unable to get the ammonia results back that day, she decided to send him to the hospital. When asked what her expectation was for Resident #3 ' s return from the hospital, she replied that she expected him to receive his evening dose of [MEDICATION NAME] and if there was any doubt to call the physician. On admission the nurse was to call the physician to verify the medications and then fax them to the pharmacy. The physician added that when she readmitted Resident #3, she had spoken to the nurses about his condition and need for his medications. During an interview on 1/17/2014 at 2:33 pm, the nurse manager stated that if she knew the physician was coming to the facility that day, she waited for the physician to come to the floor to see the patient to inform them about changes. She added that when the nurse told her Resident #3 was lethargic on 1/3 and on 1/7/2014 and she assessed the resident she was not aware that he had missed any doses of his [MEDICATION NAME]. The nurse manager further stated that she didn't check the MAR as she expected her nurses to let her know of missed medications. She said that when the hospital physician called and talked to the nurses, he educated them that this resident could not miss even a single dose of [MEDICATION NAME] due to his advanced liver disease. The nurse manager also said she did not know if the night nurse (11pm to 7am) had given the [MEDICATION NAME] for 12 midnight and 6 am on 1/7/2014. At 3:42 pm on 1/17/2014 Nurse #4 stated in an interview that she admitted Resident #3 on 1/3 and 1/6/2014. When he came in she called the physician service and had his orders verified. The orders were then faxed to the pharmacy. If he didn't have any [MEDICATION NAME] when due, they would have to call the back up pharmacy to get it. Nurse #4 added that Resident #3 had several bottles of [MEDICATION NAME] on hand so he could get it. She said that she gave the 5 pm dose on 1/3/2014, but was late since he had just arrived. The nurse said she doesn't know why she didn't initial the MAR except it was a busy night. Nurse #4 said she gave the 6 pm dose of [MEDICATION NAME] on 1/6/2014, but Resident #3 arrived over an hour after the 5 pm dose of Rifaximin was due so it wasn't given. Several attempts were made to contact the 11pm to 7am nurse and she was unavailable for an interview. On 1/17/2014 at 4:49 pm the Director of Nurses (DON) was asked what her expectations were of her nurses if a resident had AMS. The DON said she expected the nurse to notify the physician. She indicated that if medications were not available the nurse should call the back up pharmacy. She had no explanation for the missing administration of [MEDICATION NAME] on 1/6/14 at 12 midnight and 1/7/2014 at 6 am. The DON confirmed that circled initials on the MAR indicated a medication was not given. She added that the reason should be documented on the back of the MAR

Based on observation, record review and staff interviews, the facility failed to administer the ordered medications of [MEDICATION NAME] (an ammonia detoxicant) and Rifaximin (for hepatic [MEDICAL CONDITION]), which resulted in a significant medication error for 1 of 5 residents (Resident #3). Findings included: Resident # 3 was admitted to the facility on [DATE] with re-admissions on 1/2/2014, 1/6/2014, and 1/10/2014. [DIAGNOSES REDACTED]. Hospital records reviewed documented that in November 2013 Resident # 3 had a Transjugular intrahepatic portosystemic shunt (TIPS) which was a procedure to create new connections between two blood vessels in the liver due to severe liver problems. Physician orders [REDACTED]. The MAR for December 23-27, 2013 documented that Resident #3 received each ordered dose of [MEDICATION NAME] 30 ml po and Rifaximin 500 mg po starting the night of 12/23/2013 and ending with the last dose the morning of 12/27/2013 before going to the hospital. physician progress notes [REDACTED]. Initially resident was able to sit up in bed and communicate with staff. Today it was reported that he had been presenting with increased lethargy and somnolence since 2 days ago. His ammonia level yesterday was 177 (normal 20-70). On eval very lethargic. Will transfer to the hospital for further management. Review of a hospital Discharge Summary dated 1/2/2014 found that Resident # 3 had been admitted on [DATE] with altered mental status secondary to hepatic [MEDICAL CONDITION]. Resident #3 ' s ammonia level checked at the facility was 177. The summary noted that the [MEDICAL CONDITION] gradually occurred despite receiving the ordered doses of [MEDICATION NAME] 20 gm in 30 ml bid and Rifaximin 550 mg bid. On discharge the [MEDICATION NAME] was increased from bid to three times a day (tid) and Resident #3 was counseled on the importance of taking the [MEDICATION NAME] titrated to 2-3 bowel movements per day. (The liver normally breaks down ammonia, but in liver disease such as [MEDICAL CONDITION] the blood may bypass the liver, allowing this poisonous substance to pass to the brain. Here it can impair brain function, causing confusion, drowsiness and finally coma. Per the 2013 Lippincotts Nursing Drug Handbook [MEDICATION NAME] causes the migration of blood ammonia into the colon trapping and expelling it in the feces. Rifaximin is used for reduction of recurrence of hepatic [MEDICAL CONDITION] in patients with advanced liver disease. ) Pyssician orders dated January 2, 2014 [MEDICATION NAME] 30 ml po (by mouth) tid at 9am, 1pm, 5pm and Rifaximin 550 mg po bid at 9am and 5pm. The Medication Administration Record (MAR) for January 2-3, 2014 was reviewed. For 1/2/2014 the MAR had no initials indicating administration of [MEDICATION NAME] 30 ml po at 5 pm and the initials were circled at 9 am and 1 pm on 1/3/2014. Rifaximin 550 mg po bid had no initials on 1/2/2014 at 5 pm and the initials were circled for 9 am on 1/3/2014. There was no documentation on the back to indicate the reason for missed doses. A review of Nurses' notes found that Resident # 3 arrived at the facility on 1/2/2014 around 5:45 pm, was able to verbalize needs, and had no pain or distress. Medications were verified by the nurse practitioner (NP) and faxed to the pharmacy. On 1/3/2014 the Nurses' notes indicated that at 2 am Resident # 3 was alert and oriented, able to make needs known. At 8 am the nurse manager noted that during rounds Resident #3 was found to be very lethargic and unable to arouse. "Will have Dr. to see this am." At 9 am the note indicated the physician was there to see the patient and new orders were written. At 2 pm the note indicated there was an order to send Resident #3 to the hospital and at 3 pm 911 was there to transport. Physician's Progress Note of 1/3/2014 Transition into care was reviewed for the following information. [MEDICATION NAME] was increased to tid ...On eval today pt (patient) was resting in bed, asleep, difficult to arouse, unable to keep eyes open or answer simple questions. According to daytime nurse, he had been like this all morning today and was not able to eat lunch due to AMS (altered mental status). Nighttime nurse reported he was awake and alert .... "Since he failed to wake up and become more interactive as was his baseline and requested blood work won ' t be available today, will transfer back to the hospital." A review of the hospital Discharge Summary dated 1/6/2014 noted that Resident # 3 was admitted to the hospital on [DATE] with hepatic [MEDICAL CONDITION] with altered mental status and somnolence. His ammonia level was on admission was 181. The summary indicated that it was thought the cause was possibly due to missed doses of [MEDICATION NAME]. After being given [MEDICATION NAME] in the hospital by a nasal gastric (ng) tube over 12 hours, Resident # 3 was back to his baseline. On discharge the [MEDICATION NAME] was being given by mouth and was to be given q (every) 6 hours. Instructions noted the [MEDICATION NAME] was to be given for a goal of 3-4 bowel movements a day. If the scheduled dose was not sufficient to achieve 3-4 bowel movements a day extra doses could be given q 4 hours. Physician orders [REDACTED]. Also ordered was [MEDICATION NAME] (20 gm/30 ml) po q 4 hrs as needed titrate to 3-4 bowel movements per day. The MAR for January 6-31, 2014 revealed that on 1/6/2014 [MEDICATION NAME] 30 ml po was initialed given at 6 pm, had no initials for 12 midnight or 6 am, and had circled initials for 12 noon. The Rifaximin 550 mg po bid had no initial for 5 pm on 1/6/2014 and a circled initial for 9 am on 1/7/2014. The back of the MAR documented that at 9 am and 12 noon all meds were held due to resident very drowsy at 9 am and unable to rouse at noon.The MAR had not documented any PRN (as needed) doses of [MEDICATION NAME] given. The Nurses' notes for 1/6/2014 documented that Resident #3 arrived at the facility around 6 pm, was alert and responsive with no complaints of pain or discomfort. On 1/7/14 at 2 am the notes indicated no distress was observed for Resident #3. At 8 am Resident #3 was assessed by the nurse manager and aroused enough to open eyes with sternal rub being done and moaned a little. Will continue to monitor and have MD (physician) to see patient today. At 12pm the nurse manager assessed Resident #3 and found no changes. At 2:30 pm the MD was with the patient and orders given to send the resident to the hospital. At 3:50 pm 911 was called and at 4:15 pm Resident #3 was transported to the hospital. A review of the Physician's 1/7/2014 Transition into care note revealed the following. After hospitalization the [MEDICATION NAME] was titrated up to q 6 hrs. He was transferred back to the facility on [DATE] and it is not clear whether he tolerated his oral medications. Today on my exam he was not responding to stimulation, painful stimulation, or sternal rub. Staff stated resident not able to take medications due to somnolence, decreased level of consciousness. Patient will be transferred to the hospital via EMS (emergency medical services). The hospital Discharge Summary dated 1/10/2014 for an admission on 1/7/2014 was reviewed. The Summary indicated that Resident # 3 was again admitted for portosystemic [MEDICAL CONDITION]. His ammonia level was 163. Search for the cause of the recurrent hepatic [MEDICAL CONDITION] "revealed medication noncompliance by the facility." The Summary added that the physician spoke with the 7 am to 3 pm nurse and had her read the Medication Administration Record (MAR) revealing that Resident # 3 went 24 hours without receiving any [MEDICATION NAME] resulting in the [MEDICAL CONDITION]. The physician noted that he had spoken with Resident # 3's regular care nurse and again emphasized the importance of not missing any doses of [MEDICATION NAME] given his TIPS procedure and his high tendency to develop hepatic [MEDICAL CONDITION]. The physician added that attempts had been made to contact the medical director of the facility to express the concerns and avoid recurrent facility caused hepatic [MEDICAL CONDITION]. Physician orders [REDACTED]. The MAR for January 10 - 31, 2014 documented that Resident #3 had received each ordered dose of [MEDICATION NAME] 30 ml po and Rifaximin 550 mg po since his return on 1/10/2014. On 1/15/2014 at 3:36 pm the nurse manager stated in an interview that Resident #3 had been to the hospital 3 times for end stage liver disease with high ammonia levels. She added that Resident #3 was on [MEDICATION NAME] for the ammonia and had refused a couple of doses. With missing doses she said his ammonia levels go up. She educated him and he had been taking it since he came back. Resident #3 was now on the [MEDICATION NAME] q 6 hours and PRN. Resident # 3 was observed during Medication Administration observation on 1/15/2014 at 4:10 pm. He was alert and aware of each medication he received. He kept asking if it was time for his [MEDICATION NAME]. Nurse # 3 explained that his [MEDICATION NAME] was due at 6 pm so it was too early to give it at this time. Asked if he knew why he received the [MEDICATION NAME], Resident # 3 said yes he did On 1/17/2014 at 8:45 am Nurse #5 stated that Resident #3 had never refused his medications when alert. When he got confused that could change. The nurse revealed that on 1/3/2014 and 1/7/2014 when she went to give Resident #3 his morning medications he was so lethargic that he could not take his medications. His medications at noon on 1/3/2014 and at 1pm on 1/7/2014 were also held due to the lethargy and then he was sent to the hospital. The nurse added that before his last hospitalization they didn ' t know that missing even one dose of [MEDICATION NAME] would cause an increase in Resident #3's lethargy. They know now and make sure he takes it. Asked what circled initials on a MAR indicated she replied that the medication was not given and they usually noted on the back of the MAR the reason. During an interview on 1/17/2014 at 10:10 am the physician (also the Medical Director for the facility) who sent Resident #3 to the hospital on [DATE] stated that she saw him on 1/7/13 for a re-admission note. She was not sure what time she saw Resident #3, but thought it was around noon and the nurse reported that he had not taken his scheduled [MEDICATION NAME] for her due to his lethargy. The physician said when she examined Resident #3, he was limp and very lethargic. She indicated he did not respond at all for her sternal rub. She added that with his advanced liver disease missing 1 or 2 doses of [MEDICATION NAME] would lead to the same effect. Asked when he missed his doses what were her expectations of the nurse, she responded that she expected the nurse to call right away. When Resident #3 was arousable only to sternal rub, she would have expected someone to call the physician service or the physician herself. If she had known he had missed his medications and had lethargy, she would have sent him to the hospital right away. The physician further stated that she had returned the hospital physician ' s call and was forwarded to another number. She left her number. She indicated that she and the hospital physician spoke on 1/16/2014 and he said all had been worked out. On 1/17/2014 at 11:59 am the physician who sent Resident #3 to the hospital on [DATE] stated in an interview that when she saw him on the morning of 1/7, the resident was hard to keep awake. The physician added that she ordered a STAT (immediate) ammonia level with the hopes of getting it back that day. In 2-3 hours when he was still difficult to arouse and she was unable to get the ammonia results back that day, she decided to send him to the hospital. When asked what her expectation was for Resident #3's return from the hospital. She replied that she expected him to receive his evening dose of [MEDICATION NAME] and if there was any doubt to call the physician. On admission the nurse was to call the physician to verify the medications and then fax them to the pharmacy. The physician added that when she readmitted Resident #3, she had spoken to the nurses about his condition and need for his medications. The nurse manager stated in an interview on 1/17/2014 at 2:33 pm that when the nurse told her Resident #3 was lethargic on 1/3 and on 1/7/2014 and she assessed the resident she was not aware that he had missed any doses of his [MEDICATION NAME]. The nurse manager further stated that she didn ' t check the MAR as she expected her nurses to let her know of missed medications. She said that when the hospital physician called and talked to the nurses, he educated them that this resident could not miss even a single dose of [MEDICATION NAME] due to his advanced liver disease. The nurse manager also said she did not know if the night nurse (11pm to 7am) had given the [MEDICATION NAME] for 12 midnight and 6 am on 1/7/2014. On 1/17/2014 at 3:42 pm Nurse #4 said that she gave the 5 pm dose of [MEDICATION NAME] on 1/3/2014, late since Resident #3 had just arrived. The nurse said she doesn ' t know why she didn ' t initial the MAR except it was a busy night. Nurse #4 said she gave the 6 pm dose of [MEDICATION NAME] on 1/6/2014, but Resident #3 arrived over an hour after the 5 pm dose of Rifaximin was due so it wasn't given. Several attempts were made to contact the 11pm to 7am nurse and she was unavailable for an interview. On 1/17/2014 at 4:49 pm the Director of Nurses (DON) stated she had no explanation for the missing administration of [MEDICATION NAME] on 1/6/2014 at midnight and 1/7/2014 at 6 am. The DON confirmed that circled initials on the MAR indicated a medication was not given. She added that the reason should be documented on the back of the MAR

Based on observation, resident and staff interview and record review, the facility failed to put interventions in place to prevent elopement by 1 of 1 resident (Resident #1). On 7/9/13 Resident #1 exited the building unsupervised via the rehab door and was found in the facility parking lot. He was unharmed and placed on every 15 minute checks for 24 hours. On 7/10/13 the facility determined no further interventions to prevent elopement were needed and the 15 minute checks were discontinued. On 7/12/13 Resident #1 again left the building unsupervised via the main entrance door and walked 0.9 miles, crossing a 4 lane street, to a bus stop after obtaining a bus ticket. He was found unharmed. The facility implemented 1:1 supervision. On 7/13/13 Resident #1 again left the facility via the rehab door during a breech in the 1:1 supervision. He was found in the parking lot, unharmed. Immediate Jeopardy began on 7/12/13 when Resident #1 exited the facility unsupervised via the main entrance door and walked 0.9 miles, crossing a 4 lane street, to a bus stop after obtaining a bus ticket. Immediate Jeopardy was identified on 7/19/13 at 3:51 PM and was removed on 7/21/13 at 11:23 AM when the facility provided a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS indicated Resident #1 was severely cognitively impaired, had no wandering behavior, ambulated in room with supervision and had unsteady balance but was able to stabilize without human assistance. The care plan dated 9/17/12 indicated a problem of "scores poorly on the BIMS (Brief Interview for Mental Status) due to not answering questions or unable to understand due to poor speech, with poor safety awareness placing him at risk for decline in cognitive status r/t (related to) (neurologic disorder)." Goal: "will remain alert and oriented x 3 (to person, place and time) through next review." Approaches included "Monitor for increased safety issues." "Elopement Risk Observation" assessments, dated 9/10/12, 12/10/12, 3/5/13 and 6/5/13 indicated Resident #1 was at low risk for elopement. The assessments indicated he was alert and oriented to person, place and time and had no known exit-seeking behavior. Nurse's Notes by Nurse #1, dated 7/10/13 on the 11 PM - 7 AM shift 7/9/13 indicated that around 11:15 PM she observed Resident #1 approach the elevator and tell the 3-11 shift nurse (Nurse #2) that he was going to the VA (Veterans' Administration). Nurse #2 told him he cannot go to the VA now and to go back to his room. Around 11:30 PM a nursing assistant (NA #1) came to the floor and informed staff that Resident #1 was on the facility grounds. The resident became agitated and uncontrollable when asked to go back inside the facility. He was given Ativan (an antianxiety drug) 1 milligram (mg) intramuscularly. The resident calmed down a short time later and slept well. Frequent checks were done while the resident was in his room. The resident woke up at 6:30 AM with no mood and behaviors noted. The plan was to continue to monitor behavior. During an interview on 7/18/13 at 5:25 PM, Nurse #2 recalled on the night of 7/9/13 she had reported off to Nurse #1 and was finishing her paperwork. The resident went to the elevator and said he was going outside to smoke. Nurse #2 indicated this was normal behavior for him and she had never known him to try to get away from the facility or to talk about leaving the facility. Nurse #2 denied hearing the resident say he was going to the VA. During an interview on 7/19/13 at 3:45 PM, Nurse #1 stated she recalled Resident #1 approaching the elevator, while she and Nurse #2 were counting narcotics, shortly after 11 PM, and telling Nurse #2 he was going to the VA. Nurse #1 said Nurse #2 told the resident to go back to his room and he did. Nurse #1 said a little bit later NA #1 came to the floor to report the resident was in the basement headed towards the exit into the courtyard. Nurse #1 indicated she immediately left to go check, going to the basement and out through the rehab door. She did not see him and walked through the courtyard into the parking lot. She saw the resident in the front of the building with two male nurses assisting him inside. He was agitated. One of the nurses called the physician and gave Ativan. The male nurses then assisted the resident to his room and put him in bed. The nurse stated she checked Resident #1 ' s vital signs and encouraged him to lie down. He was checked every 15 minutes and made no further elopement attempts that night. During an interview on 7/20/13 at 9:45 AM, NA #1, who was assigned to Resident #1 on 7/9/13, recalled that she was leaving the floor to go home after working the 3-11 shift on 7/9/13. As she got on the elevator, Resident #1 got on with her. She said she went to the basement to clock out. (The "Time Card Report" revealed NA #1 clocked out at 11:32 PM on 7/9/13.) When she got off the elevator she turned left to the time clock and expected the resident to do the same since she thought he was going to the nearby vending machine, but the resident turned right to walk down the hall towards the exit door going into the courtyard. (The courtyard is a fenced in area with 2 gates that are always kept open.) NA #1 said she asked Resident #1 where he was going and he pointed down the hall and said, "over there". NA #1 stated she immediately went back upstairs to report that Resident #1 was going outside. She said 2 nursing assistants (NA #2 and another) immediately left the floor, taking the stairs while NA #1 took the elevator. She went to the basement hall and out the door to the courtyard but did not see the resident. She said she got into her car, drove to the front of the building and saw the resident with several staff members. NA #1 indicated she had never known Resident #1 to try to get away from the facility before, and had not heard him say anything about leaving. During an interview on 7/20/13 at 12:34 PM, NA #2 recalled that Resident #1 had walked out of the facility on the night of 7/9/13, shortly after her shift started. NA #2 stated she had never known the resident to try to elope or talk about leaving the facility. NA #2 indicated she was not aware of anything that might have caused the resident to want to leave. Review of "Fifteen Minute Check" forms dated 7/9 /13 - 7/10/13 indicated Resident #1's location was documented every 15 minutes from 7/9/13 at 11:45 PM - 7/10/13 at 11 PM. During an interview on 7/18/13, Administrative Staff #1 indicated Resident #1's elopement was discussed in the morning meeting on 7/10/13. During the meeting Administrative Staff #3, the unit coordinator for Resident #1, voiced that she believed the elopement was an isolated incident. Administrative Staff #1 stated she talked with Resident #1 who said his plan was to go to his home in (name of town). She told the resident the facility would arrange for him to be moved to that town and he agreed to wait. Administrative Staff #1 said that since the resident made no further attempts to leave the facility during the 24 hour period he was on 15 minute checks, the checks were stopped and no further interventions were warranted. During an interview on 7/19/13 at 9:30 AM, Administrative Staff #3 said it was completely out of character for Resident #1 to leave the building, and since he made no further attempts to leave during the next 24 hours, she felt no additional measures were needed after completion of the 15 minute checks. Nurse's Notes by Administrative Staff #2 dated 7/12/13 at 8:50 AM indicated she and Administrative Staff #1 were notified that staff were unable to locate Resident #1 in the facility. At 8:55 AM a complete head count of residents and search of entire facility and grounds was initiated. Staff were deployed via vehicles to surrounding area and community. At 9:05 AM confirmed Resident #1 was not in facility or grounds. Staff continued the search of surrounding area and community. At 9:15 AM Resident #1 was located by facility staff and returned to the facility. During an interview on 7/20/13 at 11:46 AM, Nurse #3 acknowledged she worked on 7/11/13 from 11 PM to 7/12/13 at 7 AM. Nurse #3 stated she arrived on duty after 11 PM but before midnight, and she was the only licensed nurse scheduled for the floor. The nurse indicated she was very busy and did not see Resident #1 that night. She said when she went into his room to give the roommate medications the curtain was pulled between the two beds. Since Resident #1's bed was on the far side of the curtain she did not see him. The nurse added that she was not concerned because the resident was fairly independent and could let staff know if he needed anything. During an interview on 7/24/13 at 6:55 AM, NA #3 acknowledged Resident #1 was on her assignment beginning 7/11/13 at 11 PM. The NA stated the resident was not in his room when she made her first rounds at approximately 11:05 PM, but the curtain between the two beds was open. NA #3 thought he was downstairs, which was not unusual. NA #3 said when she made subsequent rounds the curtain was pulled so she assumed he was in bed. NA #3 recalled the resident had told her in the past that if his curtain was pulled that meant he did not want to be touched. She added she had seen how combative he had been the night of 7/9/13 and she did not want to take any chance of irritating him. On 7/19/13 at 2:35 PM, NA #4, assigned to Resident #1 for the 7-3 shift on 7/12/13, was interviewed. NA #4 stated Resident #1 was not in his room when she made her first rounds a few minutes after 7 AM, but she was not concerned since she knew him to get around the building independently and thought he might be out smoking or walking around. NA #4 roughly estimated that 45 minutes later the nurse (Nurse #4) asked if she had seen Resident #1 and she said no. NA #4 then started to look for him on the unit. NA #4 indicated that she floated to different assignments and this was the first time she had been assigned to Resident #1. She was not aware that he had any exit seeking behaviors. On 7/19/13 at 10:06 AM, Nurse #4 was interviewed. She stated she first went to Resident #1's room between 7:50 AM and 8:00 AM and did not see him, but his cane and wheelchair were there so she thought he was with a nursing assistant in the shower. The nurse said she saw NA #4 around 8:15 - 8:20 AM and asked where the resident was. The NA said she had not seen him yet that morning. At that time the housekeeper (HK #1) was going down to the break area and the nurse asked her to check in the smoking area for Resident #1. HK #1 returned in about 10 minutes and said he was not there. Nurse #4 then checked both elevators and the 2nd floor but did not find him. She then called Administrative Staff #3. During an interview on 7/19/13 at 9:30 AM, Administrative Staff #3 said that Nurse #4 called her around 8:50 AM to report that the resident was missing. She instructed the nurse to start searching rooms and bathrooms. Administrative Staff #3 indicated she was with all the administrative staff and managers getting ready for the morning meeting, and immediately a full search was organized to include the facility and grounds. During an interview on 7/18/13 at 12:08 PM, Administrative Staff #1 said when the call came that Resident #1 was missing she deployed staff immediately to count all residents in the building and search all areas of the facility. Others were to search the grounds and community. The search began at 8:50 AM and the resident was found at the bus stop by the VA Hospital between 9:10 - 9:15 AM. Resident #1 was interviewed on 7/19/13 at 11 AM. His voice was soft and speech difficult to understand at times but he willingly repeated what he said and was understood. Resident #1 said he wanted to go home and to die at home. In the meantime, he did not belong at the facility with all the old, sick people since he still had a lot of life to live. He stated he was a soldier and will always be a soldier. He saw an opportunity to leave the facility and he took it. Resident #1 explained that around 4:30 AM on 7/12/13 he left the building with the plan to walk to the VA Hospital to get a bus ticket for (name of home town). He indicated he left through the front door by pushing the handicap button that automatically opens the doors. He relayed how he walked to the VA and entered the emergency room . The attendant asked if he had an emergent condition and he said no, he needed a bus ticket to his home town. He stated the attendant got a social worker for him who issued the ticket, then he proceeded to the bus stop. Resident #1 said he still had the bus ticket, and produced it on request. During an interview on 7/19/13 at 9:30 AM, Administrative Staff #3 said she had searched via car and found Resident #1 at the bus stop. Additional facility staff arrived and convinced him to return to the facility. The distance from the facility to the VA hospital was clocked on an odometer at 0.9 miles. There was a city sidewalk from the facility to the VA. Seven cross streets were counted between the facility and the VA. The bus stop where Resident #1 was found was directly across a 4 lane street from the VA. On 7/20/13 at 2:00 PM, the Administrator on Duty (AOD) at the VA hospital was interviewed. She stated that the VA did issue bus tickets to veterans but only tracked those who seemed to be over-using the system. She pulled up Resident #1 and said there was no record of him being at the VA on 7/12/13 or getting a bus ticket and could not say who the social worker may have been. Per Nurse's Notes by the Administrative Staff #2 dated 7/12/13 at 9:20 AM, the resident returned to his room; he was severely agitated. One-on-one (1:1) supervision was initiated. Continual attempts by staff to redirect the resident failed. At 9:45 AM the physician was notified and Ativan was ordered. At 11 AM the resident was calm. At 11:15 AM a Wanderguard was placed to the resident's left ankle. 1:1 supervision continued. At 10:15 PM he continued to be calm; 1:1 supervision was maintained. The Care Plan was updated on 7/12/13 for the problem of risk for elopement. Interventions included 1:1 supervision, do not allow resident to leave the facility without supervision and ensure Wanderguard is in place and functioning every shift. Nurse's Notes, written by Nurse #5, dated 7/13/13 at 3:45 AM read, "Resident sitting up in bed. Has put all of his clothes and shoes on. When asked what he is doing, resident stated 'Going to the bathroom.' After using restroom, resident layed (sic) back down." Notes at 5:45 AM indicated Resident #1 was at the elevator with alarm ringing. He was asked to return to his room, glared at the nurse and got on the elevator. He exited the building through the basement and was seen in the parking lot. He ignored staff requests to stop and kept walking toward the street. Staff intercepted and the resident became combative; he placed himself on the sidewalk in a prone position. The notes indicated Administrative Staff #1 arrived and coaxed the resident back into the building. He was escorted back to his room and remained on 1:1 watch. On 7/24/13 at 5:10 AM, Nurse #5 was interviewed. She stated there were 3 staff members present on the unit that shift and they rotated doing 1:1 supervision for Resident #1. She recalled that NA #5, with her permission, left her station outside the resident ' s door to help a resident across the hall who was calling out for the bedpan. The nurse said she herself went to the bathroom and was off the hall for less than a minute. When she came out, Resident #1 was at the elevator, the alarm was ringing and he glared at her. Nurse #5 opted to let the resident get on the elevator by himself. He went to the basement. Nurse #5 immediately went downstairs and enlisted the help of the first floor nurse. They went to the basement and saw the resident just outside the courtyard going into the parking lot. Nurse #5 said she called him and he just walked faster. When they passed by the front of the building 2 nursing assistants came out to help. As the staff approached him, he started shouting and swinging his arms at them. He sat down on the sidewalk (parallel and just off the 4-lane street in front of the facility). Nurse #5 indicated Administrative Staff #1 arrived and talked the resident into coming back into the facility. During an interview on 7/24/13 at 5:18 AM, NA #5 stated she thought she would be able to maintain the 1:1 while helping the resident across the hall with the bedpan. NA #5 said was just getting the bedpan under the resident when she heard the alarm at the elevator. When she came out of the room the nurse had already left to find him. NA #5 added, "When he came back to the floor he told me he had been listening for me, did not hear me so he made a move for it." On 7/19/13 at 10:26 AM, Administrative Staff #1 said she often came to work early, and she happened to be pulling into the facility parking lot and saw 4 or 5 staff standing at the end of the driveway on the sidewalk. Resident #5 was sitting on the sidewalk. She said she talked to him and said they would get a plan together on Monday (7/13/13 was a Saturday) for him to move back to his hometown. He agreed to remain at the facility until Monday. He then willingly went back inside the facility. Administrative Staff #1 added that normally the facility had a designated staff member to do 1:1 supervision, with the 1:1 being the only assigned responsibility. She said her expectation was for the resident to have continuous supervision and that did not happen. During an interview on 7/19/13 at 11 AM, Resident #1 indicated he left the morning of the 13th because he had another opportunity (the resident laughed when he said this), and that he thought the staff were lying to him about helping him to go home. Subsequent Nurse's Notes from 7/13/13 at 7 AM - 7/17/13 at 6:30 AM revealed no exit seeking behavior and continuous 1:1 supervision. Throughout the survey, Resident #1 was observed to have a designated staff member sit with him or stand immediately outside his door. On 7/18/13 at 11:30 AM, Resident #1 was observed in his room, lying on the bed. His left leg had large involuntary movements, other extremities had finer involuntary movements. Upon request and without assistance, Resident #1 sat up, then rose and walked from his bed to the doorway and back. His gait was unsteady and balance impaired but he was observed to correct his balance without any assistance or devices. NA #6 stood outside his door and said her assigned duty for the day was 1:1 supervision of the resident. The resident said that he wanted to go home, but was now waiting to move to a facility in his hometown where he will get the assistance he needs. A tour of the facility was conducted on 7/20/13 at 3: 15 PM with Administrative Staff #2 and Maintenance Director. The only doors with Wanderguard sensors were two of two elevator doors on the third floor. The Maintenance Director indicated that the sensor will cause an alarm to sound when a resident wearing a Wanderguard transmitter approaches the elevator but the elevator will continue to function normally. The second and third floors each had 3 doors leading to stairwells. The doors were locked. To unlock the door from inside the unit, a code could be entered on a keypad. To unlock the door from the stairwell a green button, adjacent to the door frame, could be pushed. From inside the unit, the door could be pushed open without entering a code and an alarm would sound. Staff demonstrated during the tour that the door could be opened and the green button immediately pushed and the alarm would stop. On the ground/basement floor, exit doors from the physical therapy gym could be opened after pressing on the bar for 15 seconds. The door was not alarmed. The door exited to a fenced in courtyard with two gates that were continually open. A door at the rehab reception area also exited directly to the courtyard and was not alarmed. A door near the elevator closest to the kitchen was also not alarmed. This door exited to the back of the building. An additional door, just outside the kitchen and leading to the side of the building, had no alarm. The Maintenance Director indicated that the 3-11 shift laundry staff locked the basement doors at night. An interview with the 3-11 laundry staff on 7/20/13 at 5:05 revealed she was the only staff in the laundry that shift and she did not know who was responsible for locking the exit doors. The tour continued to the first floor. Double doors were observed in the main entrance/lobby. Buttons for handicapped were situated on the front porch and on the main hall near the lobby. Facing the entrance doors from the lobby, a decorative column was situated just to the left of the doors. On the left side of the column was a switch similar to a single light switch. The top of the switch was labeled "Nite" and the bottom "Day". The Maintenance Director explained that when the switch was in the "Day" position the door was unlocked and the handicapped button, when pushed, would cause the doors to open. When in the "Nite" position, the door was locked but could be opened if the bar was pushed for 15 seconds. The handicapped button would not function when the door was locked. The door was not alarmed. Neither the Maintenance Director nor Administrative Staff #2 indicated who was responsible for locking the front door at night. An interview had been conducted with NA #2, who worked the 11-7 shift, on 7/20/13 at 12:34 PM. She stated that at night staff go out the front door to smoke because they cannot get back into the building if they go out the basement door to the courtyard where the designated smoking area is. NA #2 said when she steps out to smoke she flips the switch to unlock the door, pushes the door open and then flips the switch back before stepping outside. To re-enter, she puts the code into the keypad. NA #2 said staff could also elect to leave the door unlocked and flip the switch when they come back to save having to put the code into the keypad. The administrator was notified of the Immediate Jeopardy on 7/19/13 at 3:51 PM. A credible allegation of compliance was received on 7/21/13 at 11:23 AM. The credible allegation included: A. On 7/9/13 at approximately 11:30 PM Resident #1 was found in the facility parking lot. B. On 7/12/13 Resident #1 left the building and walked a mile away, was found at a bus stop at 9:15 AM C. On 7/13/13 Resident # 1 got on the elevator in view of nurse and exited the building in view of nurse.What Corrective action will be accomplished for the residents found to have been affected by the deficient practice?A. On 7/9/13 at approximately 11:15 PM Resident #1 told the 11-7 and 3-11 nurses he was going to the VA and the nurses told resident to go back to room. At approximately 11:30 pm Certified Nursing Assistant reported resident was on facility grounds. Resident # 1 was brought back in facility and placed on every 15 minute checks for 24 hours. Nursing staff were responsible for 15 minute checks and visually layed eyes on Resident #1 at least every 15 minutes. 15 minute Patient Check Sheet includes Staff initials every 15 minutes and location of patient. On 7/10/13 the social worker called the guardian and asked the guardian to come talk to Resident # 1 because he wants to go home to Raleigh. Guardian came to facility and spoke with social worker and resident #1 to explain that his home was foreclosed on and this was the best place for him. B. On 7/12/13 Resident was returned to facility by Director of Nursing Services and Rehabilitation Aide at 9:20 AM and was placed on one to one supervision and a wander guard transmitter was applied - one staff person was in visual view of Resident at all times, 24 hours a day. 1:1 remains ongoing until more appropriate placement is found. A wander Guard transmitter was placed on the resident on 7/12/2013. This transmitter will set off an alarm if patient approaches the elevator. Other exit door on 3rd floor are key pad coded and will alarm if door is left open. Door located at stairwells are key pad coded, the front door is locked at 8pm by the door monitor. Upon interview with resident # 1, conducted by the administrator resident # 1 stated he watched the nursing staff and waited till they were busy so he could go to the VA to get a bus ticket to Raleigh. Resident #1 stated he left around 5am and exited the building via the Therapy Door. Upon interview with staff the resident was observed in his bed around 5-5:30am while medication was given to the roommate. Roommate ' s medication administration record was reviewed and was confirmed that the roommate was given a medication at 5:30am. Resident # 1 had no medications ordered during the 11pm-7am shift. The 7-3 Certified Nursing assistant and Licensed Nurse noted at 7am the resident was not in his room. At approximately 7:20am the Certified Nursing Assistant notified the Licensed Nurse that the resident was still not on the floor at this point the Licensed Nurse instructed the staff to search the floor and the courtyard. C. On 7/13/13 at approximately 5:45am resident was noted at elevator with alarm ringing, Nurse asked resident to go back to room and resident continued to proceed in elevator. Nurse ran down the stairway to meet resident on the first floor, the elevator continued to basement. Nurse ran down the stairway to the basement and followed resident outside. Staff attempted to bring resident back in the facility resident began fighting and hitting the staff. Administrator was able to coax the resident back in the facility. The resident was placed on 1:1 and the administrator spoke with staff about expectations of 1:1. Resident care plan updated by MDS Coordinator to include elopement risk on 7/12/13 Inventions included 1:1 and a wander guard transmitter. The Nurse Practitioner assessed the resident on 7/12/13, Nurse Practitioner assessed resident for complaint of anxiety. The Guardian was called by the Social Worker and the Social Worker left a message for the Guardian to return call on 7/12/13. Guardian did not immediately return call. Follow up calls were made by Social Worker to Guardian on 7/15, 7/16, 7/18, 7/19 and Guardian has not yet return any of these phone calls. Elopement Books were updated by the Medical Records Coordinator to include Resident #1 on 7/12/13. Elopement books contain a picture and physical description, [DIAGNOSES REDACTED]. Elopement books are kept at the nurse's stations, receptionist, and the therapy desk.How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?Elopement Risk observation forms which includes; residents cognition, sensory deficit, predisposing conditions, ambulation and mobility, pain were completed by the Unit Coordinator/Managers, Director of Nursing and Case Mix Director for all residents on 7/12/13. None of the Resident ' s Elopement Risk observation forms revealed that any new or current identified interventions were indicated. Education was provided by the RN Clinical Competency Coordinator, Director of Health Services and Administrator to all staff, including licensed and unlicensed Nursing Staff, and all staff in each department. Education involved discussion of elopement procedure, including assessment of risk, signs of exit seeking behavior and who to report signs of exit seeking behavior to, prevention and what to do if a patient is unaccounted for and what to do upon return to facility if a patient elopes. Education began on 7/12/13, the education is ongoing and those employees who have not worked will be educated prior to their next schedule shift. This education has been completed at 95%. The assigned licensed nurse assigned for each resident is responsible for completing the Elopement Risk Observation form, and completing the care plans with the interventions. Identifying/ exit seeking behavior i.e.: voicing desire to go home, packing clothes and attempting to exit doors and history of leaving the center without needed supervision. Elopement Risk Observation forms are completed on admission/readmission, quarterly and change of condition i.e. exhibiting exit seeking behaviors. Care plans are updated with change in conditions and with assessment/observation updates. Once a resident exhibits exit seeking behavior the assigned licensed nurse will place immediate intervention to include but not limited to placing the resident on 1:1, complete an elopement observation form, a picture will be in the wander guard notebook with description of resident and a wander guard will be placed on the resident. Education completed by the Administrator, Director of Health services, and the Clinical Competency Coordinator, for all licensed nurses and direct care nursing staff on walking rounds to include Certified Nursing Assistant to walk there assignment with the oncoming shift to visualize each resident if resident not in room Certified Nursing Assistant are to report to the assigned licensed nurse, licensed nurses are to walk there assignment with the oncoming shift to visualize and give verbal report on each resident then sign the 24 hour report, if resident is not found in room Licensed nurse will start the elopement procedure which began on 7/12/13 on the 11-7 shift. Any employee that has not had the education related to walking rounds will not be allowed to work until the education is completed. What measures will be put in place or what systemic changes will be made to ensure that the deficient practice will not reoccur?1. Walking rounds initiated for shift change for licensed nurses and certified nursing assistants began on 7/12/13 on 11-7 shift and will continue every shift indefinitely. Licensed Nurses began signing the 24 hour report on 7/12/13. The Director of Health Services, Clinical Competency Coordinator, and/or Week-end Supervisor will review the 24 hour reports to ensure the licensed nurses are signing the 24 hour reports to validate that walking rounds were completed. Audits of the 24 hour report sheet will be completed daily by the Director of Health Services, Clinical Competency Coordinator and/or Week-end Supervisor for one week and weekly thereafter for two (2) months. The Director of Health Services, Clinical Competency Coordinator, Administrator, and/or Week-end Supervisor will observe Certified Nursing Assistants completing walking rounds for two shifts daily times one week, and weekly thereafter for two months. 2. All new admitted and readmitted Residents will have their Elopement Risk Observation form completed on admission by the assigned license nurse for that resident. Any Resident who voices desire to leave facility or exhibits exiting seeking behaviors will also have an Elopement Risk Observation form filled out and intervention will be put in place immediately to include but not limited to placing a wander guard on resident, move resident to the 3rd floor, which is equipped with the wander guard system and door key pads, and start 1:1 if indicated. The care plan will be updated with interventions at this time. Findings will be reported to the Director of Health Services and or Clinical Competency Coordinator and/or Weekend Supervisor. If the Director of Health Services, Clinical Competency Coordinator, and/or Week-end Supervisor is not in facility then the assigned nurse will notify Director of Health Services and/or Administrator via phone. 3. Upon completion of the Elopement Risk Observation form the licensed nurse will copy the elopement risk observation and give to the Director of Health Services, clinical Competency Coordinator and/or Weekend Supervisor to ensure completion of the form and intervention initiated if indicated with review of the care plan. The Director of Health Se

Based on observation, staff interview, emergency medical technician interview, and record review, the facility failed to properly secure 1 (Resident #196) of 4 residents during transport via facility van resulting in a fall; and failed to prevent a resident to resident altercation of two cognitively intact residents (Residents # 13 and # 62). Immediate jeopardy began on 10/20/11 and was identified on 10/27/11 at 4:27 PM. Immediate jeopardy was removed on 10/28/11 at 2:20 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). The findings included: The facility manual for the wheelchair securement and occupant restraint read in part, "Securing the Wheelchair" "With the occupant facing the front of the vehicle, center the wheelchair between the floor tracks or plates. Apply the wheel locks." "Once you have the wheelchair centered and locked between the floor tracks of plates, you are ready to attach the rear straps. Remember: for the best securement the straps should form about a 45 degree angle between the floor tracks and where the straps attach to the wheelchair. Install the track fitting end into a slot in the floor track. Use a slot just to the inside of the rear wheel. Pull on the strap to ensure the fitting is firmly engaged and locked into the slot. If you are using an S-Hook system, press the red release button and pull the web out of the Retracktor. Let go of the release button and attach the S-Hook to a structural frame member of the wheelchair, as close to the corner junction of the seat cushion and seatback as possible. Then push the button on the Retractor to remove the slack. Repeat this process for the other rear strap. "Installing the front strap is similar. Install the track fitting end of the front strap into the floor track or plate. Use a slot that's at least 3" outside the wheel. This prevents the strap from interfering with the footrest and gives better stability. Then pull on the strap to ensure that it's engaged firmly. Next, attach the S-Hook to a structural member of the wheelchair. Then push the button on the Retractor to remove the slack and crank it down for extra tension. Repeat this process for the other front strap. Once you have all four straps attached, release the brakes on the wheelchair and check for movement. Once secured, the wheelchair shouldn't move more than 2" front to back or side to side. Reapply the brakes." "Securing the Occupant" read in part, "Integrated Lap Belts: take the Snap Hook end of the belt and attach it directly to the D-Ring on the rear securement strap assembly. Adjust the lap belt through the adjusters by pulling on the free end to make the fit firm yet comfortable. The integrated lap belt attaches to the rear wheelchair securement system." "The last belt to attach before you're on your way is the shoulder belt. Bring the triangular fitting of the shoulder belt over the passenger's shoulder, past the collar bone, and diagonally across the upper chest. Attach it to the stud of the lap belt latch plate. Pull the loose end through the adjuster to achieve firm yet comfortable tension. Pull on the belt to ensure that everything is properly secured." Resident #196 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The interim admission care plan dated 10/18/11 indicated the resident was at risk for falls and required assistance with transfers. An incident report dated 10/20/11 at 3:30 PM indicated that the facility van driver notified the facility that during transport (from the dialysis center) the resident's wheelchair flipped back. Emergency Medical Services (EMS) was notified and transported Resident #196 to the emergency department (ED). The EMS report written by emergency medical technician (EMT) #1 read in part, "UPA (upon arrival) found pt. (patient) on her right side on the floor of a wheelchair van. No signs of trauma noted." Resident #196's Emergency Department (ED) report dated 10/20/11 indicated the physical assessment and diagnostic testing including computerized axial tomography (CT) scans of the head, cervical spine and abdomen/pelvis revealed no injury. The resident was admitted to the hospital for monitoring and was not in the facility at the time of the investigation. A hospital "Interim Discharge Summary" dated 10/27/11 indicated that the resident remained hospitalized primarily because of a new [DIAGNOSES REDACTED]. The summary revealed that the resident was also newly diagnosed with [REDACTED]. Consults were provided for palliative care, cardiology and nephrology. A statement dated 10/20/11, signed by the facility van driver, indicated that as the van was going up a hill to a stoplight, Resident #196 and her wheelchair tipped backward. The statement read that the resident remained strapped in the wheelchair when EMS arrived. During an interview on 10/27/11 at 11AM, the facility van driver indicated that she was a nursing assistant and a trained van driver. She stated that she started working at the facility on 8/31/11 as a van driver, and had worked for another nursing facility as a van driver prior to starting at this facility. The van driver stated that when she first started working for the facility, another nursing assistant (NA#1) rode in the van during transports and helped her secure the residents with strapping in the wheelchair and buckling seat belts and shoulder straps, but for the last few weeks she was doing the transports by herself. The van driver indicated that she had not been trained on how to secure residents in the van by anyone at the facility, but she knew the procedure. In October a corporate staff person evaluated her and there were no problems. The van driver indicated she kept a daily validation checklist which included seatbelts, shoulder straps and the straps used to secure the wheelchair in the van. A facility "Van Drivers Training" form, dated 10/7/11, indicated that the van driver received training on securing residents in van, demonstrated proper securing of residents in the van, stated what to do in an emergency, and demonstrated proper way to load residents in the van. The form was signed by a corporate staff member as having been the trainer. During an interview on 10/27/11 at 1:14 PM, NA#1 confirmed that she rode in the van during transports from July until sometime in September. NA#1 stated she had been trained by the previous driver on how to secure residents during transport. NA#1 explained that wheelchairs were secured in the van by 4 straps - 2 in front and 2 in back. The straps were secured to tracks in the floor of the van with one track for the front straps and one for the back. The straps could be removed from the tracks and repositioned as needed. The track-fitting ends of the straps made a clicking sound when they locked into the tracks. To secure the wheelchair, the back straps were secured to the frame of the wheelchair, then the front straps. The resident was secured with the seatbelt and then shoulder strap. When asked for a copy of the driver's checklist for 10/20/11, the administrator stated on 10/27/11 at 4:04 PM that the driver told her she did not have time to do the checklist on 10/20/11 but said she followed procedure on securing all residents that day. In continuation of the interview on 10/27/11 at 11AM, the van driver explained the procedure she used for securing Resident #196 in the van prior to leaving the dialysis clinic: (1) Locked her wheelchair into position. (2) Hooked the back straps to the wheelchair frame. (3) Fastened seat belt. (4) Hooked the front straps to the crossbar under the wheelchair. (5) Fastened the shoulder strap. (6) Double check all locks for tightness. The van driver acknowledged that she was trained to hook the front straps to the frame of the wheelchair, but thought that hooking them to the crossbar would give the resident more stability since she did not have legs and had no anti-tippers on her wheelchair. The driver recalled turning a corner, heard a boom and saw that the wheelchair had flipped backward. The driver stated the resident remained in the chair and all belts and straps were in place. She said she immediately stopped and called 911. The driver said she did not move the resident or the wheelchair. During an interview on 10/27/11 at 2:49 PM, EMT #1 stated that he found Resident #196 lying directly on the floor of the van on her right side. EMT #1 stated that the wheelchair was sitting upright in the van but he was not sure if the chair was secured to the floor of the van. The resident was lying with her head toward the back of the van. On 10/27/11 at 11:30 AM, the van driver was observed demonstrating, in the facility van, how she secured residents. The driver (1) positioned the wheelchair between the front and back tracks and locked the wheelchair; (2) positioned the back straps securely in the tracks and secured the "S hook" end of the straps to the wheelchair frame, then tightened the straps using the retractor button on each strap; (3) positioned the front straps securely in the tracks and hooked them to the crossbars under the seat, tightened the straps using the retractor button on each strap; (4) buckled the seat belt and (5) buckled the shoulder strap. The wheelchair did not move or tip when manual force was exerted. During an interview on 10/27/11 at 4:07 PM, the corporate staff (CS) who trained the driver on 10/7/11 indicated that drivers were required to complete a motor vehicle safety program (MVSP) and be checked off for properly securing residents in the van. The CS acknowledged that the MVSP did not include instruction on securing residents in the van. The CS stated that checklists were used to complement the MVSP. The checklists included validation that the wheelchair was secured at 4 points and that the seat belt and shoulder strap were secured. The driver must complete the checklist with each resident transport. The CS added that double checks were to be done randomly as directed by the administrator, and anyone who was trained in transport was qualified to perform the double check. During an interview on 10/27/11 at 4:30 PM, the administrator indicated that the maintenance director (MD) was a trained back-up driver and responsible for performing double checks on the driver. The administrator added that she was not sure how often the double checks were being done as she was new to the facility and the double check system had already been put into place. During an intervew on 10/28/11 at 8:13 AM, the MD stated he was unaware that he should have been doing audits/double checks on the drivers. He added that he now understood that the audits were to be his responsibility. During an interview on 10/27/11 at 10:44 AM the administrator indicated that immediately following Resident #196's fall, the van was taken in for inspection of all tie-downs, lap and shoulder belts, for function and safety. No problem was found with the equipment/devices that were in use. The administrator produced a report dated 10/21/11 of the inspection findings. The adminstrator added that the van has not been used to transport residents since the incident of 10/20/11. The administrator was notified of the immediate jeopardy on 10/27/11 at 4:26 PM. The facility provided a credible allegation of compliance on 10/28/11 at 1:59 PM. The allegation of compliance read: "Credible Allegation of Compliance for Van Uni-Health Post Acute Care of Durham This plan of correction constitutes a written allegation of compliance. Preparation and submission of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth on the statement of deficiencies. The plan of correction is prepared and submitted solely because of requirements under state and federal law. Corrective action: a. Driver stopped van immediately and called 911. b. Resident was taken to hospital ER via EMS. c. Van was removed from service. d. Van driver was suspended pending investigation. e. Van was taken to a company specializing in safety devices for wheel chair transport for service on 10/21/11. Others with potentials to be affected a. The only facility van was removed from transport from 10-21-2011 through present. b. The only facility van was checked by a company specializing in safety devices for wheel chair transport to check all seat belts in the van for proper latches and all locked properly this includes the device locking into the floor. The company released the van for use on 10/21/11. c. The van driver was suspended. d. A Motor Vehicle Safety Program was implemented on 10/21/11 for any van drivers. The motor vehicle safety program includes inspection of vehicles, Authorized driving requirements including drivers history report, current drivers license, Basic safe driving and vehicle operation rules, Accident or loss of company vehicle, what to do if a resident has an untoward event. e. On 10/21/11, the Director of Health Services and Administrator began educating Nursing Assistants on van safety, to include what to do in an emergency situation, which includes: if a resident falls the van driver needs to pull van to the side of road and 911 needs to be called, if resident becomes unresponsive, the van driver needs to pull van to the side of road and 911 needs to be called, if resident complains of chest pain the van driver needs to pull van to the side of road and 911 needs to be called, in the event of any adverse or abnormal occurrence the van driver needs to pull van to the side of road and 911 needs to be called. The van driver will have a cell phone available during every transport. f. Nursing Assistants will not be able to ride as a passenger until the van safety education is completed. Including what to in emergency situations. Measures and systematic changes a. The facility implemented the Motor Vehicle Safety Program on 10/21/11; all van drivers must complete the program prior to driving the van. The Administrator and/or Financial counsel will ensure the Motor Vehicle Safety Program is completed for each new driver b. The facility implemented a Driver check off list incorporating use of the lift on the van, locking the wheelchair and securing the resident in a wheelchair on 10/21/11. All van drivers must complete this program prior to driving the van. The drivers check off list includes return demonstration to the Maintenance Director for all new drivers on the use of van lift, securing a wheelchair in the van, and what to do if there is: traffic accident, stolen van, resident falls out of chair, resident becomes unresponsive, any emergency occurs with a passenger. As of 10/21/11 new van drivers will be observed by the Maintenance Director and/or Housekeeping Director for securing the three residents accurately daily for one week, three residents weekly for four weeks then three residents monthly for four months. c. The Housekeeping Director was trained on 10/28/11 by the Maintenance Director on properly securing a resident and the observation check list to validate the driver has properly secured the resident. d. The van driver double checks them-selves after securing the resident into the van; this is documented on the Validation check sheet with each resident placed on the van. e. Monthly the validation log is validated by the Maintenance Director and/or Housekeeping Director to ensure residents are secured properly in the van by observing the resident in the van prior to or upon return to the facility. f. The Maintenance Director was trained by a company specializing in safety devices for wheel chair transport on May 4th, 2011 of the proper way to secure a resident in the van. Training included installing the track fitting end of the securing strap into the rear slot in the floor track; Place the straps onto the structural frame member of the wheel chair as close to the corner junction of the seat cushion and seat back as possible. Then push the button on the retracktor to remove the slack. The front straps include installing the fitting end at least 3 inches outside the wheel, attaching the S-hook to a structural member of the wheel chair, pushing on the retracktor to remove the slack and crank it down for extra tension. Check for movement and apply wheel chair brakes. Apply seat belt as low and snug across the occupant's pelvic zone, with the junction of lap and shoulder belts located near the wearer's hip. g. The safety of residents, to include what to do in an emergency situation, on the van has been added to general orientation for all new staff members as of 10/21/11. h. New van drivers will receive educational instruction by the Maintenance Director and are required to return demonstrate on the Motor Vehicle Safety Program, Van Safety, to include what to do in an emergency situation, Van Driver check off (loading and securing wheel chairs), securing the resident validation logs. Also included in training : securing of residents via the validation of seat belts in van tool, this includes restraint properly secured on frame X4 (2 front and 2 back), seat belt and shoulder strap are secured properly, locking wheel chair and ensuring grips are locked. i. The Administrator, and/or Financial Counselor will complete a "van driver verification log" identifying all areas of training and demonstration to maintain resident safety in the van, has been complete. This details that the new van driver has a current drivers license, evidence of insurance, completed a drivers history form, has been placed on company insurance for van, general orientation completed, signed copy of motor vehicle safety program, road test , van driver check off , and signed job description for Nursing Assistant and Transportation. j. The facility van will remain out of service until a new van driver has been trained. An ambulance service will provide non emergent transport for appointment. The facility van will remain out of service for 30 days, and beyond that time corporate will decide if its use will be resumed. Monitoring The van driver validated (double check) with each resident transport the securing of residents via the validation of seat belts in van tool, this includes restraint properly secured on frame X4 (2 front and 2 back), seat belt and shoulder strap are secured properly, wheel chair is locked and grips are locked. This tool is compared to the daily van transportation log to ensure all residents are identified on the transportation log are also identified on the double check validation of seat belts in van log . These logs are reviewed and analyzed by the Administrator and/or Maintenance Director, results are reviewed by in the monthly Performance improvement committee meeting (includes the Administrator, Medical Director, Director of Health Services, Financial Counselor, Maintenance Director, Housekeeping/Laundry Director, Medical Records and Social Worker) for potential revisions to tool as needed. Monthly validations of securing the resident will be monitored monthly by the Performance Improvement committee for compliance with securing the resident in the van by the van driver. The Financial Counselor will present van drivers verification log to the performance improvement committee to ensure all van drivers have been properly trained and documentation is complete. New van drivers will be observed by the Maintenance Director, and/or Housekeeping Director daily for one week, weekly for four weeks the monthly for four months for securing the residents accurately. The Maintenance Director will present the finding to the monthly Performance Improvement committee members. All audited findings from the transportation logs, van drivers verification logs, van observation logs and education in general orientation will be reviewed in the monthly Performance improvement committee meeting for patterns and trends and further interventions developed as necessary to ensure continued compliance. The facility alleged compliance as of 10/28/2011" The credible allegation was verified on 10/28/11 beginning at 12:34 PM. Six of the seven nursing assistants who were questioned regarding van safety training indicated that they had recently received training. Nurses and the staff responsible for scheduling appointments indicated they contacted the outside agency for non-emergency transportation. Review of inservice sheets indicated 17 nursing assistants had received training on 10/28/11 on van safety. Review of the "Double Check Validation of Seat Belts in Van" checklist revealed the addition of the column "Wheel Chair Locked and Floor grips locked". 2. Resident # 13 was admitted to the facility on [DATE], and then re-admitted on [DATE] with the following cumulative Diagnoses: [REDACTED]. On the quarterly Minimum Data Set ((MDS) dated [DATE], she was assessed as being cognitively intact with no moods or behaviors and limitation with her range of motion on one side of her upper and lower extremities. During an interview with Resident #13 on 11/2/11 at 9:53am she shared that she was assaulted by a former resident while eating dinner in the dining room, during August, 2011. She stated that Resident # 62 didn't like her and would say vulgar sexual comments to her and make other derogatory statements that included profanity in front of anyone. She stated from the first day that he met me, he seemed to hate her. She commented that often, when she sat in the dining room to eat her meal, he would look at her, shaking his head and tell her, "I can't stand you" . She continued by saying that on 8/19/11 at 6:00pm, there were several residents in the dining room as well as several nurse aides. Nurse Aide # 5 remained in the dining room alone with the residents. Resident #13 stated that she was sitting at a table close to Resident #62 when he became angry with her and accused her of stealing his cookies, two weeks beforehand. She denied that she stole his cookies, but Nurse Aide #5 challenged her, asking her, why did she steal his cookies? Resident #13 stated that she started to argue back with Resident #62 who continued to call her names. After several minutes, she became uncomfortable with the language Resident #62 directed toward her and left the dining room in her wheelchair to report the incident to the nurse. She stated that she told the nurse (couldn't identify her name); "Would you please tell him to stop bothering me. He's being rude and nasty to me." The nurse told her that she would tell Resident #62 to leave Resident #13 alone, but she didn't see her approach the resident. When Resident #13 went back to resume eating her meal, she stated that Resident #62 threw a chair at her, which hit her in the face, leaving a black and blue mark on her forehead. At that point, she left the dining room and went to the nurse's station to make a police report at 6:11pm. A copy of the police report was obtained and it revealed that the local police came to the facility to interview Resident #13 on 8/20/11 at 1:30pm. Resident #13 reported that on 8/19/11 she went to the dining room to eat dinner at 6:00pm. She initially approached the table of a female resident but was cursed at by this resident and was told that she could not sit there. Resident #13 moved to another table, which was adjacent to Resident #62. Resident #62 also began to curse at Resident #13, as she ate her food, trying to ignore him. After she ate her food, she told the police officer that Resident #62 stood up and threw a chair at her and it hit her in the head. Nurse Aide #5 was in the dining room but did not witness the chair being thrown. The officer recorded that Resident #13 had a small bump on her forehead. The police report stated that the officer proceeded to interview Resident # 23, who's alert and oriented and who witnessed the incident on 8/19/11. Resident #23 saw Resident #13 get yelled at by a male and female resident in the dining room. She saw Resident #13 attempt to ignore them, but she eventually tried to leave the dining room when Resident #62 stood up and threw a chair at Resident #13, hitting her on her leg. She wasn't sure if she saw the chair hit Resident #13 in the head. She also mentioned that there were no nurses or supervisors in the dining room when Resident #13 was hit. The police report indicated that next the officer interviewed NA #5. She relayed that Resident #62 was cursing at Resident #13 and accusing her of stealing his food. She stated that because Resident #13 was able to ignore Resident #62, she continued to feed her resident, who needed her assistance. At one point, she stated that it sounded like a cup fell on the floor, but she did not see Resident #62 throw a chair at Resident #13. The police took no further action. The facility's investigation file was reviewed. It revealed that on 8/20/11 a 24 hour report was filed with the state and on 8/25/11 a 5 Working Day Report was filed as well, substantiated resident abuse. The investigation report contained statements from staff on duty during the incident on 8/19/11. On 8/19/11, NA # 11 provided a written statement which stated that during dinner on 8/19/11 she heard Resident #13 and Resident #62 going back and forth, calling each other names. Once their trays were delivered, she stated that they were spoken to and the residents were calmed down, so that they could begin to eat their food. NA #5 remained in the dining room with the residents, while NA #11 resumed passing trays on the hall. NA #11 attended an In-Service on Resident to Resident Protocol and Resident to Resident Abuse for Alert and Oriented Residents, held (8/20/11-8/22/11). The personnel file of NA #11 was reviewed and it indicated that NA #11 had resigned from the facility on 10/27/11. A phone call was attempted on 11/3/11 however; NA #11 could not be reached by phone for an interview. NA # 6 worked on 8/19/11 and recorded in her written statement that when she walked into the dining room she heard Resident #62 yell a vulgar sexual request to Resident #13 and she heard Resident #13 snap back at him. She did not witness any other activity. On 11/3/11 at 3:19pm, NA #6 was interviewed. She stated that Resident #62 was confrontational all the time with anyone that made him upset. He used disrespectful language toward the nursing staff and toward Resident #13. She stated that she has witnessed Resident #13 yell back at him, and would then try to separate them but Resident #62 wouldn't listen. He would channel his anger toward her and begin to call NA #6 names too. She would report his behavior to the nurse, who could calm him down. NA #7 worked on 8/19/11 and recorded in her written statement when she walked in the dining room, she saw Resident #13 bumped into a female resident, who began to curse at her and told Resident #13 to get away from her. At that point, Resident #62 began to instigate, and started yelling at Resident #13, accusing her of stealing his cookies. Even after Resident #13 denied it, Resident #62 continued to curse at her. She then saw Resident #13 leave the dining room and NA #7 stated that she left to assist a resident. On 11/4/11 at 10:19am, Nurse #7 was interviewed. She stated that she was the Second Shift Nurse Supervisor on 8/19/11 and was working on the floor where Residents #13 and #62, ate in the dining room. She shared that she was doing rounds at dinner when she was approached by Resident #13. She was told that Resident #62 was saying bad words to her and made her feel uncomfortable. She also reported that Resident #62 kept accusing her of stealing his cookies, which she denied because she's diabetic. Resident #13 told her that Resident #62 had thrown a chair at her and that it hit her on the knee. Nurse #7 examined the knee, but could not find any injury, redness or swelling at the site. She asked Resident #13 if there were any witnesses and she mentioned Aide #5, so she went into the dining room to interview her. The aide admitted that she heard the two residents arguing. Nurse #7 stated that she didn't believe that Resident #62 had enough upper body strength to throw a chair in the air at the distance between the tables. She thinks that it was possible that he might have thrown a lighter object at her instead. Nurse #7 did not approach Resident #62 to interview him about the incident and did not try to obtain a witness account from any other alert and oriented sitting in the dining room that evening. She stated that another nurse, (who's no longer employed at the facility) went to speak with Resident #62 and was asked to stay away from Resident #13. She stated that there were no other incidents that evening. Nurse #7 stated that her expectations would be for the nurse aide to calm down the residents by talking to them. If they continued to yell at each other, then the police should be called. She also stated that the nurse aide should attempt to separate the residents and go ask for help. She didn't ask the aide if she had tried to separate the residents. She stated that both of the residents were paralyzed so she didn't think that they could make direct contact with each other, unless an item was thrown. On 11/4/11 at 9:35am, NA #5 was interviewed. She stated that she was a new employee, beginning her employment on 6/16/11. She indicated that she had received training on abuse but did not recall getting specific training on resident to resident altercation. On 8/19/11 she was assigned to the dining room on the third floor. She was feeding a resident who required extensive assistance. She stated that she was the only aide in the dining room with about six residents. She begun to hear Resident #62 argue with Resident #13 and asked him what's wrong. He told her that Resident #13 had stolen his cookies two weeks ago. NA #5 stated that the residents argued for about two minutes. She asked Resident #13 if she stole his cookies and she responded, no. She stated that I had attempted to calm them down by talking to them and noticed that Resident #13 was able to ignore Resident #62 and saw her leave the dining room. Then she thought she heard a cup drop and Resident #13 told her that Resident #62 threw a chair at her. She didn't see a chair being thrown and doubted that Resident #62 had the strength to throw a chair. She thought that perhaps, he might have shoved a chair at her. She did not go over to the residents to investigate. She stated that no other nursing staff entered the dining room to assist and she did not request anyone's assistance because she felt that she had control over the situation. NA #5 shared that if two residents got into a verbal altercation again, she would inform the nurse sooner. Nurse Aide #5 attended an In-Service on Resident to Resident Protocol and Resident to Resident Abuse for Alert and Oriented Residents, held (8/20/11-8/22/11). Nurse #8 was interviewed on 11/3/11 at 3:30pm. She stated that she was working on 8/19/11 and was on passing medications when she learned of the incident between Residents #13 and #62. She stated that she was at the far end of the hall, a considerable distance away from the dining room and could not hear the residents arguing. She shared that no one alerted her to what was taken place in the dining room, however, if they did, she would have tried to separate the residents, removing Resident #62 first, since he was in a manual wheelchair. After Resident #13 reported that she was hit, she went to speak with Resident #62 who denied hitting Resident #13. She advised him to keep his distance from Resident #13 and they stayed apart, the rest of her shift. On 11/2/11 at 5:15pm, Resident #23 was interviewed. She stated that on 8/19/11 she was in the dining room during dinner, sitting near the doorway closest to the nursing station. She heard a female resident, yelling at Resident #13, as she strolled past her table. She