Every finding on record at PruittHealth-Rockingham

Based on observations, record reviews and interviews with the Nurse Practitioner and staff, the facility transferred a resident (Resident #88) with left hip pain after a fall. Resident #88 was diagnosed with a fracture of the left hip. The facility also failed to assess and obtain treatment orders for a skin tear (Resident #9). This deficient practice affected 2 of 2 residents reviewed for professional standards (Resident #88 and Resident #9).The findings included: 1. Review of the hospital Discharge summary dated [DATE] revealed that Resident #88 presented to the emergency room (ER) with complaints of right knee and hip pain following a fall several days prior. She was diagnosed with a minimally displaced fracture of the lateral condyle of the right tibia (a partial crack in the bone to the outer portion of the upper leg bone near the knee joint). Orthopedics evaluated the fracture and recommended non-operative management with no weight bearing on the right leg and the use of a knee brace. Resident #88 was admitted to the facility on [DATE] with diagnoses that included a nondisplaced fracture of the lateral condyle of the right tibia, unspecified osteoarthritis and congestive heart failure (CHF). A baseline care plan created 1/21/26 included a problem area for risk for falls or fall related injury related to right tibia fracture, decreased mobility and potential medication side effects. The care plan also included a problem area for Activities of Daily Living (ADL) decline related to right tibia fracture, CHF and acute respiratory failure. A Social Services progress note dated 1/23/26 and timed 5:06 PM, read that Resident #88 was noted on the floor on the left side of the bed. The note indicated the Social Services Director and Nurse Aide (NA) #2 entered the room with Nurse #1. The note stated that Resident #88 was attempting to self-transfer from the left side of the bed into the wheelchair, which rolled when she got into a standing position attempting to pivot and fell on her buttocks. Resident #88 was non-weight bearing on the right leg with a brace present. When Resident #88 was asked if she was in pain she stated yes to her tailbone/right hip. The note indicated the nurse completed range of motion and assessed Resident #88. Resident #88 felt pain subsided, an attempt to transfer resident to the wheelchair was made, but upon lowering her down she verbalized 10 out of 10 level of pain. An interview occurred with the Social Services Director on 5/13/26 at 9:50 AM. She stated that she recalled walking past Resident #88's room in the later part of the day on 1/23/26 and observed Resident #88 sitting on the floor beside her bed. She explained that NA #2 and Nurse #1 entered the room at the same time she did. The Social Services Director stated Resident #88 was sitting on the floor, with complaints of pain in her left hip. She recalled Nurse #1 performed an assessment but Resident #88 was wanting to get in the wheelchair and kept repeating the pain wasn't that bad. She stated NA #2 and Nurse #1 attempted to transfer Resident #88 to the wheelchair and when she was starting to sit down that's when she complained of increased pain in the left hip and they placed her in the bed. The Social Services Director recalled Resident #88's pain was on the side that did not have a brace in place. A second interview took place with the Social Services Director on 5/14/26 at 9:57 AM. She verified she was unsure if leg length difference was present after Resident #88's fall on 1/23/26 but she did complain of pain to her hip. She explained she saw Nurse #1 have Resident #88 move her arms around but couldn't recall what type of assessment was completed for her legs. The Social Services Director explained Resident #88 kept saying she wasn't hurt and wanted to get off the floor, so Nurse #1 and NA #2 stood her up to get to the wheelchair, Resident #88 had severe pain and was placed in bed. On 5/13/26 at 1:54 PM, an interview occurred with NA #2 who had worked with Resident #88 on 1/23/26 at the time of the fall. She recalled walking by Resident #88's room and heard someone say hey. She walked into the room and observed Resident #88 sitting on the floor by her bed. She recalled the bed was in the lowest position but couldn't recall the placement of Resident #88's legs, if an assessment was performed by Nurse #1 or if Resident #88 was transferred off the floor. An eINTERACT Situation, Background, Assessment, Recommendation (SBAR) form dated 1/23/26, timed 5:15 PM and completed by Nurse #1, read that Resident #88 had a fall with left hip pain and decreased range of motion made worse with movement or pressure. Resident #88 currently had a closed fracture to the right leg. The form indicated Nurse Practitioner (NP) #1 was made aware on 1/23/26 at 5:20 PM and ordered an x-ray of the left hip and pelvis. A post fall observation form dated 1/23/26, timed 5:46 PM and completed by Nurse #1, indicated Resident #88 experienced an unwitnessed fall in her room. Resident #88 stated she wanted to get out of bed and the wheelchair was beside the bed. She stated she stood and lost her balance landing on her left hip and tail bone. Resident #88 was observed seated on the floor with her legs extended by NA #2 and Social Services Director. There was no attempt made to request assistance from Resident #88 and Resident #88 had declined NA's offer 15 minutes prior to the event. Interventions provided were marked as comfort care and diagnostic x-ray ordered. A nursing progress note dated 1/23/26, timed 5:50 PM and written by Nurse #1, read that Resident #88 continued with complaints of pain and notable shortening of the left leg with foot turned out was observed. An order was obtained to transfer Resident #88 to the ER for further evaluation. Multiple attempts were made to contact Nurse #1 on 5/13/26 and 5/14/26 without success. Nurse #1 was on duty at the time of Resident #88's fall on 1/23/26. A review of the hospital records dated 1/23/26 to 2/1/26 indicated that Resident #88 presented to the ER with complaints of left hip pain as well as left lower leg shortened and rotated out following a fall. She was diagnosed with a closed fracture of the left hip and underwent surgical repair on 1/24/26. A phone interview occurred with NP #1 on 5/13/26 at 12:17 PM, who recalled being called and informed that Resident #88 had experienced a fall from the bed. She stated she was not informed of any pain or leg length difference, or she would have ordered Resident #88 to be transferred to the ER for further evaluation rather than remaining in the facility for x-rays. NP #1 added that if a resident had a fall with visible injuries or complaints of pain, she would have expected the staff to leave the resident in place, make them comfortable, speak with the provider and allow Emergency Medical Services (EMS) to move them off the floor, to prevent further damage in the event of an injury. The Director of Nursing (DON) was interviewed on 5/13/26 at 2:06 PM and stated she recalled being informed Resident #88 had experienced a fall and she walked down to the room but couldn't recall the exact time. The DON stated when she arrived at Resident #88's room she was lying in bed, which was noted to be low to the ground. She stated she could immediately see the difference in leg length and Resident #88 was complaining of pain in her hip. The DON explained that Nurse #1 told her that a provider had been notified and an order was obtained to complete an in the facility x-ray. The DON stated she told Nurse #1 to cancel that order as Resident #88 needed to be seen at the hospital. The DON stated she called the NP, explained what she observed and received an order for Resident #88 to be evaluated at the hospital. The DON was unable to state what type of assessment was performed by Nurse #1 at the time of the fall but would have expected Resident #88 to remain in place on the floor until EMS arrived, to prevent further damage, if there were complaints of pain or if any abnormalities had been observed. 2. Resident #9 was admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare following surgical amputation. Resident #9's quarterly Minimum Data Set (MDS) dated [DATE] indicated his cognition was intact, and behaviors were not exhibited during the look-back period. Functional limitation in range of motion impairment on both sides of lower extremities. Resident #9 required substantial/maximal assistance to shower/bathe self and bed mobility. He was dependent on staff with toileting hygiene, dressing, personal hygiene, and transfers. Resident #9 had no pressure ulcers and was receiving the application of nonsurgical dressings (with or without topical medications), and applications of ointments/medications other than to feet. Resident #9's care plan, last revised on 05/08/26 did not include a focus area for skin tears to left arm/elbow. The care plan did include an area for skin tears to Resident #9's right lower extremity. The interventions included for staff to monitor for and report skin changes or deterioration in wound status to provider and to perform care to sites as ordered and as needed. An observation and interview were conducted on 05/11/26 at 9:35 AM with Resident #9. On observation of Resident #9, he had a clear rectangle dressing on top of white gauze to his left arm/elbow area. The white gauze had brown and red substance on around the edges and in the center of the gauze. The bandage had no date or any writing on it. Resident #9 stated he obtained the skin tear to his left arm, a few days ago, I think it was Friday (5/8/26). He explained that while a nursing assistant (NA) was changing his brief he turned him onto his side and he almost fell off the bed, the NA grabbed him to prevent him from falling and while doing that the NA caused the skin tear to his left arm. (He pointed at the undated dressing on his left forearm area). Resident #9 could not recall the NA's name. Resident #9's physician orders from 05/01/26 through 05/11/26 revealed no orders for skin tear treatment to Resident #9's left arm/elbow area. An order dated 05/12/26 read: apply antibiotic ointment to left elbow skin tear, cover with dressing if needed until healed. An observation and interview were conducted on 05/12/26 at 11:01 AM with Resident #9's Hospice Nurse. The Hospice Nurse stated she was unaware of a skin tear to Resident #9's left arm/elbow area and that there was not a bandage in place to the area on 05/07/26 when she last visited Resident #9. The Hospice Nurse removed the dressing, a bordered gauze that had a date of 05/11/26 with the Wound Nurse's initials on top of it. Under the removed dressing Resident #9 had two skin tears side by side with scant bleeding noted. An interview was conducted on 05/12/26 at 11:09 AM with the Wound Care Nurse. She stated a NA, (could not remember which NA), came to her on 05/11/26 in the late afternoon and advised her Resident #9 had a skin tear to his left elbow area. The Wound Care Nurse explained she had not been previously notified of the skin tear to Resident #9's left arm. She stated the area had 2 linear skin tears that had blood on them, she cleaned and bandaged the areas. The Wound Care Nurse explained that Resident #9 had told her he hit his arm on the underneath side of the bedside table and caused skin tears. She denied asking the nurse what had happened or notifying the nurse of the skin tear. An interview was conducted on 05/12/26 at 11:47 AM with NA #2. She verified she had worked with Resident #9 on 05/08/26 from 7:00 AM to 3:00 PM. She explained that Resident #9 did not have any skin tears on his left arm. NA #2 could not recall seeing a bandage on his left arm/elbow area on 05/12/26. A phone interview was conducted on 05/12/26 at 7:41 PM with NA #5. She verified she was Resident #9's direct care NA on 05/09/26 from 7:00 AM to 7:00 PM. She denied seeing a skin tear or a bandage to Resident #9's left arm. An interview was conducted on 05/12/26 at 12:14 PM with NA #1. He stated no events occurred during care with Resident #9 on 05/08/26 from 3:00 PM to 7:00 PM, 05/10/26 from 7:00 AM to 7:00 PM, or 05/11/26 from 7:00 AM to 3:00 PM. He explained that while he was providing incontinence care to Resident #9 on 05/08/26 Resident #9 told him he had almost fallen during care in the past and for NA #1 to not let him fall when he turned him onto his side. NA #1 went on to explain that at no time during providing care did Resident #9 fall or almost fall from the bed. NA #1 indicated he did not cause skin tears to Resident #9's left arm. A phone interview was conducted on 05/12/26 at 11:51 AM with Nurse #3. She verified she had worked with Resident #9 on 05/08/26, 05/09/26, or 05/10/26 from 7:00 PM to 7:00 AM. She explained she did see a bandage to Resident #9's left arm/elbow area over the weekend but could not recall what days. She explained she did not know why there was a bandage in place. No events occurred during her shift, no treatment order was scheduled for her shift, and she did not apply the bandage. An interview was conducted on 05/12/26 at 12:07 PM with NA #3. She had worked with Resident #9 on 05/10/26 from 7:00 AM to 7:00 PM and she was not aware of a skin tear to Resident #9's left arm/elbow area. She could not recall seeing a bandage on his left arm/elbow area. She then stated she could have over-looked the bandage. A phone interview was conducted on 05/12/26 at 12:51 PM with Nurse #2. She verified she was the direct care nurse for Resident #9 on 05/08/26 and 05/10/26 from 7:00 AM to 7:00 PM. She stated she did see a bandage to Resident #9's left arm/elbow area on 05/08/26 however she did not know why the bandage was in place nor did she check the treatment orders to see if he had a treatment order in place. A follow-up interview was conducted on 05/12/26 at 3:08 PM with the Wound Care Nurse. She stated she did not initiate a treatment order or complete an incident report for the skin tear on the evening of 05/11/26 at approximately 6:45 PM because she was getting ready to leave the facility for the day and figured she would complete them on the morning of 05/12/26 upon returning to work. She indicated she did not think of asking the floor nurse to complete the treatment order or incident report. The Wound Care Nurse explained she added the treatment order and completed an incident report on 05/12/26. An interview was conducted on 05/12/26 at 3:22 PM with the Director of Nursing (DON) in the presence of Administrator and Corporate Nurse Consultant. The DON indicated she was unaware Resident #9 had a skin tear to his left arm/elbow area, unaware an incident report had not been completed, and unaware a treatment order was not completed at the time a bandage was applied to the skin tears to Resident #9's left arm. The DON stated the Wound Care Nurse completed the order and an incident report on the morning of 05/12/26. Her expectation was the nurse that finds or made aware of a new skin issue to initiate the treatment order, incident report, and make the Wound Care Nurse aware of the new area. Unsuccessful attempts were made during the survey period to contact NA #4 (Scheduled for C hall on 05/08/26 and 05/09/26 from 7:00 PM-7:00 AM) and Nurse #5 (Scheduled as the shift supervisor on 05/08/26 and 05/10/26 from 7:00 PM-7:00 AM). There was no answer to the call attempts and the mailbox was full.

Based on record reviews, and pharmacist and staff interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic medications (oxycodone and hydrocodone) prescribed to treat pain. This affected 6 of 6 residents reviewed for misappropriation (Residents #6, #54, #223, #55, #27, and #224. The findings included: A review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property effective 12/1/01, revised 10/27/20 and reviewed 1/11/24, revealed it is the policy of PruittHealth and its affiliated entities to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment and misappropriation of patient property. The Organization and its partners should assure that best efforts are made to prevent any occurrences of any form of abuse, neglect, and exploitation. Further review of the policy revealed misappropriation of patient property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a patient's belongings or money without the patient's consent. a. Resident #6 was admitted to the facility on [DATE]. A review of the active physician orders for Resident #6 for August 2024 included an order dated 4/9/24 for Oxycodone-acetaminophen 5-325 milligrams (mg) tablet, one tablet by mouth twice a day; hold for sedation. A review of the controlled drug form revealed Resident #6 was signed out as receiving oxycodone-acetaminophen by Nurse #6 on 8/10/24 at 9:00 PM. Nurse #6 documented the number of pills left was 28. The corrected count completed by the Director of Nursing on 8/11/24 indicated there were 26 pills left. A review of Resident #6's Medication Administration Record (MAR) for August 2024 revealed Nurse #6 administered one oxycodone-acetaminophen tablet at 9:00 PM on 8/10/24. b. Resident #54 was admitted to the facility on [DATE]. A review of the active physician orders for Resident #54 for August 2024 included an order dated 5/29/24 for hydrocodone-acetaminophen tablet, 5-325 mg; one tablet by mouth three times a day as needed for pain. A review of the controlled drug form revealed Resident #54 was signed out as receiving hydrocodone-acetaminophen by Nurse #6 on 8/10/24 at 9:00 PM and at 4:00 AM on 8/11/24. Nurse #6 documented the number of pills left after the first dose was 12 and she documented the number of pills left after the second dose was 11. The corrected count on the Controlled Drug Form completed by the Director of Nursing on 8/11/24 indicated there were 9 pills left. A review of Resident #54's August 2024 MAR revealed Resident #54 did not receive hydrocodone-acetaminophen on 8/10/24 or 8/11/24. c. Resident #223 was admitted to the facility on [DATE]. A review of the active physician orders for Resident #223 for August 2024 included an order dated 8/6/24 for oxycodone 5 mg tablet, one tablet every 8 hours as needed for pain. A review of the Controlled Drug Form revealed Resident #223 was signed out for one oxycodone tablet on 8/10/24 at 9:00 PM by Nurse #6 leaving a remaining number of pills as 26. Resident #223 was also signed out one oxycodone tablet on 8/11/24 at 4:30 AM by Nurse #6 leaving the remaining number of pills at 25. The corrected count on the controlled drug form completed by the Director of Nursing on 8/11/24 indicated there were 23 pills left. A review of Resident #223's August 2024 MAR revealed Resident #223 did not receive oxycodone on 8/10/24 or on 8/11/24. d. Resident #55 was admitted to the facility on [DATE]. A review of the active physician's order for Resident #55 for August included an order dated 6/25/24 for oxycodone 5 mg tablet, one tablet four times a day as needed for pain. A review of the Controlled Drug Form revealed Resident #55 had one oxycodone tablet signed out by Nurse #6 on 8/11/24 at 5:30 AM leaving a total of 25 pills. The corrected count completed by the Director of Nursing on 8/11/24 indicated there were 22 pills left. A review of Resident #55's August 2024 MAR revealed Resident #55 did not receive oxycodone on 8/11/24 at 5:30 AM. e. Resident #27 was admitted to the facility on [DATE]. A review of the active physician's orders for Resident #27 for August 2024 included an order dated 5/11/24 for oxycodone 5 mg tablet, one tablet every six hours as needed for pain. A review of the Controlled Drug Form revealed that Resident #27 had one tablet signed out on 8/10/24 at 11:30 PM by Nurse #6 leaving a total of 17 pills and one signed out on 8/11/24 at 6:00 AM by Nurse #6 leaving a total of 16 pills. The corrected count completed by the Director of Nursing on 8/11/24 indicated there were 14 pills left. A review of Resident #27's August 2024 MAR revealed Resident #27 did not receive oxycodone on 8/10/24 or 8/11/24. f. Resident #224 was admitted to the facility on [DATE]. A review of the active physician's orders for Resident #224 for August 2024 included an order dated 8/8/24 for oxycodone 5 mg tablet, one tablet three times a day as needed for pain. A review of the Controlled Drug Form revealed that Nurse #6 signed out one oxycodone for Resident #224 on 8/10/24 at 9:00 PM leaving a total number of 18 pills left. A review of Resident #224's August 2024 MAR revealed Resident #224 did not receive oxycodone on 8/10/24. An initial report was submitted to the North Carolina Department of Health and Human Services Division of Health Service Regulation by Interim Administrator #3 on 8/11/2024 at 11:20 PM. The allegation of misappropriation of property was made on 8/11/2024 when narcotic discrepancies were found on six resident's narcotic records involving Nurse #6. A review of the facility investigation completed by Administrator #3 on 8/11/2024 revealed on 8/11/2024 at 11:20 PM the Director of Health Services (DHS) was notified by Nurse #3 that Nurse #6 stated she had a migraine and was going to the emergency room . When Nurse #3 went to the unit where Nurse #6 was assigned, Nurse #3 observed medication cups filled with pills with initials written on the cups on top of the medication cart. Nurse #3 called Nurse #7 to assist her with counting the narcotic medication and reviewing pill cups; Nurse #3 and Nurse #7 were unable to account for 10 narcotic pills. No medications had been signed as they were given. Residents who could be interviewed denied receiving medication that evening. Following review by Nurse #3, Nurse #7, and DHS, Nurse #3 and Nurse #7 gave medications to residents in Nurse #6's assignment. The DHS reviewed the facility cameras in Nurse #6's assignment area and medication cart. Other employees were observed walking past the medication cart; nobody had touched the medication cart until reviewed by Nurse #3 and Nurse #7. DHS contacted Nurse #6 and told her she needed to return to the facility to account for the missing narcotic pills; Nurse #6 did not return to the facility at that time. A report was made with the local police department. While the police department was in the facility, Nurse #6 returned to the facility approximately an hour after speaking with the DHS and attempted to retrieve her bag but left the facility again as the DHS was attempting to interview her regarding the occurrence. Nurse #6 stated to the DHS, I don't know what happened to it. Nurse #6 was suspended pending investigation. Nurse #6 went to the facility to retrieve her bag on 8/13/24. She provided a urine sample per request which showed a trace of opiate; urine sample sent per facility protocol for further review. Nurse #6 gave her verbal resignation to the Human Resources Coordinator on 8/13/24. A review of Nurse #6's timecard for 8/10/24 revealed she was scheduled to work from 7:00 PM to 7:00 AM. According to the time captured, she clocked in at 6:50 PM and clocked out at 7:16 AM. Nurse #6's timecard for 8/11/24 revealed she was scheduled to work from 7:00 PM to 7:00 AM. According to the time captured, she clocked in at 7:05 PM and clocked out at 9:03 PM. A witness statement dated 8/11/24 by Nurse #3 read she was made aware Nurse #6 left the facility. The statement read around 10:00 PM she walked to the D hall and noted the medication cart was sitting at the top of the C hall with cups of pills sitting on top of the cart. The statement continued that Nurse #3 and Nurse #4 counted the cart and noted the narcotic count was off. Because of the pills on top of the cart in cups Nurse #3 called Nurse #7 to help go through the pills to see if they matched the narcotics in the cart drawer. It was noted there were 10 pills missing. The Director of Nursing (DON) was then called and made aware. The cart was not touched or any pills given off the cart until the DON arrived and counted the cart with Nurse #3. The DON took the keys and called the Administrator afterwards. An interview with Nurse #3 occurred on 2/19/25 at 5:50 AM, and she stated she worked on the A hall the night of 8/11/24 and was training Nurse #4 regarding the medication pass. She stated Nurse #6 worked the D hall. She indicated Nurse #6 was the lead nurse that night. Nurse #3 stated Nurse #6 complained to her about having a headache and that she was tempted to take a resident's narcotic. Nurse #3 indicated she informed Nurse #6 that would be the dumbest thing she ever did. She did not report the statement to the DON because she did not believe Nurse #6 was serious. Nurse #3 stated that Nurse #6 had called her at some point during the night and wanted Nurse #4 to pass the pills for her before she left the facility. Nurse #3 stated she informed Nurse #6 that Nurse #4 could not pass pills for her. Nurse #3 further stated she had received a text message from Nurse #7 notifying her that Nurse #6 left her cart and went to the hospital. Nurse #3 indicated she did not make it to the D hall until 9:00 or 10:00 PM after she finished the medication pass on the A hall. She stated Nurse #7 had pushed the cart to the top of the hall where she could watch it since the cart had cups of pills on top of it and had noted the keys to the cart were sitting on top of it. Nurse #3 stated that she and Nurse #7 counted the narcotics and noted several were not signed out and missing from multiple residents' medication cards. She indicated she called the DON to report the missing narcotics. A witness statement dated 8/11/24 by Nurse #7 read around 8:30 PM she was approached by Nurse #6 who told her she was going to the emergency room across the street for a migraine cocktail and she would return shortly after. Nurse #7 wrote she informed Nurse #6 that her cart needed to be counted, and Nurse #7 was unable to accept the keys to the cart until this was done. Nurse #7 wrote she continued to pass the medications to the residents on the C hall. Nurse #7 further wrote between 8:45 PM and 9:00 PM she received a call from Nurse #6 stating she had left and was at the emergency room and would not be returning to the facility because she was loopy from the medications she received for her migraine. Nurse #7's statement indicated Nurse #6 had slurred speech. According to the statement, Nursing Assistant (NA) #4 notified Nurse #7 he had seen the D hall medication cart with 25-30 medication cups on top without supervision. Nurse #7 wrote she and NA #4 pulled the medication cart to the top of C hall within her sight while she continued to pass medications to the residents on the C hall. The statement continued at around 10:00 PM Nurse #7 was summoned to go to the D hall cart because Nurse #3 wanted to speak with her and informed her some narcotics were missing from a resident's cup. She stated Nurse #3 called the DON to make her aware of the missing narcotics around 10:15 PM. An interview was conducted with Nurse #7 on 2/20/25 at 11:48 AM, she stated Nurse #6 had reported her head was hurting on the night of 8/11/24. She indicated one of the NAs informed her the medication cart on the D hall had a bunch of medications on top of it. Nurse #7 stated she thought Nurse #6 might be outside smoking so she pulled the medication cart to the hall where she was working so she could keep an eye on it. Nurse #7 indicated she later found out that Nurse #6 had left the facility without asking anyone to count the cart with her. She stated at some point she had received a text from Nurse #6 saying she was not going to return to the facility. Nurse #7 stated until she walked to the D hall cart, she was unaware there were cups of pills or anything laying on that cart. She indicated she also found the keys to the cart lying underneath the straws. Nurse #7 stated Nurse #3 called the DON who came into the facility. She stated the DON counted the narcotics with Nurse #3 and Nurse #7 and found a bunch of medications had been pulled but not given. After counting the narcotics, the cart was left in the DON's hands. A witness statement dated 8/15/24 by NA #4 read on the evening of 8/11/24 he spoke with Nurse #6 who complained to him about having a headache. He wrote he was walking the halls performing his duties of Firewatch when he became concerned when he saw the D hall medication cart in the middle of the hall with at least 25-30 cups full of pills. His statement reflected he notified Nurse #7, and she walked with him to the cart and took control of the situation where she pushed the D hall cart over to the C hall where Nurse #7 was working where the cart remained as far as he knew. NA #4 could not be reached for an interview after multiple attempts were made. Nurse #6 was called for an interview on 2/20/25 at 10:42 AM. After initial phone greetings and introductions she refused to be interviewed and hung up the phone. The Director of Nursing was interviewed on 2/18/25 at 1:30 PM, and she stated she was notified by Nurse #3 on the night of 8/11/24 of the missing narcotics. The DON indicated when she arrived at the facility that night, she began an investigation of the event which included a review of the camera footage for Nurse #6's work area. The DON stated Nurse #6 came in to work her scheduled shift on 8/11/24 but left before it was finished. She indicated that Nurse #6 left her cart down the hall where she was working and that an NA noticed about 16 cups lined up on top of the cart with medications in them. She stated NA #4 reported to the nurse when he saw the medication cups and the nurses on duty counted the medications in the cart when they went to the hall. She further stated after counting, the nurses noted a significant number of narcotics were missing and the nurses called Nurse #6 to ask where the missing medications were. She stated Nurse #6 told the nurses she would be back to handle it. The DON stated she called the Administrator to notify her of the events. The DON reported that she collected the medication cups full of pills from the medication cart and tried to identify the pills in the cups and to whom they might have belonged. She noted all the cups had initials written on them. She stated that Nurse #6 never could tell her what happened to the missing narcotics when she spoke with her by phone. The DON stated all the nurses know to count on and off narcotics at shift change. The nurses know if there are any discrepancies, they need to notify the DON. She further stated the nurses received medication administration training after the event. The Pharmacist was interviewed on 2/19/25 at 4:02 PM. She stated she was notified of the missing narcotics at the facility, but she couldn't recall the date she was notified. The Pharmacist stated it was completely inappropriate. She indicated she visited the facility shortly after the event and completed a medication pass in-service with the nursing staff and taught what was appropriate and what was inappropriate when passing medications. Administrator #3 was interviewed on 2/20/25 at 12:10 PM. She stated she had just taken the interim role of Administrator a day or two before the incident occurred. She indicated the DON had notified her regarding a nurse who left mid-shift leaving medications on the cart and of missing narcotic medications. She stated the DON contacted the Drug Enforcement Administration, the North Carolina Board of Nursing and reported the incident to the State. She stated that the DON was the one who worked on the event.

Based on record review and staff interviews, the facility failed to maintain documentation of resolved grievances and evidence of the results of all grievances for 9 of 13 months reviewed (December 2023 to August 2024). Findings included: During an interview with Administrator #1, the current administrator, on 2/17/25 at 4:20 PM she stated the grievances from December 2023 through August 2024 were not available and could not be reviewed because she did not have the grievances. On 2/17/25 at 4:30 PM the Social Worker was interviewed. She stated the former administrator, Administrator #2, would not allow her to assist in the grievance process. She indicated Administrator #2 told her the administrator's role was the grievance official, and that the Social Worker was not to touch the grievances. The Social Worker stated she did not know where the grievance log (which was a record of the grievances) or the copies of grievances were kept. Administrator #2, the former administrator, was interviewed by phone on 2/18/25 at 10:07 AM and stated when she left the facility in August 2024, she gave the grievance log binder to the Director of Nursing in a box of stuff. She further stated the Social Worker also had copies of the grievances during the time she was the Administrator from December 2023 to August 2024. The Director of Nursing (DON) was interviewed on 2/18/25 at 3:51 PM. She stated Administrator #2 had called her in August 2024 after Administrator #2 was no longer employed at the facility and asked the DON to meet at a grocery store parking lot in a nearby town so Administrator #2 could return some papers belonging to the facility. She stated Administrator #2 handed her a box from her car, and the DON indicated she put the box in her car's trunk. The DON stated that she did not open the box to check the contents, but that she placed the box in the Administrator #1's office when she went back to work. The current administrator, Administrator #1, was interviewed on 2/17/25 at 4:20 PM. She stated she began working for the facility on 8/18/24. She stated she had searched her office and throughout the facility, but she had not been able to find the grievances or grievance logs from December 2023 to August 2024. She indicated she was unsure if grievances were recorded before she became the Administrator because she was informed by the Social Worker, the former administrator would not allow the Social Worker to participate in the grievance process. However, she stated she would continue to search for the grievances and the grievance log. During a follow up interview with Administrator #1 on 2/20/25 at 2:22 PM, she stated she began working with the Social Worker to assist with the grievance process when she became the Administrator in August 2024. She indicated grievances were discussed during the morning meeting each day, and each month the Social Worker would report to her regarding any further action required for grievances which were of concern. The facility provided a copy of the Quality Assurance and Performance Improvement (QAPI) meeting minutes dated 8/27/24 and a copy of its Performance Improvement Plan (PIP) dated 8/27/24 to review for a potential determination of past noncompliance. The measures and systemic changes put into place and monitoring in the corrective action plan did not address the deficient practice. As a result, the survey team was unable to make a determination of past noncompliance for grievances.

Based on record reviews, Pharmacist, and staff interviews, the facility failed to follow professional standards to prepare and administer medications to residents one at a time and had pre-poured pills in medication cups left on top of a medication cart (D hall) prepared by Nurse #6 for dispensing during the 9:00 PM medication pass. This affected 13 of 27 residents residing on D hall (#40, #226, #228, #58, #54, #227, #223, #225, #7, #36, #224, #55, and #20). The findings included: A review of the facility policy titled Medication Administration: General Guidelines effective 4/1/98, revised 4/10/24 and reviewed 7/22/24 read in part under the headline titled Procedure: Medications are administered at the time they are prepared. Medications are not pre-poured/pre-set/pre-crushed. Only one patient/resident's medications are prepared and administered at a time. Only the licensed or legally authorized personnel that prepare a medication may administer it. This individual records the administration on the patient/resident's MAR (medication administration record) at the time the medication is given. At the end of each medication pass the person administering the medications reviews the paper MAR or the electronic version of e-MAR (electronic medical administration record) to ascertain that all necessary doses were administered, and all administered doses were documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. The following residents were identified during the facility's investigation completed by the Director of Nursing (DON) as having cups of their evening medications pre-poured and left on top of the D hall medication cart. a. Resident #40 was admitted to the facility on [DATE]. A review of Resident #40's August 2024 active physician orders revealed the following medications: -An order dated 7/25/24 for Doxepin capsule 25 milligrams (mg) 50 mg, 2 capsules by mouth at bedtime. -An order dated 8/3/24 for doxycycline hyclate capsule 100 mg, 1 capsule by mouth twice a day for 10 days to be given at 9:00 AM and 9:00 PM. b. Resident #226 was admitted to the facility on [DATE]. A review of Resident #226's August 2024 active physician orders revealed the following medications: -An order dated 6/14/24 for atorvastatin tablet 10 mg, 1 tablet by mouth once a day at bedtime. -An order dated 6/17/24 for buspirone tablet 7.5 mg, 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. -An order dated 6/14/24 for gabapentin capsule 100 mg, 1 capsule by mouth three times a day at 09:00 AM, 02:00 PM and, 09:00 PM. -An order dated 6/14/24 for hydralazine tablet 50 mg, 1 tablet by mouth twice a day at 09:00 AM and 9:00 PM. -An order dated 6/14/24 for magnesium oral tablet 400 mg, 1 tablet by mouth once a day at bedtime. -An order for methocarbamol tablet 500 mg, 1 tablet by mouth three times a day at 9:00 AM, 1:00 PM, and 9:00 PM. -An order dated 6/14/24 for metoprolol tartrate tablet 50 mg, 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. -An order dated 6/14/24 for omeprazole capsule, delayed release 20 mg, 1 capsule by mouth twice a day at 6:00 AM and 9:00 PM. -An order dated 6/14/24 for potassium chloride tablet extended release 10 milliequivalents (mEq), 1 capsule by mouth twice a day at 09:00 AM and 09:00 PM. -An order dated 6/14/24 for tramadol 50 mg, 1 tablet by mouth once a day at bedtime. -An order dated 6/14/24 for Zyrtec (cetirizine) tablet 10 mg, 1 tablet once a day at 9:00 PM. c. Resident #228 was admitted to the facility on [DATE]. A review of Resident #228's August 2024 active physician orders revealed the following medications: -An order dated 1/22/24 for atorvastatin tablet 80 mg, 1 tablet by mouth once a day at bedtime. -An order dated 1/22/24 for duloxetine capsule, delayed release 60 mg, 1 capsule by mouth once a day at bedtime. -An order dated 1/22/24 for ferrous sulfate tablet 325 mg (65 mg iron), 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. -An order dated 3/27/24 for Remeron oral 22.5mg tablet,1 tablet by mouth once a day at bedtime. d. Resident #58 was admitted to the facility on [DATE]. A review of Resident #58's August 2024 active physician orders revealed the following medications: -An order dated 3/28/24 for Atorvastatin tablet 40 mg, 1 tablet by mouth once a day at bedtime. -An order dated 4/28/24 for colchicine tablet 0.6 mg, 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. -An order dated 5/29/24 for melatonin tablet 3 mg, 3 tablets (9 mg) by mouth once a day at bedtime. -An order dated 3/28/24 for metoprolol tartrate tablet 25 mg, 1 tablet by mouth every 12 hours at 09:00 AM and 09:00 PM. -An order dated 5/11/24 for omeprazole capsule, delayed release 20 mg, 1 tablet by mouth twice a day at 6:00 AM and 9:00 PM e. Resident #54 was admitted to the facility on [DATE]. A review of Resident #54's August 2024 active physician orders revealed the following medications: -An order dated 3/15/24 for atorvastatin tablet 80 mg, 1 tablet by mouth once a day at bedtime. -An order dated 6/13/24 for Colace (docusate sodium) capsule 100 mg, 1 capsule by mouth twice a day at 9:00 AM and 9:00 PM. -An order dated 3/15/24 for Depakote (divalproex) tablet, delayed release 250 mg, 1 tablet by mouth once a day at 9:00 PM. -An order dated 6/2/25 for Senna-S (sennosides-docusate sodium) 8.6-50 mg tablet, 2 tablets by mouth once a day at bedtime. f. Resident #227 was admitted to the facility on [DATE]. A review of Resident #227's August 2024 active physician orders revealed the following medications -An order dated 7/27/24 for benztropine tablet 1 mg, give 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM -An order dated 7/27/24 for gabapentin capsule100 mg, 1 capsule by mouth twice a day at 9:00 AM and 9:00 PM -An order dated 7/27/24 for potassium chloride capsule, extended release 10 mEq, give 2 capsules by mouth every 12 hours at 9:00 AM and 9:00 PM -An order dated 7/27/24 for senna tablet 8.6 mg, give 1tablet by mouth once a day at bedtime. -An order for Tylenol Extra Strength (acetaminophen) tablet 500 mg, 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM g. Resident #223 was admitted to the facility on [DATE] A review of Resident #223's August 2024 active physician orders revealed the following medications: -An order dated 8/6/24 for acetaminophen extra strength 500 mg tablet, 2 tablets by mouth twice a day at 9:00 AM and 9:00 PM. -An order dated 8/6/24 for atorvastatin tablet 40 mg, 1 tablet by mouth once a day at bedtime. -An order dated 8/6/24 for buspirone 7.5 mg, 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. -An order dated 8/6/24 for doxazosin 2 mg, 1 tablet by mouth once a day at bedtime. -An order dated 8/6/24 for duloxetine capsule, delayed release, 1 capsule by mouth once a day at bedtime. -An order dated 8/6/24 for gabapentin caplet 300 mg, 1 caplet by mouth twice a day at 9:00 AM and 9:00 PM. -An order dated 8/6/24 for Seroquel (quetiapine) tablet 25 mg, 1 tablet by mouth three times a day at 9:00 AM, 2:00 PM, and 9:00 PM. h. Resident #225 was admitted to the facility on [DATE]. A review of Resident #225's August 2024 active physician orders revealed the following medications: -An order dated 2/11/23 for baclofen tablet 20 mg, 1 tablet twice a day at 9:00 AM and 9:00 PM. -An order dated 1/19/24 for divalproex tablet, delayed release 125 mg, 1 tablet by mouth once a day at bedtime. -An order dated 6/28/24 for ferrous sulfate tablet 325 mg (65 mg iron), 1 tablet by mouth three times a day at 9:00 AM, 2:00PM, and 9:00 PM. -An order dated 2/9/23 for gabapentin capsule 300 mg, 1 capsule three times a day at 9:00 AM, 1:00 PM, and 9:00 PM. -An order dated 2/11/23 for metformin tablet 1,000 mg, 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. -An order dated 2/11/23 for metoprolol succinate tablet extended release 24-hour 50 mg, 1.5 tablets twice a day at 9:00 AM and 9:00 PM. -An order dated 3/22/23 for Vitamin C (ascorbic acid(vitamin C) tablet 500 mg, 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. i. Resident #7 was admitted to the facility on [DATE]. A review of Resident #7's August 2024 active physician orders revealed the following medications: -An order dated 11/8/23 for atorvastatin 10 mg, 1 tablet by mouth once a day at bedtime. -An order dated 11/8/23 for Protonix (pantoprazole) tablet, delayed release 40 mg, 1 tablet by mouth twice a day at 6:30 AM and 9:00 PM. j. Resident #36 was admitted to the facility on [DATE]. A review of Resident #36's August 2024 active physician orders revealed the following medication: -An order written 7/25/24 for Risperdal (risperidone) tablet 0.5 mg, 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. k. Resident #224 was admitted to the facility on [DATE]. A review of Resident #36's August 2024 active physician orders revealed the following medications: -An order dated 7/29/24 for Eliquis (apixaban) tablet 2.5 mg, 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. -An order dated 7/29/24 for sennosides-docusate sodium tablet 8.6-50 mg, 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. l. Resident #55 was admitted to the facility on [DATE]. A review of Resident #55's August 2024 active physician orders revealed the following medications: -An order written on 4/18/24 for tamsulosin 0.4 mg, 1 tablet by mouth once a day at 9:00 PM. -An order written on 4/25/24 for trazodone 100 mg, 1 tablet by mouth once a day at bedtime. m. Resident #20 was admitted to the facility on [DATE]. A review of Resident #20's August active physician orders revealed the following medications: -An order written on 5/28/24 for calcitriol capsule 0.25 mg, take 1 capsule by mouth every 12 hours at 9:00 AM and 9:00 PM. -An order written on 5/28/24 for docusate sodium capsule 100 mg, take 1 capsule by mouth every 12 hours on 9:00 AM and 9:00 PM. -An order written on 5/28/24 for donepezil 5 mg, take 1 tablet by mouth once a day at bedtime. -An order written on 6/18/24 for ferrous sulfate tablet 325 mg (65 mg iron), 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. -An order written on 5/28/24 for memantine tablet 5 mg, 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. -An order written on 5/28/24 for metoprolol tartrate 12.5 mg take 12.5 mg by mouth twice a day at 9:00 AM and 9:00 PM. -An order written on 5/28/24 for pantoprazole tablet delayed release 40 mg, 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. -An order written on 7/8/24 for potassium chloride tablet extended release 20 mEq, 1 tablet by mouth twice a day at 9:00 AM and 9:00 PM. A review of Nurse #6's timecard for 8/11/24 revealed she was scheduled to work from 7:00 PM to 7:00 AM. According to the time captured, she clocked in at 7:05 PM and clocked out at 9:03 PM. A witness statement dated 8/11/24 by Nurse #3 read she was made aware Nurse #6 left the facility. The statement read around 10:00 PM she walked to the D hall and noted the medication cart was sitting at the top of the C hall with cups of pills sitting on top of the cart. Because of the pills in cups on top of the cart Nurse #3 called Nurse #7 to help go through the pills to see if they matched the narcotics in the cart drawer. An interview with Nurse #3 occurred on 2/19/25 at 5:50 AM, and she stated she worked on the A hall the night of 8/11/24 and was training Nurse #4 regarding the medication pass. She indicated Nurse #6 worked the D hall and was the lead nurse that night. Nurse #3 stated that Nurse #6 had called her at some point during the night and wanted Nurse #4 to pass the pills for her before she left the facility. Nurse #3 stated she informed her that Nurse #4 could not pass pills for her. Nurse #3 further stated she had received a text message from Nurse #7 later that evening notifying her that Nurse #6 left her cart and went to the hospital. Nurse #3 indicated she did not make it to the D hall until 9:00 or 10:00 PM after she finished the medication pass on the A hall. She stated Nurse #7 had pushed the cart to the top of the hall where she could watch it since the cart had cups of pills on top of it and had noted the keys to the cart were sitting on top of it. Nurse #3 stated she reported the incident to the DON who then came to the facility. She stated the DON removed the cups of pills from the cart and had Nurse #3 and Nurse #7 interview the alert and oriented residents to determine if they had received their evening medications. The DON also reviewed the camera footage of the D hall to determine if the medication pass had been done. After verifying the medication pass had not been done, Nurse #3 and Nurse #7 administered the evening medications to the residents on the D hall from their medications in the cart. A witness statement dated 8/11/24 by Nurse #7 read around 8:30 she was approached by Nurse #6 who told her she was going to the emergency room across the street for a migraine cocktail and she would return shortly after. Nurse #7 wrote she informed Nurse #6 that her cart needed to be counted, and Nurse #7 was unable to accept the keys to the cart until this was done. Nurse #7 wrote she continued to pass the medications on the C hall. Nurse #7 further wrote between 8:45 PM and 9:00 PM she received a call from Nurse #6 stating she had left and was at the emergency room and would not be returning to the facility because she was loopy from the medications she received for her migraine. Nurse #7's statement indicated Nurse #6 had slurred speech. According to the statement, Nursing Assistant (NA) #4 notified Nurse #7 he had seen the D hall medication cart with 25-30 medication cups on top without supervision. Nurse #7 wrote she and NA #4 pulled the medication cart to the top of C hall within her sight while she continued to pass medications to the residents on the C hall. An interview was conducted with Nurse #7 on 2/20/25 at 11:48 AM, she stated Nurse #6 had reported her head was hurting on the night of 8/11/24. She indicated one of the NAs informed her the medication cart on the D hall had a bunch of medications on top of it. Nurse #7 stated she thought Nurse #6 might be outside smoking so she pulled the medication cart to the hall where she was working so she could keep an eye on it. Nurse #7 indicated she later found out that Nurse #6 had left the facility without asking anyone to count the cart with her. She stated at some point she had received a text from Nurse #6 saying she was not going to return to the facility. Nurse #7 stated until she walked to the D hall cart, she was unaware there were cups of pills or anything laying on that cart. She indicated she also found the keys to the cart lying underneath the straws. Nurse #7 stated Nurse #3 called the DON who came into the facility. Nurse #7 stated she, the DON, and Nurse #3 found a bunch of medications had been pulled but not given. After counting the narcotics, the cart was left in the DON's hands. A witness statement dated 8/15/24 by NA #4 read on the evening of 8/11/24 he spoke with Nurse #6 who complained to him about having a headache. He wrote he was walking the halls performing his duties of Firewatch when he became concerned after he saw the D hall medication cart in the middle of the hall with at least 25-30 cups full of pills. His statement reflected he notified Nurse #7, and she walked with him to the cart and took control of the situation where she pushed the D hall cart over to the C hall where Nurse #7 was working where the cart remained as far as he knew. NA #4 could not be reached for an interview after multiple attempts were made. Nurse #6 was called for an interview on 2/20/25 at 10:42 AM. After initial phone greetings and introductions she refused to be interviewed and hung up the phone. The Director of Nursing was interviewed on 2/18/25 at 1:30 PM, and she stated Nurse #6 came in to work her scheduled shift on 8/11/24 but left before it was finished. She indicated that Nurse #6 left her medication cart down the hall where she was working and that an NA noticed about 16 cups lined up on top of the cart with medications in them. She stated the NA #4 reported to the nurse when he saw the medication cups and the nurses on duty counted the medications in the cart when they went to the hall. The DON reported that she collected the medication cups full of pills from the medication cart and took them to her office where she tried to identify the pills in the cups and to whom they might belong and noted all the cups had initials written on them. The DON stated she instructed Nurse #3 and Nurse #7 to administer the medications to the residents on the D hall from the medication cart once they determined the medication pass had not been completed by Nurse #6. She stated medications should not have been sitting on top of the cart without supervision. She further stated the nurses received medication administration training after the event. The Pharmacist was interviewed on 2/19/25 at 4:02 PM. She stated she was notified about the cups of pills sitting on the medication cart at the facility, but she couldn't recall the date she was notified. The Pharmacist stated it was completely inappropriate. She indicated she visited the facility shortly after the event and completed a medication pass in-service with the nursing staff and taught what was appropriate and what was inappropriate when passing medications. Administrator #3 was interviewed on 2/20/25 at 12:10 PM. She stated she had just taken the interim role of Administrator a day or two before the incident occurred. She indicated the DON had notified her regarding a nurse who left mid-shift leaving medications on the cart. The facility's investigation documentation provided during the survey was reviewed. The documentation did not reveal a process for ongoing monitoring to ensure professional standards were observed and met by the nursing staff who were responsible for administering medications to residents which would have allowed the survey team to evaluate if the facility would be eligible for past non-compliance.

Based on record review, resident and staff interviews, the facility failed to protect a resident's right to be free from staff to resident abuse when Nurse Aide #1 tilted Resident #10's wheelchair back, let it back down then pushed the wheelchair forcefully down the hall. This was for 1 of 8 residents reviewed for accidents. The findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder, aphasia (difficulty expressing self) and lack of coordination. Resident #10 resided on the D Hall. A review of the facility Initial Allegation Report, investigation, and statements revealed on 11/12/24 Resident #10 was in the dining room when Nurse Aide (NA) #1 was observed tilting Resident #10's wheelchair back, letting it go back to the ground, pushing Resident #10's wheelchair forcefully down the hall and returning to the dining room without ensuring Resident #10 was safe. NA #1 was suspended pending the outcome of the investigation and then terminated. All staff received education on abuse. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #10 had moderately impaired cognition and verbal behavioral symptoms one to three days during the look back period. He had limited range of motion to bilateral lower extremities and utilized a wheelchair for mobility. He was coded with setup assistance for wheelchair mobility of 50 feet with two turns. Resident #10 was coded as weighing 152 pounds and was 72 inches tall. Resident #10's care plan, last reviewed 11/21/24 included the following problem areas: - Resident required assist with Activities of Daily Living (ADL) related to impaired mobility and cognitive status and was at risk for further decline in ADL function. - Resident had physical behavioral symptoms towards others (hitting, kicking, scratching). The interventions included to avoid power struggles, maintain a calm environment and approach to resident and divert resident's behavior as much as possible. On 2/19/25 at 5:51 PM, a phone interview was conducted with NA #1. She was able to recall the events of 11/12/24 and stated she was in the dining room assisting residents with their lunch meal and Resident #10 was asking for coffee. She stated he had finished his meal, and she told him to give me a few minutes. She stated Resident #10 began yelling out, so she attempted to pull him away from the table. She stated he was holding on to the table and his feet were on the floor. NA #1 confirmed she tilted the wheelchair back a little to get Resident #10's feet off the floor so she could wheel the chair and then let it back down. NA #1 stated it was not normal to tilt the wheelchair back but wanted to get his feet off the floor so she could move the wheelchair. She stated, I pushed him through the double doors of D hall and remember the floor technician standing there. NA #1 stated that Resident #10 resided on the D hall. NA #1 confirmed she was suspended pending the investigation and never returned to the facility. On 2/18/25 at 10:59 AM, an interview occurred with the Floor Technician who witnessed the events of 11/12/24. He explained that he was walking up D Hall and could see clearly in the dining room. He heard Resident #10 yelling out for coffee and had his meal tray in front of him. NA #1 was observed pulling Resident #10 away from the table, tilting the wheelchair back where Resident #10's legs were in the air and letting it drop back down to the ground. During this time Resident #10 was heard yelling leave me alone. The Floor Technician stated he began to walk in the dining room to intervene and was told by NA #1 don't touch him. NA #1 was then observed pushing Resident #10 to the double doors of the dining room and D hall, pushing the wheelchair forcefully and returning to the dining room. The Floor Technician stated the wheelchair rolled approximately 20 feet before coming to a stop on its own. He stated he reported the incident immediately to NA #2/staffing scheduler. On 2/18/25 at 2:32 PM, an interview was completed with NA #2/staff scheduler. She explained that she was approached by the floor technician and housekeeper who reported the incident they observed between Resident #10 and NA #1. She recalled they stated Resident #10 was in the dining room at the table and saw NA #1 remove him from the table as he was yelling out leave me alone. NA #1 tilted the wheelchair back, letting it go back down the ground then forcefully pushed Resident #10's wheelchair out on the hallway. It was reported that NA #1 turned around and walked back into the dining room. NA #2 stated she observed Resident #10 sitting in the hallway in a calm demeanor, after the allegation occurred. She reported the allegation directly to the Director of Nursing (DON). A phone interview occurred with the Housekeeper on 2/19/25 at 5:43 PM who observed the interaction between Resident #10 and NA #1 on 11/12/24. She explained she was standing at the nurse's station on the D Hall and observed NA #1 trying to pull Resident #10 away from the dining room table. After she pulled him away from the table, she tilted the wheelchair back where Resident #10's feet were off the ground and then let it go back towards the ground. NA #1 was observed pushing Resident #10's wheelchair roughly through the double doors of the dining room and D hall, turning around and returning to the dining room. She stated the Floor Technician began to walk in the dining room and was told by NA #1 don't touch him. The housekeeper stated that she didn't feel any resident should be treated this way. She reported it immediately to NA #2/staffing scheduler. On 2/17/25 at 10:33 AM, Resident #10 was observed sitting up in his bed with a cup of black coffee in front of him. He was unable to recall the event of 11/12/24. A phone interview was completed with the DON and Administrator on 2/20/25 at 1:01 PM. The DON explained on 11/12/24 she was notified by NA #2/staffing scheduler regarding the allegation of abuse witnessed by the housekeeping staff towards Resident #10. This was reported immediately to the Administrator and NA #1 was removed from the facility. The police department was notified, and the investigation began. The DON stated she assessed Resident #10, no injuries were noted and he had a calm demeanor. The Administrator and DON stated they were able to view video footage at the time that revealed Resident #10 was in the dining room at a table and NA #1 was assisting another resident at his table with the lunch meal. NA #1 was observed going to Resident #10, pulling him away from the table, tilting the wheelchair then putting it back down. She was then seen forcefully pushing the wheelchair at the double doors of the hallway and returning to the dining room. The Administrator stated that they substantiated the allegation of abuse and terminated NA #1. She said there was zero tolerance for abuse at the facility. A phone interview was completed with the Floor Technician on 2/24/25 at 2:56 PM. He explained that NA #1 had no change in her demeanor during the incident on 11/12/24 and was heard telling Resident #10 you need to quit your hollering while she was pushing him towards the doorway. He stated that the wheelchair came to a stop on its own after rolling approximately 20 feet. He recalled Resident #10's feet were on the floor sliding with the wheelchair. He did not witness any verbalizations from the resident during the incident but stated he had a look of surprise on his face. A second phone interview occurred with the DON and Administrator on 2/24/25 at 3:06 PM. They explained that Resident #10 was able to self-propel with his feet when up in the wheelchair. At the time of the incident on 11/12/24 Resident #10 had his feet on the floor sliding along with the wheelchair. They stated the wheelchair came to a stop on its own. On assessment Resident #10 had a calm demeanor. They both indicated that NA #1 was slightly hostile when she was asked to leave the facility on 11/12/24. The DON stated NA #1 stated she was assisting another resident with their meal, Resident #10 kept hollering and she felt like it was bothering the other residents to the reason why she removed him from the dining room. The Administrator stated that NA #1 was approximately 5 feet 7 inches in height. The facility was unable to provide evidence of a thorough, and complete, plan of correction regarding the facility's failure to protect a resident's right to be free from staff to resident abuse which would have allowed the survey team to evaluate if the facility would be eligible for past non-compliance.

Based on record review and staff interviews, the facility failed to develop an individualized and comprehensive care plan in the area of anticoagulant medication (Resident #25). This was for 1 of 21 residents whose care plans were reviewed. The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and atrial fibrillation. A review of the active medication orders for Resident #25 for February 2025 revealed an order for Xarelto (an anticoagulant medication) 20 milligrams, one tablet once a day for atrial fibrillation. The medication had a start date of 4/7/23. A quarterly Minimum Data Set (MDS) assessment for Resident #25 dated 1/7/25 indicated Resident #25 was cognitively intact. He was coded as receiving an anticoagulant. Resident's #25's active care plan updated 1/8/25 did not have a focus for anticoagulant medication. On 2/20/25 at 2:40 PM an interview was conducted with the MDS nurse. She verified Resident #25 did not have a focus for anticoagulant therapy on the care plan and that it should have included one. She stated that the missing medication focus was an oversight, and she would correct the care plan. The Director of Nursing was interviewed on 2/20/25 at 2:53 PM and stated that Resident #25 should have had an accurate care plan that included a focus that he was taking an anticoagulant medication.

Based on record review, observations and staff interviews, the facility failed to honor a resident's choice to receive coffee as requested for 1 of 3 residents reviewed for choices (Resident #10). The reasonable person concept was applied for Resident #10 due to his inability to express his feelings and a reasonable person would feel angry and frustrated if their choices were not met. The findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder and aphasia (difficulty expressing self). An annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #10 had moderately impaired cognition and required setup assistance for eating. On 2/18/25 at 10:59 AM, an interview occurred with the Floor Technician. He explained that on 11/12/24 he witnessed Resident #10 yelling out for coffee in the dining room and Nurse Aide (NA) #1 removed Resident #10 from the dining room instead of providing him with a cup of coffee as requested. A phone interview was conducted with NA #1 on 2/19/25 at 5:51 PM. She explained that on 11/12/24 Resident #10 was in the dining room, had completed his lunch meal and was requested more coffee. She was in the middle of assisting another resident at his table with their lunch and told him, give me a few minutes. She stated Resident #10 became agitated and she removed him from the dining room instead of providing him with coffee. On 2/17/25 at 10:33 AM, Resident #10 was observed sitting up in his bed with a cup of coffee in front of him. He was unable to recall the events of 11/12/24. A phone interview occurred with the Administrator and Director of Nursing (DON) on 2/20/25 at 1:01 PM. They explained that Resident #10 received meals in the dining room per his choice and loved drinking black coffee. The DON indicated that coffee was often used to help ease his anxiety and agitation when present. They both indicated that Resident #10 should have been provided with coffee as requested on 11/12/24.

Based on observations, record review, and Pharmacist and staff interviews, the facility failed to label an open and in use insulin pen with the resident's name or prescribing information that was stored in 1 of 2 medication carts (D hall cart) and the facility failed to keep unopened insulin pens refrigerated per manufacturer instructions and discard expired medications in 1 of 2 medication carts (A hall cart). The findings included: a. An observation was conducted on 2/18/25 at 11:20 AM of the D hall medication cart with Nurse #2. The observation revealed one (1) Lantus Solostar insulin pen with an open date of 2/10/25, but it did not have a label indicating the resident's name or prescribed dose for whom it was being used. An interview with Nurse #2 conducted at the same time revealed insulin pens should be labeled with the resident's name and the date it was opened. She stated insulin pens should be discarded 28 days after opening. The insulin pen was given to Nurse #2 to discard. b. An observation was conducted on 2/21/25 of the A hall medication cart at 8:15 AM with Nurse #5. The observation of the cart revealed one (1) Tresiba Flex insulin pen that was sealed and one (1) Lantus Solostar insulin pen that was also sealed. A blue sticker on the packages for both insulin pens stated, refrigerate until opened. The observation also revealed an opened and available for use Lantus Solostar insulin pen that was dated 12/12/24. Nurse #5 was interviewed at the time of the observation and stated that unopened insulin pens should be stored in the refrigerator per the manufacturer's instructions until they were opened and in use. She also stated that insulin pens should be discarded 28 days after opening. The medications were given to Nurse #5 to discard. An interview was conducted with the Director of Nursing on 2/21/25 at 8:20 AM. She stated that unopened insulin should be stored in the refrigerator until it was opened and insulin pens should be labeled with the resident's name, prescribing information, and the date they were opened. She stated insulin should be discarded 28 days after opening. The Director of Nursing stated she had the third shift nursing staff check the medication carts, and she had been training the Assistant Director of Nursing to check the carts every week. She further stated that the pharmacist checked the carts when she visited every month. An interview was conducted with the Pharmacist on 2/21/25 at 10:14 AM. She stated that she visited the facility each month to review medications. She stated insulin pens should be stored in the refrigerator until they were opened per the manufacturer's instructions and opened insulin pens should be disposed of after 28 days. She stated during her visit to the facility in January this year that she had removed an insulin pen from one of the carts with a date of 12/12/24, and that staff must have added it back to the cart instead of disposing of it. She stated that insulin pens should be labeled with a resident identifier, and the resident's name is best.

Based on record review, and Wound Care Practitioner and staff interviews, the facility failed to obtain treatment orders when pressure areas were identified on readmission from the hospital and nursing staff provided treatments without a physician's order. This deficient practice affected 1 of 7 residents reviewed for pressure ulcers (Resident #221). The findings included: Resident #221 was originally admitted to the facility on [DATE]. She required hospitalization from [DATE] to 5/1/24 for acute stroke. Resident #221 had other diagnoses that included peripheral vascular disease, Alzheimer's disease and congestive heart failure. A nursing progress note dated 5/3/24 indicated that Resident #221 had two small skin openings noted on the buttocks. Barrier cream applied during incontinence care. A significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #221 was moderately impaired with decision making skills. She required maximum assistance with bed mobility and was dependent on staff for toileting hygiene and transfers. She was coded with pressure ulcer over a bony prominence and two stage two pressure ulcers. Resident #221's care plan included a problem area dated 5/6/24 for having wounds and was at risk for deterioration in wound status or wound infection. The interventions included provide wound care as ordered and wound consult as ordered and as needed. Resident #221 was hospitalized from 5/7/24 to 5/9/24. A nursing progress note dated 5/9/24 indicated that Resident #221 had a wound to the sacral area and red area to the left outer heel. A review of the hospital discharge and after visit summaries dated 5/9/24, included no treatment orders for a wound to the sacral area or red area to the left outer heel. A review of the physician orders for Resident #221 from 5/9/24 to 5/13/24 did not include any treatment orders for a sacral wound or red area to the left outer heel. Resident #221 was transferred to the hospital on 5/27/24 for mental status changes and did not return to the facility. A phone interview occurred with Nurse #10 on 2/20/25 at 3:45 PM. She completed the readmission assessment on 5/9/24 and was assigned to care for Resident #221 on 5/10/24. Nurse #10 stated she couldn't recall Resident #221 or what might have happened when she was readmitted to the facility. Nurse #10 further explained that she no longer was employed at the facility but when a resident returned from the hospital with a wound, she would dress the area with a dry dressing to make sure it was clean. She was unable to explain why a physician order was not obtained for treatment to care for the sacral wound or left heel redness on readmission to the facility. On 2/21/25 at 11:48 AM, an interview occurred with Nurse #11 who was assigned to care for Resident #221 on 5/11/24 and 5/12/24. She was unable to recall if Resident #221 had any wounds when she returned from the hospital on 5/9/24. She explained that typically she would make sure a dry dressing was in place until a resident was seen by the wound care provider if someone returned from the hospital with any wounds. She could not recall if she had provided any wound care to Resident #221 on the days she was assigned to care for her. Attempts were made to contact Nurse #12 without success. She had been assigned to care for Resident #221 on 5/13/24. A Wound Care progress note dated 5/14/24 indicated that Resident #221 was seen for evaluation and management of a wound to the sacrum and left heel. Both wounds were classified as pressure in origin. The sacral wound was classified as a Stage 3 wound and measured 4.2 centimeters (cm) in length, 3.8 cm in width and 0.3 cm in depth. There were no signs of acute soft tissue infection. Wound care orders were provided to apply silver alginate daily. The left heel wound was classified as a deep tissue pressure injury and measured 4.2 cm in length and 4 cm in width. Wound care orders were provided to apply Betadine daily. A review of Resident #221's physician orders included the following orders: - An order dated 5/14/24 for Betadine to the left heel every day. - An order dated 5/15/24 to cleanse the sacrum with wound cleanser, apply silver alginate and a foam dressing every day. On 2/20/25 at 11:11 AM, a phone interview occurred with Wound Care Provider #1 who completed the initial evaluation for Resident #221s wounds on 5/14/24. He stated he believed there was a dressing present on the sacrum but didn't document that and was unsure what the facility was using as a treatment prior to his evaluation. He explained that Resident #221 had a stage 3 sacral wound and a deep tissue pressure injury on the left heel. At the time of the evaluation there was no concern for infection. The Wound Care Provider #1 stated he would have expected the facility to obtain wound care orders for the sacral wound and left heel wound prior to her being evaluated on 5/14/24. The Director of Nursing (DON) was interviewed on 2/20/25 at 1:01pm via phone. She verified there was a nursing progress note dated 5/9/24 indicating that Resident #221 readmitted from the hospital with a wound to her sacrum and redness to her left heel. She stated she was unable to find a physician order for the treatment of the sacral wound and left heel redness from 5/9/24 to 5/14/24. The DON stated she had a lot of new nurses during May 2024 and was unable to explain why there was no treatment order obtained for Resident #221 when she was readmitted from the hospital with skin breakdown to her sacrum and redness to her left heel. The DON stated that in May 2024 she did not have a wound care nurse. She recalled being present with the Wound Care Provider on 5/14/24 and felt like there was a dressing on the sacral wound but was unable to state who or when it was placed on the sacral wound.

Based on record review and staff interviews, the facility failed to ensure accurate daily Posted Nurse Staffing sheets for 3 of 30 days reviewed (01/24/25, 01/27/25, and 02/07/25). The findings included: A review of the daily Posted Nurse Staffing sheets compared to the Staff Schedule/Assignment sheets from 01/18/25 through 02/18/25 revealed discrepancies in the area of actual unlicensed Nursing Assistants (NAs) that worked. On 01/24/25 during 1st shift (7:00 AM-7:00 PM), the daily Posted Nurse Staffing sheet revealed 7 unlicensed staff worked and the Staff Schedule/Assignment sheet revealed 5 unlicensed staff worked. On 01/27/25 during 1st shift (7:00 AM-7:00 PM), the daily Posted Nurse Staffing sheet revealed 8 unlicensed staff worked and the Staff Schedule/Assignment sheet revealed 5 unlicensed staff worked. On 02/07/25 during 1st shift (7:00 AM-7:00 PM), the daily Posted Nurse Staffing sheet revealed 7 unlicensed staff worked and the Staff Schedule/Assignment sheet revealed 5 unlicensed staff worked. A phone interview was conducted on 02/21/25 at 11:48 AM with the NA #2/Staffing Scheduler. She verified that the daily Posted Nurse Staffing sheets compared to the Staff Schedule/Assignment sheets for 01/24/25, 01/27/25, and 02/07/25 reflected the incorrect number of unlicensed staff. She stated she was unaware she was to count 2 staff as 1 if they were splitting a shift. A phone interview was conducted on 02/21/25 at 11:55 AM with the Administrator. She stated she was unaware the daily Posted Nurse Staffing sheets were incorrect. She indicated the daily Posted Nurse Staffing sheets should accurately reflect the correct number of staff working.

Based on observation, record review, Nurse Practitioner and staff interviews, the facility failed to provide care and maintenance, such as flushing the PICC line and changing the dressing to Resident #179's Peripherally Inserted Central Catheter (PICC) line. This occurred for 1 of 1 resident (Resident #179) reviewed for surgical wounds. The findings included: Resident #179 was admitted to the facility on [DATE] with multiple diagnoses that included sepsis, perforation of the intestine and colostomy status. A review of Resident #179's hospital discharge summary dated 11/3/23 indicated that she received intravenous (IV) antibiotics but did not mention a PICC line and did not have any orders for the care or maintenance of the resident's PICC line. The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #179 was cognitively intact and was coded with an IV access. She was not coded with any antibiotic use. Review of the active physician orders dated 11/3/23 to 11/13/23 revealed no physician orders for the care and maintenance of Resident #179's PICC line. On 11/14/23 at 1:05 PM, a surgical wound care observation was completed to Resident #179's abdominal wound with Nurse #1. The surgical wound was clean and dry with wound care completed as ordered. Resident #179 had her left arm lifted to her head and a PICC line was observed to the left upper arm. The date on the dressing was 11/3/23 and the site was without redness or drainage. Nurse #1 was interviewed on 11/14/23 at 1:56 PM and stated she was aware Resident #179 had a PICC line but couldn't answer why the resident did not have orders for the care and maintenance of the PICC line. She added that to flush the PICC line and change the dressing, there had to be a physician's order. On 11/16/23 at 8:28 AM, a phone interview was completed with Nurse #3 who was familiar with Resident #179. She was aware there was a PICC line present but was unable to state why there were no orders for the care and maintenance of the PICC line. Nurse #2 was interviewed on 11/16/23 at 855 AM. She was the admitting nurse for Resident #179 on 11/3/23 and stated she was aware a PICC line was present to her left upper arm. Stated a phone call should have occurred to the physician/Nurse Practitioner to either obtain an order to discontinue or for the care and maintenance of the PICC line. She felt it was an oversight that she did not do this. On 11/16/23 at 9:38 AM, a phone interview occurred with the Nurse Practitioner (NP). She stated she was aware of a PICC line being in place which was free from any concerns during her assessments of Resident #179 but thought there were orders already in place for the care and maintenance of the PICC line. During an interview with the Director of Nursing (DON) on 11/15/23 at 3:30 PM, she stated when a resident was admitted with an IV device the admitting nurse should call the physician/NP and either obtain orders to maintain/care for the IV device or have it discontinued. She felt it was an oversight.

Based on record review and staff interviews, the facility failed to transmit a discharge Minimum Data Set (MDS) assessment within the required timeframe for 1 of 3 residents reviewed for discharge. (Resident #33). The findings included: Resident #33 was admitted to the facility on [DATE]. A record review was completed 11/15/2023. Resident #33's medical record revealed the resident was discharged to the hospital on 10/17/2023. The discharge Minimum Data Set (MDS) assessment was not transmitted. During an interview with the MDS nurse on 11/15/2023 at 9:56AM. She indicated she failed to complete the discharge MDS and transmit it. She further stated the Administrator was made aware of the past due assessments. Most were waiting for the Social Worker to complete her part. The Social Worker was no longer employed with the facility and the facility was currently working to transmit all past due MDS assessments. During an interview with the Director of Nursing (DON) on 11/15/23 at 10:00AM, She stated Resident #33 was sent to the hospital directly from the dialysis center on 10/17/2023. The discharge MDS assessment should have been completed and transmitted within the required timeframe.

Based on record reviews and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required time frame for 5 of 19 residents selected to be reviewed for Resident Assessments (Residents #10, #63, #64, #18 and #19). The findings included: A. Resident #10 was admitted to the facility on [DATE]. A record review was completed 11/15/2023. Resident #10's most recent MDS was dated 9/29/23 and was coded as a quarterly assessment. The electronic medical record indicated the assessment was in process and had not been completed. B. Resident #63 was admitted to the facility on [DATE]. A record review was completed 11/15/2023. Resident #63's most recent MDS was dated 9/27/23 and was coded as a quarterly assessment. The electronic medical record indicated the assessment was in process and had not been completed. C. Resident #64 was admitted to the facility on [DATE]. A record review was completed 11/15/2023. Resident #64's most recent MDS was dated 8/30/23 and was coded as a quarterly assessment. The electronic medical record indicated the assessment was in process and had not been completed. On 11/15/23 at 9:56 AM, an interview occurred with MDS Nurse #1 who stated the quarterly MDS assessments for Residents #10, #63, and #64 had not been completed as required. She explained that there had been an ongoing issue with the former Social Worker not completing her areas of the MDS assessment in the required time frame. She had gone to the former Administrator and created calendars for the Social Worker so she would know when to complete her sections of the MDS assessments. In addition, MDS Nurse #1 stated they were in the process of getting the assessments completed and transmitted. 31227 4. Resident #19 was admitted on [DATE]. Review of Resident #19's electronic medical record revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] that read in process and had not yet been completed. Resident #19's next quarterly MDS assessment dated [DATE] that read in process and had not yet been completed. On 11/15/23 at 9:56 AM, an interview was completed with MDS Nurse #1 who stated the quarterly MDS assessments for Resident #19 had not been completed as required. She explained that there had been an ongoing issue with the former Social Worker (SW) not completing her area of the MDS assessment within the required time frame. She stated she informed the former Administrator about the late MDS assessments. The MDS Nurse #1 stated she created and updated calendars for the SW so she would know when she needed to complete her area of the MDS assessments. In addition, MDS Nurse #1 stated they were in the process of getting the assessments completed and transmitted. 41437 5. Resident #18 was admitted to the facility on [DATE]. A review of Resident #18's most recent quarterly MDS was dated 10/1/2023. The electronic medical record indicated the assessment was in process and had not been completed. On 11/15/23 at 9:56 AM, an interview occurred with MDS Nurse #1 who stated the quarterly MDS assessment for Resident #18 had not been completed in the time frame required. She stated there had been an ongoing issue with the former Social Worker not completing her areas of the MDS assessment in the required time frame. MDS Nurse #1 stated she made the Administrator aware. MDS Nurse #1 stated the facility was currenly working to transmitt all past due assessments.

Based on record reviews and staff interviews, the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frame for 4 of 19 residents selected to be reviewed for Resident Assessments (Residents #20, #178, #180 and #182). The findings included: A. Resident #20 was admitted to the facility on [DATE]. A record review was completed 11/15/2023. Resident #20's most recent annual MDS was dated 10/5/23. The electronic medical record indicated this assessment was in process and had not been completed. B. Resident #178 was admitted to the facility on [DATE]. A record review was completd 11/15/2023. Resident #178's most recent MDS was dated 10/9/23 and was coded as an admission assessment. The electronic medical record indicated this assessment was in process and had not been completed. C. Resident #180 was admitted to the facility on [DATE]. A record review was completed 11/15/2023. Resident #180's most recent MDS was dated 10/7/23 and was coded as an admission assessment. The electronic medical record indicated this assessment was in process and had not been completed. D. Resident #182 was admitted to the facility on [DATE]. A record review was completed 11/15/2023. Resident #182's most recent MDS was dated 10/17/23 and was coded as an admission assessment. The electronic medical record indicated this assessment was in process and had not been completed. On 11/15/23 at 9:56 AM, an interview occurred with MDS Nurse #1 who stated the MDS assessments for Residents #20, #178, #180 and #182 had not been completed as required. She explained that there had been an ongoing issue with the former Social Worker not completing her areas of the MDS assessment in the required time frame. She had gone to the former Administrator and created calendars for the Social Worker so she would know when to complete her sections of the MDS assessments. In addition, MDS Nurse #1 stated they were in the process of getting the assessments completed and transmitted.

Based on record review, interviews with staff and previous Social Worker (SW), the facility failed to complete a referral to hospice for 1 of 3 residents (Resident #77) reviewed for closed records. The findings included: Resident #77 was admitted to the facility 6/5/2023 with diagnoses that included end stage renal disease and pneumocystis pneumonia. The resident's significant change in status Minimum Data Set (MDS) dated [DATE] indicated the resident had severely impaired decision-making ability. The resident's care plan was last updated 8/23/2023 and contained a focus for advanced directives. The care plan indicated the resident wished to remain a full code. The resident's medical record contained a Do Not Resuscitate (DNR) order dated 8/17/2023. A review of Resident #77's medical record revealed a physician's order for hospice consult/referral. The order was dated 8/17/2023. Resident #77's medical record reviewed on 11/14/2023 did not contain SW notes regarding a referral to hospice, hospice admission, hospice care plan, or hospice nursing progress notes prior to the resident's death in the facility on 8/26/2023. On 11/15/2023 at 9:54 AM a phone interview with the previous SW. She stated her last day of employment with the facility was a week ago. The SW stated she sent the referral to [NAME] Health Hospice via email. She further stated with some insurances, the resident will become a private pay when they transition to hospice, so Resident #77 was not transitioned to hospice services with [NAME] Health. She stated she spoke with the business office regarding the referral. She did not send the referral to agencies outside of [NAME] Health. The SW stated she did not know why there were no SW notes regarding the reason for not transitioning the resident to hospice. She explained most of the communication between her and [NAME] Hospice and the Financial Manager was conducted via email. She did not have access to those emails any longer. On 11/15/2023 at 10:25 AM an interview was conducted with the Financial Manager. She stated insurance was not the reason Resident #77 did not get referred to hospice. He was managed Medicaid and that did not prevent the resident from receiving reimbursement for hospice services with [NAME] Health Hospice. She did not recall any communication, email or otherwise, regarding Resident #77's referral to hospice. 11/15/23 10:28 AM Interview with the Regional MDS Consultant. She stated she contacted [NAME] Health Hospice, and they never received a referral for Resident #77. She was not sure why the referral was never made. The SW was responsible for making sure the hospice referral was completed. An interview was conducted with the Director of Nursing (DON) on 11/16/2023. She stated it was her expectation that residents with hospice referrals/consults be provided hospice services if they qualify.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately in the area of weight loss. This was for 1 (Resident #14) of 19 residents assessments reviewed. The findings included: Resident #14 was admitted on [DATE]. Review of Resident #14's electronic medical record read a weight of 128 pounds on 7/26/23 and 8/15/23. His weight on 9/18/23 was 114 pounds. Review of Resident #14's quarterly MDS dated [DATE] read his weight was 114 pounds and not coded for any weight loss. An interview was completed on 11/16/23 at 9:30 AM with the Dietary Manager (DM). She stated she coded Resident #14 with no weight loss and it was a mistake. She stated Resident #14 should have been coded to a weight loss. An interview was completed on 11/16/23 at 9:45 AM with the Director of Nursing (DON). She stated Resident #14's quarterly MDS should have been coded for weight loss.

Based on record reviews, observations, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification surveys conducted on 3/26/2021 and 8/31/2022 and during a complaint investigation conducted 5/24/2023. This was for 2 deficiencies that were cited in the area of accurate assessments and care plan revision. The deficient practice areas were recited on the current recertification and complaint survey on 11/16/2023. The duplicate citation of F641 during four federal surveys and F657 during two consecutive federal surveys of record shows a pattern of the facility ' s inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: F 641: Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately in the area of weight loss. This was for 1 (Resident #14) of 19 residents assessments reviewed. During a complaint investigation conducted 5/24/2023 the facility failed to code the Minimum Data Set assessment accurately in the area of Activities of Daily Living. During the facility's recertification survey 8/31/2022 the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of medication, nutrition, cognition, mood, and pain. During the facility's recertification survey 3/26/2021 the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of medication, Preadmission Screening and Resident Review Level II, cognition, indwelling urinary catheter, skin conditions, tobacco use, bowel and bladder, and activities of daily living. F 657: Based on record review, interviews with staff and previous Social Worker (SW), the facility failed to revise a care plan in the area of advanced directives for 1 of 19 residents (Resident #77) reviewed. During the facility's recertification survey 8/31/2023 the facility failed to review and revise the care plan in the areas of fall interventions, pressure ulcers, and urinary incontinence. In the absence of the Interim Administrator, an interview was conducted with the Regional MDS Coordinator on 11/16/2023 at 9:50AM. She stated the QAA committee is comprised of all department heads, the Medical Director, Nurse Practitioner, and Pharmacy Consultant. The Regional MDS Consultant stated lack of oversight was the reason for repeat citations.

Based on record review, interviews with staff and previous Social Worker (SW), the facility failed to revise a care plan in the area of advanced directives for 1 of 19 residents (Resident #77) reviewed. The findings included: Resident #77 was admitted to the facility 6/5/2023 with diagnoses that included end stage renal disease and pneumocystis pneumonia. The resident's significant change in status Minimum Data Set (MDS) dated [DATE] indicated the resident had severely impaired decision-making ability. The resident's care plan was last updated 8/23/2023 and contained a focus for advanced directives. The care plan indicated the resident wished to remain a full code. The resident's medical record contained a paper copy of a Do Not Resuscitate (DNR) order dated 8/17/2023. A review of Resident #77's medical record revealed a physician's order for hospice consult/referral. The order was dated 8/17/2023. On 11/15/2023 an interview was conducted with MDS Nurse #1. She stated the lack of communication by the SW and the lack of documentation by the SW lead to the care plan not getting revised on 8/23/2023 to reflect the new DNR order.

Based on record review, interviews with staff and Social Worker (SW), the facility failed to have complete and accurate medical records in the area of social services for 2 of 3 residents (Resident #77, Resident # 51) reviewed for closed records. The findings included: Resident #77 was admitted to the facility 6/5/2023 with diagnoses that included end stage renal disease and pneumocystis pneumonia. The resident's significant change in status Minimum Data Set (MDS) dated [DATE] indicated the resident had severely impaired decision-making ability. A review of Resident #77's medical record revealed a physician's order for hospice consult/referral. The order was dated 8/17/2023. Resident #77's medical record was reviewed on 11/14/2023 did not contain SW notes regarding a referral to hospice or hospice admission prior to the resident's death in the facility on 8/26/2023. On 11/15/2023 at 9:54 AM a phone interview with the previous SW. She stated her last day of employment with the facility was a week ago. The SW stated she sent the referral to [NAME] Health Hospice via email and most of the communication between her and [NAME] Hospice and the Financial Manager was conducted via email. The SW stated she thought she had documented in the resident's medical record. 2. Resident #51 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of the left foot. Resident #51's medical record contained a discharge assessment by Nurse Practitioner #1 with referral to home health for skilled nursing and aide, physical therapy and/or occupational therapy to evaluate and treat as indicated as well as skilled nursing for wound management. A review of Resident #51's medical record completed on 11/14/2023 did not contain SW notes regarding the resident's disposition, home health referral, or skilled nursing referral for wound management. On 11/14/2023 at 3:38 PM a phone interview was conducted with Resident #51. He stated he initiated the discharge home. The SW told him she sent his referral to home health, and they would contact him to set up a visit. The resident stated after he arrived home, the SW called and informed him the home health company she referred him could not provide service. She told him she would send the referral out to other agencies. The SW made him an appointment with the wound clinic, and he followed up with the wound clinic until he could get home health set up. On 11/14/2023 at 3:47 PM a second phone interview was conducted with the SW. She stated Resident #51 only gave the facility a few hours notice that he was going home with his wife. She discussed an Against Medical Advice (AMA) discharge with the Administrator. The Administrator told her to avoid an AMA discharge, if possible. The SW stated she made the referral to the home health agency that serviced the resident prior to his admission to the facility. The agency declined the referral, and she sent the referral out to several other agencies. Resident #51 discharge home with a vacuum assisted wound device (wound vac). She called the wound clinic and made Resident #51 a follow up appointment until they could get home health in place. The SW stated she did not document any action taken regarding the resident's discharge because she was more concerned with getting the services he needed in place.

Based on record review and staff interviews, the facility failed to accurately transcribe the physician order for a protective skin covering (Resident #71) for 1 of 1 resident reviewed for skin impairments. The findings included: Resident #71 was originally admitted to the facility on [DATE] with diagnoses that included weakness and protein-calorie malnutrition. A skin assessment dated [DATE] indicated Resident #71 had an intact pink/red area to her coccyx. Review of the physician orders included an order dated 8/2/23 for a foam dressing to the coccyx area every seven days. The order revealed it to be scheduled on Monday, Wednesday, and Thursday at 9:00 PM. The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #71 had moderately impaired cognition. She was free from any pressure ulcers or other skin impairments. Resident #71's active care plan, last reviewed 9/12/23, included a problem area for being at risk for development of pressure injuries related to decreased mobility and incontinence. The Director of Nursing (DON) was interviewed on 11/15/23 at 3:30 PM and stated Resident #71 used the foam dressing to her coccyx as protection due to her bony prominence. The DON was the nurse that put the order in on 8/2/23. She explained that the Nurse Practitioner initiated the protective foam dressing for every seven days in Resident #71's electronic medical record. The DON then activated the order to ensure it went on the Medication Administration Record. She further stated she inadvertently put the frequency to change the dressing every Monday, Wednesday, and Thursday instead of once a week as ordered. She felt this was an oversight.

Based on observations, record review, and resident, staff, nurse practitioner, and facility physician interview, the facility allowed a resident to smoke in his room for over a year (9/1/2019 through 3/24/2021) in a building where oxygen was used and stored or 1 of 4 sampled residents (Resident #23) which was a fire hazard. There was a high likelihood for a fire to occur while this resident smoked in his room and oxygen was in use in the facility. The facility also failed to lock the wheels on the sit to stand lift device during transfer with a mechanical lift (Resident #41), and failed to implement fall interventions (Residents #50) for 2 of 5 sampled residents reviewed for supervision to prevent falls. Immediate Jeopardy began on 9/8/2019 for Resident #23. The resident was documented by facility staff to be smoking in his room after being educated on the facility smoking policy and hazards (during oxygen use and storage and smoking in bed). Immediate jeopardy was removed on 3/25/2021 when the facility implemented a credible allegation of immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) for finding 1 to ensure monitoring of systems are put in place and to complete employee in-service and resident education. The severity for findings 2 and 3 is no actual harm with a potential for minimal harm that is not immediate jeopardy. Findings included: 1. Facility smoking policy was dated 1/1/2015 and revised on 10/15/2019. The policy documented that smoking was not allowed on the healthcare center premises by visitors, partners or patients/residents. Smoking will only be allowed in outdoor designated areas for those residents grandfathered in prior to January 1, 2015. The Admission Director or admitting licensed nurse will inform patient/residents and/or legal representative of the smoking policy upon admission. The policy also included the following: · At no time should any fire igniting material (matches/lighters) and smoking materials to include cigarettes, smokeless, electronic cigarettes, vaping devices, cigars, snuff or loose tobacco be in a patient/resident ' s possession. Patient/resident igniting, and smoking materials will be maintained at the nurse ' s station for the safety of smokers. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #23 had an intact cognition and rejection of care behavior. He required limited assistance for activities of daily living and had no functional limitation in upper extremity range of motion. The care plan start date was 10/15/19 with problem resident is a smoker and there has been smoke in his room. The approach was to keep smoking materials at the nurses ' station, resident was informed of smoking policy, and was issued a 30-day discharge (when non-compliant). The resident ' s care plan updated on 1/19/21 revealed problem: resident indulges in marijuana use, despite concealing an illicit drug use. Resident is a smoker and has had smoke odor in his room. The goal was for the resident not to smoke in his room. A review of Resident #23 ' s documented nurses ' notes from 8/29/19 (last recertification survey) through 3/21/21 revealed: Nurses Note (NN) 9/8/19 Resident noted with a pack of cigarettes opened on nightstand and a glass cup with partially smoked cigarettes and ashes. NN 10/9/19 Resident noted to be sitting up in his room in a wheelchair from another hall. The two were watching television this nurse stated to resident due to such a strong fresh smell of cigarette smoke in room when this nurse opened resident's door that he needed to stop smoking in the room. Resident began raising his voice to this nurse stating ain't nobody smoking in here you full of sh-t and you just going off of what the other nurse said get out of my room resident has frequently smoked in the room and denies smoking. NN 10/15/19 Continues to smoke in room (the resident). Will monitor. NN 11/15/19 This nurse making rounds and noted resident to be sitting up in wheelchair in room with door wide open smoking and also a strong smell of cigarette odor traveling up and down the hallway. NN 11/19/19 Resident continues to smoke in room, Administrator aware. NN 11/24/19 Smoke was smelled coming from his room and you can smell it all the way at the nursing station. NN 12/6/19 This nurse entered facility this am and noted Daisy hall to smell of marijuana smoke. This nurse then informed by 3rd shift nurse and nursing assistant (NA) that the resident was observed in his room in bed all night smoking cigarettes and marijuana. Administrative staff made aware. NN 12/7/19 The resident has continued to smoke in his bed throughout the night on this 11pm-7am shift and resident has continued to smoke both cigarettes and marijuana with the strong odor all the way up the hall past the nurses ' station. NN 12/9/19 Smell of smoke noted to come from the resident's room. No sign of cigarettes upon inspection of room. Nursing education given on smoking policy and dangers of smoking with oxygen in next room. Resident nodded his head and continued to watch television The Administrator made aware. Will continue to monitor. NN 12/10/19 Resident awake sitting up in wheelchair in room with the strong odor of fresh cigarette smoke coming from his room out into the hall. NN 1/24/20 During rounds this nurse and other staff members observed a very strong odor of marijuana coming from the resident's room. Also, resident in room smoking regular cigarette. NN 1/30/20 (observed) The resident had one hand up in the air with a lit cigarette up and room filled with smoke. The resident since then has smoked more cigarettes while awake and sitting up the rest of the time the morning. NN 2/15/20 The resident continued to smoke cigarettes in his room off and on throughout the night. Also, this nurse and NAs have smelled the strong odor of marijuana from the resident's room all up and down the hall and up past the nurses ' station resident. NN 3/27/20 On this shift the resident has smoked cigarettes in his room while in bed. The resident also noted to have the very strong odor of marijuana coming from his room all the way up and down the hall past the nurses ' station. This nurse noted four different episodes and had his door closed and the window in his room opened. NN 3/28/20 This nurse and staff noted the strong odor of marijuana coming from the resident's room again. This nurse and staff have smelled very strong odor of marijuana coming from this resident ' s room at 1:05am and 3:00am and the odor traveled all up and down halls around to the nurses ' station. NN 5/23/2020 11-7 shift: Resident for the past few nights has been having a very strong odor of smoking marijuana with the smell so strong that it travels all the way up the hall and past the nurses ' station. NN 6/27/20 Resident had a very strong odor of marijuana coming from room. This nurse entered the resident's room and observed the strong odor of marijuana. NN 9/11/2020 Resident was up smoking in room all night. NN 9/21/2020 The patient was smoking in his room. NN 9/23/2020 The resident smoked in his room. 10/13/20 Smoking assessment documented the resident was a supervised smoker. Facility protocol was for all residents to wear an apron. All questions were answered no except the resident was unable to get out of the chair independently (which made him supervised). NN 1/27/21 This nurse entered the resident ' s room and was greeted by a very strong cigarette smell. The resident also had a self-made pipe to smoke used for smoking marijuana on his bedside table. The entire hall and nurses ' station has smelled like cigarette smoke all shift. Director of Nursing made aware. NN 3/3/21 Nursing documented the resident continues to smoke. On 3/22/2020 a review of the facility matrix revealed continuous oxygen was being administered in rooms [ROOM NUMBERS] on Resident #23 ' s hall, and a total of 16 residents received oxygen facility-wide. There was bottled oxygen in storage (inside the building). On 3/22/2021 at 10:50 am a strong odor that resembled cigarette smoke was smelled on Hall C. The odor came from Resident #23 ' s room. Entry to the room for observation and interview was conducted. Resident #23 had a burned cigarette with ashes in an ash tray. The resident stated that since COVID, the facility staff refused to take him outside to smoke after repeatedly asking. The resident decided to smoke in his room. The resident provided a cigarette and means to light it which was housed in his room. The resident commented that the facility staff were aware that he smoked in his room and that he was asked not to smoke due to fire hazard. On 3/24/2021 at 8:20 am an interview was conducted with Resident #23. The resident stated that he obtained his cigarettes and lighter from the internet, which was delivered to the facility. The resident commented that he obtained his marijuana from outside the facility through his window and did not want to discuss. The resident acknowledged that he has been smoking cigarettes and marijuana in his room since he got here (was admitted ). The resident agreed that the bottle with brown water on his bedside table was a bong to smoke marijuana. The resident also commented that the facility was aware that he smoked in his room and that he was asked not to. An observation of Resident #23 ' s self and room (private) was done on 3/24/2021 at 8:20 am. A strong odor of cigarette smoke was noted in the room. A plastic bottle with brown water, foil cup, and large straw was observed on the bedside table. The foil cup had black residue and gray ash present. A package of cigarettes was lying on the bedside table. On 3/24/2021 at 1:00 pm an observation was done of Resident #23 ' s room while present. The resident ' s self-made pipe to smoke was sitting on the bedside table with what appeared to be a marijuana bud in the tinfoil cup. On 3/24/2021 at 12:30 pm an interview was conducted with the Administrator. The Administrator stated that she and staff had educated Resident #23 on safe smoking (outside only), fire hazard, and illegal marijuana use since his admission. The resident continued to smoke in his room. There have been numerous attempts to retrieve smoking material from the resident ' s room, but he had hidden the material. The Administrator commented that she was unaware how the resident obtained his smoking material. The Administrator had called the police in the past (last year) and the police officer informed her that there were no criminal charges, and he could not involuntarily remove the resident. The Administrator stated October 2020 the resident had ran his wheelchair into the leg of a staff member and caused injury. The resident was provided a 30-day discharge which the resident appealed. The appeal was won and there had been no further attempts to discharge the resident. The Administrator also commented that staff were instructed to inform her of the resident ' s smoking and not to attempt to retrieve the material due to the resident ' s behaviors. When informed, the Administrator stated she would enter the resident ' s room and look for and ask for smoking material. The resident would not comply. Lastly, the Administrator stated the police could not do anything. The Administrator acknowledged that there was continuous oxygen administration and oxygen storage on the resident ' s hall and that it was a fire hazard. The Administrator and DON were notified of the Immediate Jeopardy on 3/24/21 at 2:30 PM. The following nurses interviewed had documented nurses ' notes: An interview was conducted with Nurse #1 on 3/24/2021 at 8:10 am. Nurse #1 was very familiar with and assigned (day shift) to Resident #23. Nurse #1 was aware of the cigarette and marijuana smoke in the resident ' s room and facility hallway. Nurse #1 stated she informed the Director of Nursing and Administrator when the resident smoked and documented this in the resident ' s notes (since resident ' s admission). Nurse #1 had also observed a self-made pipe for smoking marijuana in the resident ' s room and was not aware how the resident was obtaining his smoking material. This problem had been going on for a while and was reported each time. Nurse #1 indicated that the resident can reach the window and open it when up in his wheelchair. The resident used to be able to reach the window from his bed, but his bed has since been moved and is no longer reachable. Nurse #1 was aware that there were residents who received continuous oxygen and oxygen was stored on the same hall which made smoking a fire hazard. The Administrator advised staff to inform her and take smoking material away from the resident. On 3/25/2021 at 12:20 pm an interview by telephone was conducted with Nurse #1 who was day shift nurse regularly assigned to Resident #23. Nurse #1 stated that she had observed and smelled the resident smoke cigarettes and marijuana in the resident ' s room. Nurse #1 commented that she had not tried to take away the cigarettes or marijuana because the resident was known to be violent and she was afraid. She indicated that the resident had thrown his meal tray at staff and that the Administrator was made aware. On 3/25/2021 at 12:30 pm an interview by telephone was conducted with Nurse #2. Nurse #2 (night shift) stated she was familiar with and assigned to Resident #23. She had smelled a strong odor of cigarette smoke on the hall that was coming from Resident #23 ' s room. She entered the resident ' s room and talked to him about smoking in the facility and the policy. The resident denied cigarettes or lighter to Nurse #2. She commented that he had taken the resident ' s cigarettes to storage for scheduled/supervised smoking outside in the past. The resident was known to have outbursts when his cigarettes had been taken away. On 3/25/2021 at 12:40 pm an interview was conducted with Nurse #3. Nurse #3 (day shift) stated that she had smelled the smoke of cigarettes and marijuana in the hall coming from Resident #23 ' s room. When Nurse #3 tried to remove the cigarettes or marijuana, the resident yelled at me and I was concerned for safety. The resident has had verbal behavior and aggression towards me. She also stated that the Charge Nurse on duty and the Administrator were informed and documented in the nurses ' notes (approximately 2 months ago). On 3/25/2021 at 2:40 pm an interview was conducted with Nurse #4. Nurse #4 stated she knew and was assigned to Resident #23. The resident had in the past dismissed me from his room when asked not to smoke. Nurse #4 commented that she had observed the resident smoke cigarettes in his room and this was problematic because he would not stop at the request of staff. I was not asked to write a statement of my observation. I did not know what to do. The concern was sent up to management and I was informed not to retrieve his smoking material. Nurse #4 stated she and the other nursing staff on Resident #23 ' s hall were concerned for fire hazard (smoking with oxygen) and were not comfortable and did not know how we would remove the residents if a fire occurred. Nurse #4 stated there were residents on the same hall who use oxygen continuously and oxygen tanks were stored. Nurse #4 commented that she informed the Director of Nursing (DON) of her concerns on several occasions (over the past several months) and that the smoking had been going on for months. On 3/26/2021 at 12:05 pm an interview was conducted with the nurse practitioner (NP) for the facility. The NP stated that she knew Resident #23 very well. The resident smoked in his room and felt it was his right to smoke. The resident was resourceful and ordered what he wanted from the internet. The resident was large and was verbally threatening. The facility was not able to handle him and keep him and other residents safe. The resident was informed of the guidelines regarding smoking and the hazards. On 3/26/2021 at 1:10 pm an interview was conducted with the facility physician who knew Resident #23. The resident was known to smoke and be non-compliant after multiple attempts to educate and work with him. The physician commented the Administrator tried to find other suitable places for the resident to reside, but no other facility offered a transfer. There were not enough mental health facilities for the resident to transfer and as a last resort, the resident was placed in a skilled nursing facility. The resident did not take his medication to help with his psychiatric [DIAGNOSES REDACTED]. The resident would not allow care. The resident had a wheelchair to get around and felt it was his right to go outside to retrieve packages during COVID before they were cleaned and refused to follow COVID restrictions when there was an outbreak. The resident needed to be in a psychiatric facility that can manage the behaviors and has a higher level of supervision and training for advanced mental health behaviors. The Administrator was notified of the Immediate Jeopardy on 3/24/2021 at 2:30 pm. On 3/25/2021 at 7:15 pm the facility provided an acceptable credible allegation for Immediate Jeopardy removal that included the following: The Removal Plan: The entity ' s removal plan must include the following: ·Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and a) Facility failed to provide a safe environment and protect residents from harm when Resident #23 smoked inside of the facility creating a fire hazard for current residents and staff inside the facility. Smoking inside of the facility could cause harm to residents on the hall should oxygen in use on the hall ignite as well as residents walking in the hallway have the potential to suffer serious bodily injury. This is evidenced by Care Plan dated 10/15/19 stating resident #23 was a problem smoker and smoked in his room to include illicit drug use. Resident #23 ' s medical record revealed Nursing notes dated 9/8/19, 10/9/19, 10/15/19, 11/15/19, 11/19/19, 11/24/19, 12/6/19, 12/7/19, 12/9/19, 12/10/19, 1/24/19, 1/30/19, 1/24/20, 1/30/20, 2/15/20, 3/27/10, 3/28/20, 5/23/20, 6/27/20, 9/11/20, 9/23/20, 9/21/20, 9/23/20, 10/13/20, 1/27/21, 3/3/21, and 3/22/21 documenting smoke and weed odors coming from room of resident#23 and smelling strongly the hallway. Notes also show cigarettes and ashtray type holders in room of resident#23. On 3/24/2021 State Surveyor observed Resident #23 ' s self and room at 8:20 am. A strong smell of cigarette smoke was noted in the room. A plastic bottle with brown water, foil cup, and large straw was observed on the bedside table. The foil cup had black residue and gray ash present. A package of cigarettes was lying on the bedside table. On 3/24/2021 at 8:20 am an interview was conduct with Resident #23. The resident stated that he obtained his cigarettes and lighter from the internet, which was delivered to the facility. The resident commented that he obtained his marijuana from outside the facility through his window and did not want to discuss. The resident acknowledged that he has been smoking cigarettes and marijuana in his room since he got here (was admitted ). The resident agreed that the bottle with brown water on his bedside table was a bong to smoke marijuana. The resident also commented that the facility was aware that he smoked in his room. It helps him with pain and anxiety. I have [MEDICAL CONDITION]. The facility should have determined if this issue could or would affect other residents. ·Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. b) Resolution includes - o Rockingham Police Officer called to facility at 1:44pm to remove remaining materials from room of Resident #23. Materials included ashtray, 2 packs of cigarettes, Dr. Pepper bottle cut to be used as drug paraphernalia, glass tray (Resident #23 told Officer Harris he uses this to smoke Marijuana), lighter, and mini blow torch. Facility administrator issued discharge notice to resident on 3/24/2021 at 1:20pm with a copy faxed to Ombudsman on 3/24/2021. Resident #23 was issued an Involuntary Commitment on 3/24/2021 at 4:38pm by Richmond County Magistrate after becoming verbally aggressive with facility employees. Discharging MD order notes resident #23 needs in-patient psychiatric facility. Facility will follow state and federal guidelines related to discharge. Resident #23 will be placed on 1:1 upon return to the facility with an alarm on the window (due to him stating the illegal drugs and materials are received through the window). Resident #23 will have room searches 3 times a week. Facility will involve Rockingham police department if resident refuses room search or becomes violent with employees. o All facility resident rooms (smoking and non-smoking) were searched on 3/24/2021 at 5:00p by Activity Director, Medical Records Coordinator, Financial Counselor, Human Resources Director, Environmental Services Director, Certified Dietary Manager, Maintenance Director, Admissions Director, and Social Services Director for smoking and flame igniting materials related to non-smokers and smokers residing and fell owshipping together. During the room sweep 1 resident (not #23) was found with cigarettes (removed by Admission Director) but no flame igniting materials. This resident was educated by the Admissions Director regarding the facility smoking policy. o Residents noted to be grandfathered in as smokers (11 total residents) were re-educated on 3/24/2021 by facility Activity Director, Medical Records, Financial Counselor, and Nursing Scheduler regarding facility smoking policy. Residents noted to be grandfathered in as smokers were educated by Social Services and Environmental Services Director on 3/25/2021 regarding the dangers of smoking inside of the facility due to being near oxygen sources and residents walking in the hallways because this can cause [MEDICAL CONDITION] oxygen will caused an increased combustible burn event. Residents noted to be grandfathered in as smokers were educated by Social Services and Environmental Services Director on 3/25/2021 regarding the dangers of using illegal drugs related to negative effects on the body and mental disturbances causing resident to be a danger to self and others. o Smoking screens were completed on current facility residents on 3/24/2021 by facility Director of Health Services and Clinical Competency RN. o RN Senior Nurse Consultant educated facility Administrator and Director of Health Services on 3/24/2021 regarding safe smoking policy with emphasis on reporting smell of smoke with removal of smoking and flame igniting materials. On 3/25/2021 RN Senior Nurse Consultant educated Administrator and Director of Health Services regarding illegal drug use and related paraphernalia on the premises, calling the police for removal, and the dangers involved in allowing use. o Facility employees (Dietary, Environmental Services, Administration, Therapy and Nursing) were educated on 3/24/2021 by Director of Health Services, Environmental Services Director, and Certified Dietary Manager, RN Treatment Nurse, Financial Counselor about safe smoking policy with emphasis on reporting smell of smoke to facility Administrator and/or Director of Nursing with removal of smoking and flame igniting materials. On 3/25/2021 current facility employees were educated by Director of Health Services, Environmental Services Director, and Certified Dietary Manager, RN Treatment Nurse, Financial Counselor regarding illegal drug use and related paraphernalia on the premises, calling the police for removal, and the dangers involved in allowing use. Newly hired employees will be educated by Human Resources/RN Clinical Competency regarding safe smoking policy with emphasis on reporting smell of smoke with removal of smoking and flame igniting materials as well as illegal drug use and related paraphernalia on the premises, calling the police for removal, and the dangers involved in allowing use. Facility employees (Dietary, Environmental Services, Administration, Therapy and Nursing) were educated on 3/25/2021 by Certified Dietary Manager, RN Treatment Nurse, Financial Counselor, and Admissions Director about the dangers of smoking inside the facility and dangers of illegal drug use. Education included noting facility has oxygen and open flame will cause severe injury to residents and employees. Education also stated illegal drug use is dangerous to residents and employees due to challenging behaviors and negative physical effects from their use. o Care Plans have been updated on 3/24/2021 by MDS Coordinators for residents noted to be grandfathered in as smokers. o Starting 3/24/2021 facility Administrative Team (Administrator, Financial Counselor, Environmental Services Director, Human Resources, Activity Director, Medical Records Coordinator, Maintenance Director, Social Service Director, and Certified Dietary Manager) will conduct 7 days of room surveillance room for residents grandfathered in as smokers to ensure smoking and flame igniting materials as well as illegal drugs and related paraphernalia on the premises to include calling the police for removal and the dangers involved in allowing use are not present. Resident room smoking searches will then be conducted by Administrative team (Administrator, Financial Counselor, Environmental Services Director, Human Resources, Activity Director, Medical Records Coordinator, Maintenance Director, Social Service Director, and Certified Dietary Manager) weekly for 3 weeks and monthly to ensure compliance with facility smoking policy and procedures. Residents found to be noncompliant with smoking in non-designated areas, using illegal drugs, having flame igniting materials, or illegal drug use materials will have their rooms searched by a member of the facility Administrative Team (Administrator, Financial Counselor, Environmental Services Director, Human Resources, Activity Director, Medical Records Coordinator, Maintenance Director, Social Service Director, and Certified Dietary Manager) daily with Rockingham Police being called if search is refused. Facility is alleging removal of the jeopardy on 3/25/2021 Validation: Validation began on 3/26/2021 at 9:00 am. As part of validation, in-service education and sign in sheets were reviewed and 91employees (including contract) participated in mandatory education for smoking and illegal substances in the facility and policy on 3/24/2021 and 3/25/2021. NA #3 was interviewed on 3/26/21 at 9:00 AM. She was educated on 3/24/21 by the DON and 3/25/2021. NA #3 was able to report on all information noted in the IJ removal plan. An interview was conducted with the DON on 3/26/21 at 9:30 am. She was educated by the Corporate Nurse Consultant on 3/24 and 3/25 on all required information noted in the IJ removal plan. 3/26/21 at 10:15am an interview with infection control/staff development coordinator (IC/SDC) confirmed she had received education on 3/25/21 regarding no smoking in the building and no smoking materials kept in rooms. If items were present, they were to be confiscated and reported to the Administrator immediately. Smell of cigarette smoke or illicit drugs was to be reported to the Police Department. On 3/26/21 at 10:37am Resident #27, who was a supervised smoker, stated he had received education on smoking (policy and safety) yesterday (3/25/2021). Resident # 46 commented on 3/26/21 at 10:35 am that three different people (facility staff) had come in his room to tell him about no smoking in the facility and no drugs. He stated he was not aware that a resident was smoking and using marijuana in his room. Interview with the Administrator on 3/26/21 at 11:48 am confirmed education was received from the facility consultant on 3/24 and again on 3/25 for all required information in the IJ removal plan. Immediate jeopardy was removed on 3/25/21. 2. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #41 ' s annual MDS dated [DATE] revealed that he was moderately cognitively impaired. The resident required extensive assistance of 1 staff for all activities of daily living (including transfer). His [DIAGNOSES REDACTED]. Resident #41 ' s initial care plan dated 1/12/20 revealed the problem of falls and potential. The approach to was to implement an exercise program that targets strength, gait and balance and a cushion will be placed in wheelchair to prevent sliding out of chair (did not indicate transfer status). On 3/22/2021 at 10:35 am an observation was done of Resident #41 in his room after morning care. The resident was transferred by NA #1 from his bed to his wheelchair by using a sit to stand transfer device. The NA placed the sling across the resident ' s back and began to lift the resident. The NA failed to lock the device wheels before standing the resident. The device moved during the transfer. NA #1 had to reposition the resident's legs during transfer due to contraction and stiffness. An interview was conducted with Nurse #3 on 3/25/2021 at 1:40 pm. Nurse #3 stated that Resident #41 required the assistance of the sit to stand device for transfer. Staff were required to lock the wheels of the device before attaching and lifting the resident to stand position before the transfer to prevent unwanted movement. Staff were informed of locked wheels during training upon hire. On 3/25/2021 at 2:06 pm an interview was conducted with NA #1. NA #1 commented that she was told by staff that Resident #41 required the sit to stand device for transfer. She stated that she does not usually use the sit to stand device for resident transfer. NA #1 had training for the device in January 2021 (when she was hired) but did not remember that the device needed the wheels locked before attaching and lifting the resident. NA #1 acknowledged that she did not lock the sit to stand device when transferring Resident #41 on 3/22/21. The Director of Nursing (DON) was interviewed on 3/25/2021 at 4:05 pm. The DON commented that staff were required to lock the sit to stand device before attaching and transferring a resident to prevent unwanted movement (potential for injury). There was training for all new employees and employees who have not had experience with the sit to stand transfer device. The DON provided a device maintenance policy for the battery and care. There was no facility policy or manufacturer ' s recommendation for device use. The DON commented that NA #1 should have locked the wheels of the device before use (sling placement and standing the resident). 3. Resident #50 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #50 ' s care plan included, in part, a problem area related to the risk for falls. This area was initiated on 11/13/19 and revised on 1/23/20. The interventions included, in part: - Offer to lay down resident down after meals and appointments (initiated on 11/13/19) - Monitor for changes in condition that may warrant increased supervision (initiated on 11/13/19) - Hoyer lift for transfers (initiated on 11/13/19) - Encourage resident to call for assistance (initiated on 11/13/19) - Rear wheelchair anti-tippers (initiated on 1/23/20)<br (TRUNCATED)

Based on record review, facility staff interviews, and laboratory company staff interviews, the facility failed to implement their policy and procedure in the areas of reporting and investigating allegations of abuse. The facility also failed to ensure contracted staff providing services to residents within the facility were trained on abuse reporting requirements for 1 of 2 residents (Resident #1) reviewed for staff to resident abuse. Immediate Jeopardy began on 1/9/19 when a Laboratory Phlebotomist failed to immediately report an observation of Nursing Assistant #1 hitting a cognitively impaired resident (Resident #1) on her face with a closed fist and on the shoulder with an open hand while Nursing Assistant #2 restrained the resident in her wheelchair. Immediate Jeopardy was removed on 2/8/19 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: A review of the facility ' s Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property policy, last revised 4/26/17, stated that this policy applied to all facility employees and its affiliated entities that provided goods or services to residents. This policy indicated that any allegation of resident abuse was to be immediately reported to the Administrator. The Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property policy, last revised 11/21/16, indicated the Administrator was responsible for assuring that an accurate and timely investigation was completed. This policy also indicated that for investigations when the alleged perpetrator was a Nursing Assistant that the facility ' s investigation was to include any personnel actions taken by the facility. The No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property policy, last revised, 11/21/16, indicated that if there was any suspicion of abuse the suspected staff was not to have direct contact with the resident at issue until the investigation was completed and the issue was resolved. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 was not completed in the area of cognition as the resident interview for mental status and staff interview for mental status were blank. She was assessed with [REDACTED]. Resident #1 had no physical behaviors, no verbal behaviors, and no rejection of care. She was noted with other behavioral symptoms and wandering behaviors on 1 to 3 days. Resident #1 was assessed as requiring the limited assistance of 1 for bed mobility, transfers, and locomotion on/off the unit. She required the extensive assistance of 1 with dressing, toileting, and personal hygiene. She was not steady on her feet and was only able to stabilize with staff assistance. Resident #1 utilized a walker and wheelchair, she was occasionally incontinent of bladder and bowel, she had no skin issues, and she had sustained no falls. The initial allegation (24-hour report) dated 1/9/19 completed by the Administrator indicated an allegation of staff to resident physical abuse. The incident occurred on 1/9/19 at approximately 5:15 AM and the facility became aware of the incident on 1/9/19 at 1:15 PM. The allegation details stated that Laboratory Phlebotomist (LP) witnessed Nursing Assistant (NA) #1 strike Resident #1 on her left shoulder while NA #2 held her by the shirt. The LP stated that she stayed in the room with Resident #1 to ensure she was not touched anymore by NA #1 or NA #2. Both NAs (NA #1 and NA #2) were noted to leave the room and the LP pushed Resident #1 in her wheelchair to the nurse ' s station. The details of physical or mental injury/harm read, Body audit revealed bruise to the face area (of Resident #1). This form was completed by the Administrator on 1/9/19. NA #1 and NA #2 were suspended on 1/9/19 pending the results of the investigation. The police were notified on 1/9/19 at 2:08 PM as required. The investigation report (5-working day report) dated 1/16/19 completed by the Administrator repeated the same allegation details and had no comments written in the section for additions/changes/updates to description of allegation details. This investigation report provided conflicting information from the previous initial allegation as it stated no physical injury/harm and no substantial risk of injury/harm for Resident #1 and it made no mention of the bruises to Resident #1 ' s face area identified during her 1/9/19 body audit (as indicated on the initial allegation report). Resident #1 ' s emotional response and behaviors indicated, No emotional response as resident has severe cognitive deficit at time of incident. The investigative actions section of this report indicated the following: - Allegation was unsubstantiated. - The accused individuals were not terminated. - Other employment actions: Accused individuals were to receive written warning related to resident safety as well as abuse prevention and training on the care of the combative/agitated resident. - Summary of facility investigation: Facility interviewed the LP, NA #1, NA #2, and Nurse #1 (charge nurse on duty during the time of the incident), residents on the hallway assigned to NA #1 an NA #2, and other staff who provided care to Resident #1. The medical record of Resident #1 was noted to be reviewed as well as skin audits. Based on the interviews and results of the skin audit the facility is not able to substantiate the allegations of abuse. The facility did find the accused (NA #1 and NA #2) at fault for leaving an agitated resident (Resident #1) in the care of an untrained person not in the employ of the facility (LP). NA #1 and NA #2 returned to work on 1/17/19 following completion of the investigation. An interview was conducted with the Administrator on 2/5/19 at 12:57 PM. The 24-hour report and the Administrator ' s typed summary of Resident #1 ' s medical record review that indicated a bruise was present on Resident #1 ' s lower right side of her face on 1/9/19 was reviewed with the Administrator. The part of the summary that indicated, bruise on resident ' s face was noted on a skin audit performed on 12/13/2019 was reviewed with the Administrator. The body audit form dated 1/5/19 that showed no bruising to Resident #1 ' s facial region was reviewed with the Administrator. The Administrator revealed she had not known where the information about Resident #1 ' s facial bruise came from. She also revealed that the date, 12/13/2019, was a typo, but that she had not known what the correct date was. The Administrator reviewed Resident #1 ' s medical record and she was unable to find any additional documentation of the facial bruising for Resident #1. The Administrator was asked how Resident #1 ' s facial bruising on 1/9/19 was ruled out as an injury from the 1/9/19 staff to resident abuse allegation. Her explanation was that the LP had reported to her by phone that NA #1 hit Resident #1 with a closed fist on the shoulder. She denied the LP reporting that NA #1 hit Resident #1 in the face in addition to the shoulder. The Administrator was unable to explain how Resident #1 ' s facial bruising was sustained. A family interview was conducted by phone with Resident #1 ' s Responsible Party (RP) on 2/6/19 at 8:50 AM. He stated that Resident #1 had a bruise on her face several weeks ago, but he was not sure how she had sustained the bruise. Resident #1 ' s RP revealed he was aware that an allegation of staff to resident abuse was made involving Resident #1, but he stated he had not been made aware of the results of the investigation. A verbal statement by the LP made by phone to the Administrator on 1/9/19 at approximately 1:15 PM was transcribed in handwriting by the Administrator. The report from the LP indicated that she heard a loud noise that sounded like grunting and hollering from a resident ' s room. She reported she opened the door to the resident ' s room without knocking and NA #1 stated to her, you need to turn around because I don ' t want you to see what I do to her. Resident #1 was seated in her wheelchair, NA #2 was behind resident #1 and appeared to be pulling the resident by the back of her shirt to keep her seated in the wheelchair. NA #1 had her fist drawn back, struck (Resident #1) on her (left) shoulder . (Resident #1) had hands up .reacting to being hit. The LP reported she had not seen NA #2 strike Resident #1, but that NA #2 had not stopped NA #1. The LP indicated she drew Resident #1 ' s blood as ordered while NA #1 and NA #2 were still in the room. She indicated she stayed with Resident #1 until both NAs left the room. A typed statement, undated, signed by the LP indicated that on 1/9/19 at approximately 5:45 AM she was walking toward Resident #1 ' s room to complete a blood draw as ordered. She reported that when she started getting close to the room she heard several voices along with Resident #1 grunting and hollering. The LP wrote that she opened the door and saw an NA (NA #2) standing behind Resident #1 holding her down in the wheelchair and another NA (NA #1) hitting Resident #1. The LP indicated that she opened the door wider and NA #1 said to her, you might want to go somewhere else so that you don ' t see what I am about to do to her. The LP reported she told NA #1 that, I don ' t have anything to do with that, I ' m here to draw her blood and she is first on my list. The LP wrote that Resident #1 was very agitated at that point, so she called her name several times to get her attention and explain why she was there. NA #1 and NA #2 changed Resident #1 ' s bed and then left the room. The LP reported that she completed the blood draw and then pushed Resident #1 in her wheelchair toward the nurse ' s desk and Nurse #1 said she was going to take care of Resident #1 from there. The LP indicated she had not reported the incident to Nurse #1, but instead continued to complete blood draws, completed her duties around 6:45 AM, left the facility, and then called her direct supervisor and reported the incident. The LP ' s Supervisor recommended she report the incident urgently to the Director of Nursing (DON) at the facility. She indicated she phoned the Assistant Director of Nursing (ADON) around 11:00 AM, but that during the phone call she had to disconnect the call because she was at work and needed to attend to a patient. The LP wrote that she became very busy and it took a while for her to call back to finish her report of the incident. A phone interview was conducted with the LP on 2/5/19 at 2:24 PM. She stated between 5:00 AM and 6:00 AM on 1/9/19 she was walking down a facility hallway enroute to Resident #1 ' s room to draw blood as ordered by the physician. She reported that as she was approaching the door, which was partially cracked open, she heard sounds of distress described as grunting, moaning, hollering, and screaming. She stated that she opened the door without knocking because the sounds she heard coming from the room made her worried. The LP indicated that when she entered the room Resident #1 was seated in her wheelchair, NA #1 was standing in front of the resident and NA #2 was standing behind the resident. She reported that NA #2 was holding Resident #1 by her shirt at the shoulders (from behind) to keep her seated in the wheelchair. She explained that Resident #1 was moving around in the wheelchair and it appeared NA #2 was restraining her by holding her back in the chair to keep her from moving around. The LP stated that NA #1 said to her something like, you might want to go and do someone else because I don ' t want you to see what I ' m going to do to her. She reported that she witnessed NA #1 hit Resident #1 on the cheek area with a closed fist and then on the left shoulder with an open hand. She indicated that Resident #1 was swinging her arms around in a reaction after she was hit by NA #1. The LP reported that she had not witnessed NA #2 hit Resident #1, she had only observed her holding the resident back in the wheelchair. The LP stated that after NA #1 had struck Resident #1 she told NA #1 and NA #2 she was not leaving the room until she completed the blood draw. She indicated that she had not wanted to leave Resident #1 alone in the room with either of the NAs (NA #1 or NA #2). She reported that she approached Resident #1 and the NAs left her side and began to change the linens on Resident #1 ' s bed. She stated that after the NAs had changed the linens they left the room and she was able to complete with blood draw with no issues. She reported that Resident #1 was not combative with her during the blood draw. The LP stated that she pushed Resident #1 from her room to the nurse ' s station, so she was not alone. She reported that she was unable to recall if there were any marks or bruising to Resident #1 ' s face at that time. The LP revealed she had not reported the incident to the nurse on duty following the incident. She stated that she believed NA #1 and NA #2 were friends with Nurse #1 and she hadn ' t felt comfortable reporting the incident to her because she feared retaliation from the staff. The LP reported that she phoned her supervisor around 7:00 AM when she left the facility to report the incident and he instructed her to report the incident to the facility Administration. She stated that she had a good relationship with the ADON and she wanted to make sure the information got into the right hands and so it was taken seriously. She reported that she phoned the ADON later that morning around 10:00 AM/11:00 AM to report the incident. She was asked why she had waited until 10:00 AM/11:00 AM and she stated that she knew the ADON was not present at the facility at 7:00 AM so she proceeded to her next job and she phoned the ADON when she had an opportunity to step away from work. A phone interview was conducted with the LP ' s supervisor on 2/6/19 at 4:35 PM. He confirmed that the LP contacted him by phone on 1/9/19 immediately after leaving the facility and reported to him the allegation of staff to resident abuse. He stated that the LP was very upset and audibly crying during the phone call. He stated that he instructed her to contact the facility ' s DON and report the incident. The LP ' s supervisor was asked if they provided any training to their employees related to reporting allegations of abuse. He revealed that they had not provided any training related to reporting allegations of abuse. An interview was conducted with the ADON on 2/5/19 at 4:20 PM. She stated that the LP contacted her by phone on 1/9/19 around 10:00 AM and reported an incident of staff to resident abuse. She indicated the LP had not provided her with the resident ' s name or the staff members name during this phone call. The LP reported that she walked into the resident ' s room and she saw 1 staff member standing behind the resident restraining her in the wheelchair while the other staff member hit the resident from the front. The ADON stated that the LP was crying when she reported the information. She indicated the LP told her that she had not wanted to get involved, but that she also knew it was her job to protect the residents. She indicated that the LP was at work while she was reporting this information and she told the ADON she had to call her back later. The ADON stated that she reported this phone call to the DON and the Administrator. She reported that it was not until later that afternoon that she and the Administrator spoke to the LP by phone to obtain the more detailed verbal statement. An interview was conducted with the Administrator on 2/6/19 at 4:00 PM. The Administrator stated that she was initially informed of the allegation of staff to resident abuse by the ADON around 10:00 AM/11:00 AM on 1/9/19. She stated that at that time she had no actionable information because she had no resident name and no staff names. She reported that she needed to at least have a resident or staff name to make her initial allegation report and to begin an investigation. The Administrator stated she asked the ADON to try to get in touch with the LP to get more information. She reported that she also contacted the LPs supervisor and asked him to have the LP contact them as soon as possible. She indicated it was not until later that afternoon, around 1:00 PM, that she was able to get in touch with the LP by phone and obtain a verbal report identifying Resident #1, NA #1, and NA #2. The Administrator stated that NA #1 and NA #2 were no longer present at the facility at that time, so they were notified by phone that they were suspended pending the results of investigation. A joint interview was conducted with NA #1 and NA #2 on 2/6/19 at 3:05 PM. The DON was present for this interview. NA #2 stated that on the morning of 1/9/19 she walked by Resident #1 ' s room and saw that she was trying to get out of bed. She indicated she went to ask Nurse #1 for assistance with getting Resident #1 out of bed because she had behaviors of swinging and hitting at staff. NA #2 stated that NA #1 was sent to help her. The NAs (NA #1 and NA #2) stated that Resident #1 was having verbal behaviors of yelling out, grunting, moaning and physical behaviors of swinging and hitting at them that morning and they had a tough time getting the resident out of the bed, providing incontinent care, getting her dressed, and then transferred to the wheelchair. They reported that the LP walked in the room without knocking. They stated that at that time Resident #1 was already seated in the wheelchair and that NA #1 said something to the LP like, oh honey you might not want to come in here. NA #1 stated that this was a joke and she recalled laughing when she said this to the LP because she and NA #2 had such a difficult time getting Resident #1 up that day. They indicated that NA #2 was standing in front of Resident #1 and NA #1 was standing on the side of the wheelchair. Resident #1 was reportedly leaning forward in the wheelchair. NA #1 and NA #2 revealed that Resident #1 rarely attempted to stand, but that she had frequently leaned forward in the chair and they were afraid she was going to tip over and land head first on the floor. NA #2 stated that she asked Resident #1 to sit back in the wheelchair, but she had not complied. She revealed she put one hand to Resident #1 ' s forehead and one hand to her shoulder/chest region and pushed the resident back into an upright position in the wheelchair. Then NA #2 moved to the back of the wheelchair and NA #1 remained at the side of the wheelchair. The LP was then preparing for Resident #1 ' s blood draw and the resident started to lean forward again so NA #2 reached from behind the resident and placed one hand on her forehead and one on her shoulder/chest region to pull her back into an upright position. NA #1 stated that when the LP was preparing for the blood draw that Resident #1 was swinging her hands around, so she placed one hand in front of her shoulder and one hand behind her shoulder to keep her from being able to swing around the arm that blood was going to be drawn from. NA #1 denied hitting Resident #1 on the face and/or on the shoulder. NA #2 denied witnessing NA #1 hit Resident #1. They both denied Resident #1 having any bruising or redness to her face on 1/9/19 or on any other date. NA #1 was unable to explain why her verbal statement to the Administrator indicated that Resident #1 was not making any noises during care on the morning of 1/9/19 and also was unable to explain why she previously denied touching Resident #1 while the LP was in the room and denied telling the LP to leave the room. NA #1 and NA #2 were unable to explain why the LP reported this allegation of staff to resident abuse if it had not happened. This joint interview with NA #1 and NA #2 continued. NA #1 stated that after the incident she had been re-educated on abuse and combative behaviors. She reported that she would not have changed any of the actions taken by herself or NA #2 after being provided with the re-education. NA #2 stated that after the incident she had been re-educated on abuse and combative behaviors. She reported that she had not thought any of the actions taken by herself or NA #1 were inappropriate after being provided with the re-education. She indicated that the only thing she might have done differently would have been to stand back for a few minutes when Resident #1 was swinging her arms around to give her time to calm down. An interview was conducted with the Administrator on 2/6/19 at 4:00 PM. The Administrator was asked why she had not substantiated the allegation of staff to resident abuse related to the 1/9/19 allegation involving Resident #1. She stated that she had not found any negative physical or mental/emotional findings on behalf of the resident. She re-iterated from her previous interview that Resident #1 ' s facial bruising noted on the 1/9/19 24-hour report was ruled out as an injury because the LP had reported to her that NA #1 hit Resident #1 with a closed fist on the shoulder. The Administrator stated that another factor for her was that since the LP had not immediately reported the allegation to the nurse on duty at the time of the incident, she doubted that it actually happened. She explained that she thought that if the LP had observed NA #1 hit Resident #1 that she would ' ve have immediately reported it rather than waiting until she left the facility. The Administrator stated that she had thought that NA #2 ' s actions of placing her hands on Resident #1 ' s forehead and chest/shoulder region twice was not the best way to manage the leaning behaviors of a combative resident. The Administrator explained that because there was no negative intent from either staff, NA #1 or NA #2, she had not thought this was physical abuse. She was asked if NA #1 or NA #2 had any previous disciplinary actions during their employment at the facility and she reported she was unsure and needed to look at their personnel records to find out. She indicated this information was not included in their investigation of staff to resident abuse involving Resident #1, NA #1, and NA #2. The Administrator was then asked who was responsible for providing training on abuse reporting to their contracted providers, such as the LP. She stated that she was not sure, but she thought the contracted provider was responsible for providing training to their own staff. She revealed she had not checked with the laboratory company after this incident to verify if training on abuse reporting had been provided to their staff. A re-interview was conducted by phone with the LP on 2/6/19 at 2:45 PM. She re-iterated the information provided during the 2/5/19 phone interview that took place at 2:24 PM. She was informed that the Administrator denied the LP reporting to her that NA #1 hit Resident #1 with a closed fist on the cheek. The LP stated that she told the Administrator during a phone call on 1/9/19 that NA #1 was observed hitting Resident #1 once on the cheek with a closed fist and once on the left shoulder with an open hand. The LP ' s typed statement that indicated NA #2 was holding Resident #1 down in the wheelchair while NA #1 was hitting Resident #1 was reviewed with the LP. She explained that she used the word hitting to imply more than one hit. She stated that in hindsight she should have been more specific when she typed her statement. An interview was conducted with the DON on 2/8/19 at 8:48 AM. She was asked if there were any previous concerns reported for NA #1 or NA #2. She stated that NA #2 had no previous concerns reported. She stated that NA #1 had disciplinary action over a year ago related to customer service. The DON reported that NA #1 said something like, I hate working this hall, when she was providing care to an alert and oriented resident. NA #1 ' s most recent quarterly performance evaluation revealed that she had grievances on file related to customer service during the review period (7/1/18 through 9/30/18). A final interview was conducted with the Administrator on 2/8/19 at 10:33 AM. She indicated that she expected all staff, including contracted providers, to immediately report any allegation of abuse. She additionally indicated that she expected abuse investigations to be thorough to ensure residents were protected from physical abuse. The Administrator acknowledged that the LP failed to follow facility policy and procedure related to reporting of abuse to facility when she had not immediately reported the incident after witnessing it on 1/9/19. She also acknowledged that the facility failed to follow its abuse policy when the allegation of abuse was unsubstantiated, and NA #1 and NA #2 returned to work on 1/17/19 despite a verbal statement and typed statement by the LP of staff to resident abuse. The Administrator and DON were notified of Immediate Jeopardy on 2/6/19 at 5:43 PM. On 2/8/19 at 10:54 AM the facility provided the following credible allegation of Immediate Jeopardy removal: This plan of correction constitutes a written allegation of substantial compliance with Federal and Medicaid requirements. Preparation and/or execution of this correction does not constitute admission or agreement by the provider of the truth of items alleged or conclusions set forth for the alleged deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of the state and federal law. It also demonstrates our good faith and desire to continue to improve the quality of care and services to our residents. - Process that lead to the deficiency On 1/9/2019 Laboratory Phlebotomist reported to facility Administrator and Assistant Administrator at 1:15p by phone that at approximately 5:45a on 1/9/2019 she witnessed two facility Certified Nursing Assistants on night shift hit resident #1 when she entered the resident ' s room to draw blood. When further questioned during this phone call by facility Administrator and facility Assistant Director of Health Services the Laboratory Phlebotomist stated she saw one Certified Nursing Assistant (NA #1) draw back a fist and hit resident #1 on her left shoulder while the second Certified Nursing assistant (NA #2) held resident by the back of her shirt while she was sitting in her wheelchair. Facility Administrator and Assistant Director of Nursing asked Laboratory Phlebotomist why she did not report this to charge nurse at the time of the incident she stated she felt the Charge Nurse would not handle information correctly and she did not trust her to do the right thing. Laboratory Phlebotomist stated she waited to speak with Assistant Director of Health Services because she trusted her to handle information correctly as she feared retaliation from Certified Nursing Assistants (NA #1 & NA #2). In a typed statement signed by the Laboratory Phlebotomist provided to the facility the next day (1/10/2019) at approximately 6:00a placed under Administrative door the Laboratory Phlebotomist stated one Certified Nursing Assistant (NA #2) was standing behind the resident ' s wheelchair holding resident #1 down while another Certified Nursing Assistant (NA#1) was hitting her. Certified Nursing Assistants (NA #1 & NA #2) fitting the description provided by the Laboratory Phlebotomist were not in the facility while statements were taken via phone. Both Certified Nursing Assistants fitting the description provided by the Laboratory Phlebotomist were suspended pending investigation prior to working another shift on 1/9/2019. Certified Nursing Assistant NA#2 who was suspended at approximately 2:45p by facility Administrator and Certified Nursing Assistant (NA #1) was suspended at approximately 10:30p by facility Registered Nurse (RN) Clinical Competency Nurse. Statements provided by Certified Nursing Assistants (NA #1 and NA #2) on 1/9/2019 to facility Administrator, Assistant Director of Health Services, and RN Clinical Competency Nurse revealed NA #2 placed hand on forehead and chest/shoulder area of resident #1 to prevent resident #1 from falling forward out of wheelchair while NA#1 watched. Resident #1 is a resident with a [DIAGNOSES REDACTED]. Investigation was closed on (MONTH) 17, 2019 by facility Administrator with an unsubstantiated finding and Certified Nursing Assistants (NA #1 & NA #2) were returned to employment on (MONTH) 17, 2019 after receiving education from facility RN Clinical Competency Nurse regarding facility abuse policy and Care of Dementia residents with behaviors. Facility failed to follow abuse prevention policy related to staff to resident abuse when Certified Nursing Assistants (NA #1 & NA #2) were returned to work on (MONTH) 17, 2019 in light of witness statements of Laboratory Phlebotomist and Certified Nursing Assistant (NA #1 & NA #2) statements given on 1/9/2019 to facility administration. Laboratory Phlebotomist failed to follow contractual standards of conduct related to resident safety and facility policy and procedure related to reporting of abuse to facility when they did not immediately report the incident after witnessing it on 1/9/2019. Resolution includes re-suspension of Certified Nursing Assistants (NA #1) approximately 5:30p and Certified Nursing Assistant (NA#2) approximately 10:30p on (MONTH) 7, 2019 by facility Administrator and Director of Nursing to ensure safety of current facility residents. Facility Administrator and Regional Registered Nurse Senior Nurse Consultant terminated NA #1 and NA#2 from employment on (MONTH) 8, 2019 related to allegations of resident abuse with supporting Laboratory Phlebotomist witness statement and statements of NA #1 and NA #2. NA #1 and NA #2 did not work in facility after re-suspension on (MONTH) 7, 2019 in accordance with facility policy regarding protecting residents from abuse. Resolution includes Phlebotomist being verbally trained via phone by Assistant Director of Nursing regarding timely and appropriate abuse reporting. Management of the Laboratory Phlebotomist were trained on 2/7/2019 by facility Registered Nurse Clinical Competency Nurse regarding facility policy related to abuse prevention, identification, and reporting. On 2/7/2019 Management of the Laboratory Phlebotomist told the Registered Nurse Clinical Competency Nurse they would ensure staff assigned to the facility receive training prior to working with facility residents. Resolution also included the Regional Senior Nurse Consultant conducting education with facility Administrator, Assistant Director of Health Services, Clinical Competency Coordinator and Director of Health Services related to facility policy regarding prevention of abuse, indicators of abuse, reporting abuse, and investigation abuse on 2/6/2019 to ensure resident safety. Current facility residents had skin audits conducted by facility Registered Nurse Treatment Nurse and facility Charge nurses starting 2/6/2019 to ensure residents remain safe while in facility. These audits ensure residents with Brief Interview of Mental Status (BIMS) of 7 or below were checked for signs of possible physical abuse. Residents with a Brief Interview of Mental Status (BIMS) score of 8 or above were interviewed by facility Activities Director, Director of Health Services, MDS Coordinator, and Licensed Practical Charge Nurse starting 2/6/2019 to ensure any possible staff to resident abuse was reported and investigated appropriately. - Process for implementing a plan of correction for specific deficiency<

Based on record review, observation, family interview, facility staff interviews, and laboratory company staff interviews, the facility failed to protect a resident from staff to resident physical abuse for 1 of 2 residents (Resident #1) reviewed for staff to resident abuse. Immediate Jeopardy began on 1/9/19 when a Laboratory Phlebotomist observed Nursing Assistant #1 hit a cognitively impaired resident (Resident #1) on her face with a closed fist and on the shoulder with an open hand as Nursing Assistant #2 restrained the resident in her wheelchair. Immediate Jeopardy was removed on 2/8/19 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1' s undated baseline care plan indicated she had an adjustment difficulty to new environment related to recent admission and a [DIAGNOSES REDACTED]. The interventions included: assess and monitor mood and behavior and address emotional and psychosocial needs. This baseline care plan also indicated Resident #1 had an Activities of Daily Living (ADL) decline, impaired physical mobility, and was a fall risk related to right sided paralysis/weakness following a [MEDICAL CONDITIONS]. The interventions included encouraging Resident #1 to do as much as possible, keep environment safe, and cue for safety awareness. On 12/26/18 the baseline care plan was updated to include the area of behavioral symptoms with a handwritten note that stated a new physician's order [REDACTED].#1 for [MEDICATION NAME] (cognition enhancing medication) related to dementia with behaviors. There were no interventions added to the baseline care plan related to behavioral symptoms. The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 was not completed in the area of cognition as the resident interview for mental status and staff interview for mental status were blank. She was assessed with [REDACTED]. Resident #1 had no physical behaviors, no verbal behaviors, and no rejection of care. She was noted with other behavioral symptoms and wandering behaviors on 1 to 3 days. Resident #1 was assessed as requiring the limited assistance of 1 for bed mobility, transfers, and locomotion on/off the unit. She required the extensive assistance of 1 with dressing, toileting, and personal hygiene. She was not steady on her feet and was only able to stabilize with staff assistance. Resident #1 utilized a walker and wheelchair, she was occasionally incontinent of bladder and bowel, she had no skin issues, and she had sustained no falls. A body audit form dated 1/5/19 indicated no bruising to Resident #1 on her facial region or any other area. The initial allegation (24-hour report) dated 1/9/19 completed by the Administrator indicated an allegation of the staff to resident physical abuse. The incident occurred on 1/9/19 at approximately 5:15 AM. The allegation details stated that Laboratory Phlebotomist (LP) witnessed Nursing Assistant (NA) #1 strike Resident #1 on her left shoulder while NA #2 held her by the shirt. LP stated that she stayed in the room with Resident #1 to ensure she was not touched anymore by NA #1 or NA #2. Both NAs (NA #1 and NA #2) were noted to leave the room and LP pushed Resident #1 in her wheelchair to the nurse ' s station. The details of physical or mental injury/harm read, Body audit revealed bruise to the face area (of Resident #1). This form was completed by the Administrator on 1/9/19. The investigation report (5-working day report) dated 1/16/19 completed by the Administrator repeated the same allegation details and had no comments written in the section for additions/changes/updates to description of allegation details. This investigation report provided conflicting information from the previous initial allegation as it stated no physical injury/harm and no substantial risk of injury/harm for Resident #1 and it made no mention of the bruises to Resident #1 ' s face area identified during her 1/9/19 body audit (as indicated on the initial allegation report). Resident #1 ' s emotional response and behaviors indicated, No emotional response as resident has severe cognitive deficit at time of incident. The investigative actions section of this report indicated the following: - Allegation was unsubstantiated. - The accused individuals were not terminated. - Other employment actions: Accused individuals were to receive written warning related to resident safety as well as abuse prevention and training on the care of the combative/agitated resident. - Summary of facility investigation: Facility interviewed the LP, NA #1, NA #2, and Nurse #1 (charge nurse on duty during the time of the incident), residents on the hallway assigned to NA #1 an NA #2, and other staff who provided care to Resident #1. The medical record of Resident #1 was noted to be reviewed as well as skin audits. Based on the interviews and results of the skin audit the facility is not able to substantiate the allegations of abuse. The facility did find the accused (NA #1 and NA #2) at fault for leaving an agitated resident (Resident #1) in the care of an untrained person not in the employ of the facility (LP). The Administrator completed a typed summary of Resident #1 ' s record review related to the investigation of staff to resident abuse. This typed summary stated, Skin audit on 1/9/2019 showed purple bruise to lower right side of (Resident #1 ' s) face .skin audit conducted on 1/17/2019 showed no bruising (on Resident #1 ' s) face .bruise on resident ' s face was noted on a skin audit performed on 12/13/2019. A review of the medical record showed no documentation of skin audit conducted for Resident #1 on 1/9/19. Additionally, there were no skin audits found in Resident #1 ' s medical record that showed any mention of facial bruising. An interview was conducted with the Administrator on 2/5/19 at 12:57 PM. The 24-hour report and the Administrator ' s typed summary of Resident #1 ' s medical record review that indicated a bruise was present on Resident #1 ' s lower right side of her face on 1/9/19 was reviewed with the Administrator. The part of the summary that indicated, bruise on resident ' s face was noted on a skin audit performed on 12/13/2019 was reviewed with the Administrator. The body audit form dated 1/5/19 that showed no bruising to Resident #1 ' s facial region was reviewed with the Administrator. The Administrator revealed she had not known where the information about Resident #1 ' s facial bruise came from. She also revealed that the date, 12/13/2019, was a typo, but that she had not known what the correct date was. The Administrator reviewed Resident #1 ' s medical record and she was unable to find any additional documentation of the facial bruising for Resident #1. The Administrator was asked how Resident #1 ' s facial bruising on 1/9/19 was ruled out as an injury from the 1/9/19 staff to resident abuse allegation. Her explanation was that the LP had reported to her by phone that NA #1 hit resident #1 with a closed fist on the shoulder. She denied LP reporting that NA #1 hit Resident #1 in the face in addition to the shoulder. The Administrator was unable to explain how Resident #1 ' s facial bruising was sustained. The following interviews were conducted related to Resident #1 ' s facial bruising noted on the 1/9/19 24-hour report: - An interview was conducted with Treatment Nurse #1 on 2/6/19 at 9:11 AM. She stated that she and Treatment Nurse #2 completed body audit forms weekly. She stated she was unaware of any facial bruising for Resident #1 at any time during her stay at the facility. - An interview was conducted with Treatment Nurse #2 on 2/6/19 at 9:30 AM. She stated that she and Treatment Nurse #1 completed body audit forms weekly. She stated she was unaware of any facial bruising for Resident #1 at any time during her stay at the facility. - An interview was conducted with Nurse #1 on 2/6/19 at 10:00 AM. She stated that she had not recalled Resident #1 ever having a bruise to her face during her stay at the facility. - A family interview was conducted by phone with Resident #1 ' s Responsible Party (RP) on 2/6/19 at 8:50 AM. He stated that Resident #1 had a bruise on her face several weeks ago, but he was not sure how she had sustained the bruise. A verbal statement by the LP made by phone to the Administrator on 1/9/19 at approximately 1:15 PM was transcribed in handwriting by the Administrator. The report from the LP indicated that she heard a loud noise that sounded like grunting and hollering from a resident ' s room. She reported she opened the door to the resident ' s room without knocking and NA #1 stated to her, you need to turn around because I don ' t want you to see what I do to her. LP stated that Resident #1 was seated in her wheelchair, NA #2 was behind the wheelchair and appeared to be pulling the resident by the back of her shirt to keep her seated in the wheelchair. NA #1 had her fist drawn back, struck (Resident #1) on her (left) shoulder . (Resident #1) had hands up .reacting to being hit. LP reported she had not seen NA #2 strike Resident #1, but that NA #2 had not stopped NA #1. LP indicated she drew Resident #1 ' s blood as ordered while NA #1 and NA #2 were still in the room. She indicated she stayed with Resident #1 until both NAs left the room. A typed statement, undated, signed by the LP indicated that on 1/9/19 at approximately 5:45 AM she was walking toward Resident #1 ' s room to complete a blood draw as ordered. She reported that when she started getting close to the room she heard several voices along with Resident #1 grunting and hollering. LP wrote that she opened the door and saw an NA (NA #2) standing behind Resident #1 holding her down in the wheelchair and another NA (NA #1) hitting Resident #1. LP indicated that she opened the door wider and NA #1 said to her, you might want to go somewhere else so that you don ' t see what I am about to do to her. LP reported she told NA #1 that she was there to draw Resident #1 ' s blood. LP wrote that Resident #1 was very agitated at that point, so she called her name several times to get her attention and explain why she was there. NA #1 and NA #2 proceeded to change Resident #1 ' s bed linens and then left the room. LP reported that she completed the blood draw and then pushed Resident #1 in her wheelchair toward the nurse ' s desk and Nurse #1 said she was going to take care of Resident #1 from there. LP indicated she had not reported the incident to Nurse #1, but instead continued with blood draws. She completed her duties around 6:45 AM, left the facility, and then called her direct supervisor and reported the incident. A phone interview was conducted with LP on 2/5/19 at 2:24 PM. She stated between 5:00 AM and 6:00 AM on 1/9/19 she was walking down a facility hallway enroute to Resident #1 ' s room to draw blood as ordered by the physician. She reported that as she was approaching the door, which was partially cracked open, she heard sounds of distress described as grunting, moaning, hollering, and screaming. She stated that she opened the door without knocking because the sounds she heard coming from the room made her worried. LP indicated that when she entered the room Resident #1 was seated in her wheelchair, NA #1 was standing in front of the resident and NA #2 was standing behind the resident. She reported that NA #2 was holding Resident #1 by her shirt at the shoulders (from behind) to keep her seated in the wheelchair. She explained that Resident #1 was moving around in the wheelchair and it appeared NA #2 was restraining her by holding her back in the chair to keep her from moving around. LP stated that NA #1 said to her something like, you might want to go and do someone else because I don ' t want you to see what I ' m going to do to her. She reported that she witnessed NA #1 hit Resident #1 on the cheek area with a closed fist and then on the left shoulder with an open hand. She indicated that Resident #1 was swinging her arms around in a reaction after she was hit by NA #1. She indicated it appeared NA #1 was frustrated with Resident #1 as she was gritting her teeth at the resident. LP reported that she had not witnessed NA #2 hit Resident #1, she had only observed her holding the resident back in the wheelchair. LP stated that after NA #1 had struck Resident #1 she told NA #1 and NA #2 she was not leaving the room until she completed the blood draw. She reported that she was unable to recall if there were any marks or bruising to Resident #1 ' s face at that time. LP revealed she had not reported the incident to the nurse on duty following the incident. She stated that she believed NA #1 and NA #2 were friends with Nurse #1 and she hadn ' t felt comfortable reporting the incident to her because she feared retaliation from the staff. LP reported that she phoned her supervisor around 7:00 AM when she left the facility to report the incident and he instructed her to report the incident to the facility Administration. A phone interview was conducted with LP ' s supervisor on 2/6/19 at 4:35 PM. He confirmed that LP contacted him by phone on 1/9/19 immediately after leaving the facility and reported to him the allegation of staff to resident abuse. He stated that LP was very upset and audibly crying during the phone call. A verbal statement by NA #1 typed by the Administrator and included in the facility ' s 1/17/19 summary of the investigation for the allegation of abuse involving Resident #1 was reviewed. This statement indicated that Nurse #1 asked her to help NA #2 with getting Resident #1 out of bed on 1/9/19. NA #1 indicated that Resident #1 was not making any noises while she and NA #2 were in the room. She reported that LP entered the room and she was standing to the left side of Resident #1 ' s wheelchair an NA #2 was standing behind the wheelchair. Resident #1 tried to get up and NA #2 put one hand on (Resident #1 ' s) chest and another on her forehead. Pushed her back to an upright position in the wheelchair. NA #1 stated that she had not touched Resident #1 while the LP was in the room nor did she tell the LP to leave the room. She indicated that she and NA #2 changed Resident #1 ' s sheets and then left the room after asking LP to bring Resident #1 to the nurse ' s station when she was done with her blood draw. A verbal statement by NA #2 typed by the Administrator and included in the facility ' s 1/17/19 summary of the investigation for the allegation of abuse involving Resident #1 was reviewed. This statement indicated that NA #2 saw Resident #1 moving around in bed and she went to ask Nurse #1 for help with getting the resident up. Nurse #1 sent NA #1 to help NA #2 with Resident #1. NA #2 reported that she and NA #2 got Resident #1 dressed and into her wheelchair. She indicated that Resident #1 was making noises the whole time they were getting her up. NA #2 stated that she and NA #1 were standing in front of Resident #1 when LP entered the room. NA #2 reported that Resident #1 tried to stand up from her wheelchair and she had not wanted the resident to fall so she put one hand in the center of (Resident #1 ' s) chest and the other hand on (her) forehead and pushed her back to an upright position in the chair. NA #2 indicated that LP proceeded to draw Resident #1 ' s blood and she and NA #1 changed the bed linens and left the room after asking LP to bring Resident #1 to the nurse ' s station when she was done with her blood draw. A joint interview was conducted with NA #1 and NA #2 on 2/6/19 at 3:05 PM. The DON was present for this interview. NA #2 stated that on the morning of 1/9/19 she walked by Resident #1 ' s room and saw that she was trying to get out of bed. She indicated she went to ask Nurse #1 for assistance with getting Resident #1 out of bed because she had behaviors of swinging and hitting at staff. NA #2 stated that NA #1 was sent to help her. The NAs (NA #1 and NA #2) stated that Resident #1 was having verbal behaviors of yelling out, grunting, moaning and physical behaviors of swinging and hitting at them that morning and they had a tough time getting the resident out of the bed, providing incontinent care, getting her dressed, and then transferred to the wheelchair. They reported that LP walked in the room without knocking. They stated that at that time Resident #1 was already seated in the wheelchair and that NA #1 said something to the LP like, oh honey you might not want to come in here. NA #1 stated that this was a joke and she recalled laughing when she said this to the LP because she and NA #2 had such a difficult time getting Resident #1 up that day. They indicated that NA #2 was standing in front of Resident #1 and NA #1 was standing on the side of the wheelchair. Resident #1 was reportedly leaning forward in the wheelchair. NA #1 and NA #2 revealed that Resident #1 rarely attempted to stand, but that she had frequently leaned forward in the chair and they were afraid she was going to tip over and land head first on the floor. NA #2 stated that she asked Resident #1 to sit back in the wheelchair, but she had not complied. She revealed she put one hand to Resident #1 ' s forehead and one hand to her shoulder/chest region and pushed the resident back into an upright position in the wheelchair. Then NA #2 moved to the back of the wheelchair and NA #1 remained at the side of the wheelchair. LP was then preparing for Resident #1 ' s blood draw and the resident started to lean forward again so NA #2 reached from behind the resident and placed one hand on her forehead and one on her shoulder/chest region to pull her back into an upright position. NA #1 stated that when LP was preparing for the blood draw that Resident #1 was swinging her hands around, so she placed one hand in front of her shoulder and one hand behind her shoulder to keep her from being able to swing around the arm that blood was going to be drawn from. NA #1 denied hitting Resident #1 on the face and/or on the shoulder. NA #2 denied witnessing NA #1 hit Resident #1. They both denied Resident #1 having any bruising or redness to her face on 1/9/19 or on any other date. NA #1 was unable to explain why her verbal statement to the Administrator indicated that Resident #1 was not making any noises during care on the morning of 1/9/19 and also was unable to explain why she previously denied touching Resident #1 while the LP was in the room and denied telling LP to leave the room. NA #1 and NA #2 were unable to explain why LP reported this allegation of staff to resident abuse if it had not happened. They indicated there had been no previous conflicts with LP. This joint interview with NA #1 and NA #2 continued. NA #1 stated that after the incident she had been re-educated on abuse and combative behaviors. She reported that she would not have changed any of the actions taken by herself or NA #2 after being provided with the re-education. NA #2 stated that after the incident she had been re-educated on abuse and combative behaviors. She reported that she had not thought any of the actions taken by herself or NA #1 were inappropriate after being provided with the re-education. She indicated that the only thing she might have done differently would have been to stand back for a few minutes when Resident #1 swinging her arms around to give her time to calm down. An interview was conducted with the Administrator on 2/6/19 at 4:00 PM. The Administrator was asked why she had not substantiated the allegation of staff to resident abuse related to the 1/9/19 allegation involving Resident #1. She stated that she had not found any negative physical or mental/emotional findings on behalf of the resident. She re-iterated from her previous interview that Resident #1 ' s facial bruising noted on the 1/9/19 24-hour report was ruled out as an injury because the LP had reported to her that NA #1 hit Resident #1 with a closed fist on the shoulder. The Administrator stated that another factor for her was that since the LP had not immediately reported the allegation to the nurse on duty at the time of the incident, she doubted that it actually happened. She explained that she thought that if the LP had observed NA #1 hit Resident #1 that she would ' ve have immediately reported it rather than waiting until she left the facility. The Administrator stated that she had thought that NA #2 ' s actions of placing her hands on Resident #1 ' s forehead and chest/shoulder region twice was not the best way to manage the leaning behaviors of a combative resident. The Administrator explained that because there was no negative intent from either staff, NA #1 or NA #2, she had not thought this was physical abuse. A re-interview was conducted by phone with LP on 2/6/19 at 2:45 PM. She was informed that the Administrator denied LP reporting to her that NA #1 hit Resident #1 with a closed fist on the cheek. LP stated that she told the Administrator during a phone call on 1/9/19 that NA #1 was observed hitting Resident #1 once on the cheek with a closed fist and once on the left shoulder with an open hand. LP ' s typed statement that indicated NA #2 was holding Resident #1 down in the wheelchair while NA #1 was hitting Resident #1 was reviewed with LP. She explained that she used the word hitting to imply more than one hit. She stated that in hindsight she should have been more specific when she typed her statement. An interview was conducted with the Director of Nursing (DON) on 2/8/19 at 8:48 AM. She was asked if there were any previous concerns reported for NA #1 or NA #2. She stated that NA #2 had no previous concerns reported. She revealed that NA #1 had disciplinary action over a year ago related to customer service. The DON reported that NA #1 pulled an alert and oriented resident ' s covers back as the resident was lying in bed and said something like, I hate working this hall. The DON also revealed that NA #1 ' s most recent quarterly performance evaluation showed that she had grievances on file related to customer service during the review period (7/1/18 through 9/30/18). An observation was conducted of Resident #1 lying in bed in her room on 2/5/19 at 10:45 AM. Resident #1 was alert with confusion and she was unable to be interviewed. There were no bruises or other skin conditions noted. The Administrator and DON were notified of Immediate Jeopardy on 2/6/19 at 5:43 PM. On 2/7/19 at 5:17 PM the facility provided the following credible allegation of Immediate Jeopardy removal: This plan of correction constitutes a written allegation of substantial compliance with Federal and Medicaid requirements. Preparation and/or execution of this correction does not constitute admission or agreement by the provider of the truth of items alleged or conclusions set forth for the alleged deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of the state and federal law. It also demonstrates our good faith and desire to continue to improve the quality of care and services to our residents. - Process that lead to the deficiency On 1/9/2019 Laboratory Phlebotomist reported to facility Administrator and Assistant Administrator at 1:15p by phone that at approximately 5:45a on 1/9/2019 she witnessed two facility Certified Nursing Assistants on night shift hit resident #1 when she entered the resident ' s room to draw blood. When further questioned during this phone call by facility Administrator and facility Assistant Director of Health Services the Laboratory Phlebotomist stated she saw one Certified Nursing Assistant (NA #1) draw back a fist and hit resident #1 on her left shoulder while the second Certified Nursing assistant (NA #2) held resident by the back of her shirt while she was sitting in her wheelchair. Facility Administrator and Assistant Director of Nursing asked Laboratory Phlebotomist why she did not report this to charge nurse at the time of the incident she stated she felt the Charge Nurse would not handle information correctly and she did not trust her to do the right thing. Laboratory Phlebotomist stated she waited to speak with Assistant Director of Health Services because she trusted her to handle information correctly as she feared retaliation from Certified Nursing Assistants (NA #1 & NA #2). In a typed statement signed by the Laboratory Phlebotomist provided to the facility the next day (1/10/2019) at approximately 6:00a placed under Administrative door the Laboratory Phlebotomist stated one Certified Nursing Assistant NA #2 was standing behind the resident ' s wheelchair holding resident #1 down while another Certified Nursing Assistant NA #1 was hitting her. Certified Nursing Assistants (NA #1 & NA #2) fitting the description provided by the Laboratory Phlebotomist were not in the facility while statements were taken via phone. Both Certified Nursing Assistants fitting the description provided by the Laboratory Phlebotomist were suspended pending investigation prior to working another shift on 1/9/2019. Certified Nursing Assistant (NA #2) who was suspended approximately 2:45p by facility Administrator and Certified Nursing Assistant (NA #1) was suspended approximately 10:30p by facility Registered Nurse (RN) Clinical Competency Nurse. Statements provided by Certified Nursing Assistants (NA #1 and NA #2) on 1/9/2019 to facility Administrator, Assistant Director of Health Services, and RN Clinical Competency Nurse revealed NA #2 placed hand on forehead and chest/shoulder area of resident #1 to prevent resident #1 from falling forward out of wheelchair while Certified Nursing Assistant NA #1 watched. Resident #1 is a resident with a [DIAGNOSES REDACTED]. Investigation was closed on (MONTH) 17, 2019 by facility Administrator with an unsubstantiated finding and Certified Nursing Assistants (NA #1 & NA #2) were returned to employment on (MONTH) 17, 2019 after receiving education from facility RN Clinical Competency Nurse regarding facility abuse policy and Care of Dementia residents with behaviors. Facility failed to provide a safe environment and protect resident from physical abuse when Certified Nursing Assistants (NA #1 &NA #2) were returned to work on (MONTH) 17, 2019 in light of statements of Laboratory Phlebotomist and Certified Nursing Assistant (NA #1 & NA #2) stating they placed hand on the body of Resident #1. Resolution includes re-suspension of Certified Nursing Assistants (NA #1) approximately 5:30p and Certified Nursing Assistant (NA #2) approximately 10:30p on (MONTH) 7, 2019 by facility Administrator and Director of Nursing to ensure safety of current facility residents. Resolution also included the Regional Senior Nurse Consultant conducting education with facility Administrator, Assistant Director of Health Services, Clinical Competency Coordinator and Director of Health Services related to prevention of abuse, indicators of abuse, reporting abuse, and investigation abuse to ensure resident safety. To help resolve this current facility residents had skin audits conducted by facility Registered Nurse Treatment Nurse and facility Charge nurses starting 2/6/2019 to ensure residents remain safe while in facility. Residents with a Brief Interview of Mental Status (BIMS) score of 8 or above were interviewed by facility Activities Director, Director of Health Services, MDS Coordinator, and Licensed Practical Charge Nurse to ensure any possible staff to resident abuse was reported and investigated appropriately. - Process for implementing a plan of correction for specific deficiency The facility Administrator should have determined if this issue could or would affect other residents. On 2/6/2019 the Regional Senior Nurse Consultant conducted education with facility Administrator, Assistant Director of Health Services, Clinical Competency Coordinator and Director of Health Services related to prevention of abuse, indicators of abuse, reporting abuse, and investigation abuse. On 2/6/2019 the facility Clinical Competency Coordinator began educating Licensed and Unlicensed Nursing Clinical staff, Dietary staff, Environmental staff, Administrative staff, and Rehabilitation staff on proper procedures for preventing and reporting abuse to ensure resident safety. Facility staff who have not completed education will be removed from the schedule until education is complete. On 2/6/2019 the facility Clinical Competency Coordinator began educating Licensed and Unlicensed Nursing Clinical staff, Dietary staff, Environmental staff, Administrative staff, and Rehabilitation staff on Basic Concepts and Guidelines for caregiving for individuals with Dementia to ensure resident safety. Facility staff who have not completed education will be removed from the schedule until education is complete. Beginning on 2/6/2019 accused Certified Nursing Assistants (NA #1 & NA #2) were re-interviewed and suspended pending further investigation to ensure resident safety. Starting 2/6/2019 and ending 2/7/2019 facility Administrative Nurses interviewed residents with Brief Interview of Mental Status (BIMS) of 8 or above to find out if they have been abused or have witnessed abuse. If residents have statements positive for abuse those residents will be re-interviewed by Administrator and Director of Health Services to ensure they are free from harm and statements are thoroughly investigated and reported to appropriate agency. Staring 2/6/2019 and ending 2/7/2019 facility Administrative Nurses conducted and documented skin audits for current facility residents to include those with a Brief Interview of Mental Status (BIMS) of 7 or below to ensure residents were identified via these audits for potential abuse. Any abnormal bruising will be flagged with complete investigation to be completed by Director of Nursing and Assistant Director of Nursing with report to appropriate agency to ensure current facility residents are free from harm. New hires will be educated by the facility RN Clinical Competency Nurse during orientation on facility policy and procedure related abuse prevention and reporting as well as Basic Concepts and Guidelines for caregiving for individuals with Dementia to ensure resident safety. - The monitoring procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements Starting 2/6/2019 residents with Brief Interview of Mental Status (BIMS) of 8 or above were interviewed by facility Nursing Administration interviewed to find out if they have been abused or have witnessed abuse. Continued monitoring to ensure no occurrence of resident to staff abuse will include random interviews of 10 residents with 8 or above Brief Interview of Mental Status (BIMS)and 10 random skin audits for residents Brief Interview of Mental Status (BIMS) below 8 daily for 14 days, then weekly for three weeks, then monthly. Starting 2/7/2019 facility Director of Healthcare Services, Assistant Director of Healthcare Services, Registered Nurse Clinical Competency Coordinator, Registered Nurse MDS Coordinator, and Registered Nurse Treatment Nurses will conduct 10 random visual audits of staff to resident interaction during caregiving procedures on each shift daily for 14 days, weekly for three weeks, and monthly to ensure no instance of staff to resident abuse. <b

Based on record review, observation and staff interviews, the facility failed to care plan an applied seat cushion on the wheel chair and a pressure ulcer located on a left hip for 1 of 3 sampled residents reviewed for pressure ulcer. (Resident #54) Findings included: Resident was readmitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) completed on 4/28/2014 indicated Resident # 54 had problems with short and long-term memory. Decision-making was indicated as severely impaired. The assessment further indicated the resident required extensive assistance of two persons with bed mobility. The MDS assessment further indicated the resident was at risk for developing pressure ulcers. The care plan dated 4/28/2014 for Resident # 54 revealed the resident was at risk for skin breakdown due to poor mobility. Listed as goal for skin breakdown in part read "breakdown will be minimized as much as possible through next review." interventions included: "Assist with turning and repositioning" Further review of the care plan revealed the resident ' s cushion which was on the wheel chair was not care planned. Review of the rehab note dated 6/16/2014 revealed "PT (patient) has standard wheel chair with left foot rest-self propels. He sits on contoured cushion, which is applying pressure to left hip where he has a wound." Observation of the resident's wheel chair on 6/26/2014 at 9:00 AM revealed a resident had a cushion applied in his wheel chair. Interview on 6/26/14 at 2:45pm, the Rehab manager stated they placed a new cushion in the resident's wheel chair on 6/16/2014 when the treatment nurse requested it two weeks ago. The Rehab Director further stated she ordered a new one to replace the one in the resident's wheel chair because the older cushion was causing the pressure ulcer on the resident ' s left hip. Interview on 6/26/2014 at 3: 00 PM, the Minimum Data Set (MDS) nurse when questioned regarding the residents care plan stated that it was her responsibility to update the residents' care plans at the facility. The MDS nurse stated she receives information in the morning stand up meetings about the residents and updates the care plan. She added that she was aware that Resident # 54 had a cushion in his wheel chair but she forgot to update the care plan. She further reported that she knew the resident had a pressure ulcer identified by the treatment nurse on 5/4/2014 on the left hip but did not update the care plan until 6/25/2014. Interview on 6/26/2014 at 6:45 PM, the Director of Nursing (DON) stated it was her expectation for the care plan to be updated to reflect the resident current status and condition. She added Resident # 54's care plan should have been updated to reflect the cushion on the wheel chair and the pressure ulcer on the resident's left hip.

Based on medical record review, observation, physician interview and staff interviews, the facility failed to prevent unstageable pressure ulcer by using a collapsed contoured cushion for 1 of 3 sampled residents reviewed for pressure ulcer. (Resident # 54) The findings included: Resident was readmitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) completed on 4/28/2014 indicated Resident # 54 had problems with short and long-term memory. Decision-making was indicated as severely impaired. The assessment further indicated extensive assistance of two persons was required with bed mobility. The MDS indicated the resident was at risk for developing pressure ulcers. The assessment did not indicate any healed or unhealed pressure ulcers. The care plan dated 4/28/2014 for Resident # 54 revealed the resident was at risk for skin breakdown due to poor mobility. Listed as a goal for skin breakdown in part read " Breakdown will be minimized as much as possible through next review with interventions which included: Assist with turning and repositioning during care rounds and PRN (as needed)." Wound assessment report dated 5/4/2014 revealed in part "noted denuded skin to left hip, no signs of infection or drainage, cause unknown. " Further review of the note revealed the wound measured "3 cm (centimeters) x 2.50 cm x 0 cm." Further review of the wound assessment revealed there was no investigation completed to determine the cause of the denuded skin to left hip. The report also did not indicate any interventions to prevent the wound from worsening. Wound assessment report dated 5/10/2014 revealed, abrasion on the left hip deteriorated and the wound measured 5cmx3cmx0cm. The treatment plan for the wound was indicated as " treated with [MEDICATION NAME] and [MEDICATION NAME] every 3 days. Review of the wound assessment report dated 5/16/2014 revealed, "Noted with dressing change this morning of abrasion site that wound has changed to DTI (deep tissue injury), deep purple-black tissue. No pain noted with dressing changed to silver alginate with foam dressing every 3 days. The wound measurement is 7 cm x 3 cm x 0 cm." The report did not indicate any interventions to prevent the wound from worsening. Wound assessment report dated 5/22/2014 indicated under wound type subheading as "pressure ulcer. " The location of the wound was indicated "left hip" and under the wound status subheading the report indicated as "deteriorated " Further review of the assessment revealed the pressure ulcer was "unsageable due to slough/eschar." and the wound measured 7.00 cm x 3.00 cm x 0.00 cm. The report did not indicate any interventions to prevent the wound from worsening. Review of the rehab note dated 6/16/2014 revealed "PT (patient) has standard wheel chair with left foot rest-self propels. He sits on contoured cushion, which is applying pressure to hip where he has a wound. " Wound observation on 6/26/2014 at 9:00 am revealed the Wound Medical Doctor cleaned the wound with wound cleanser. The left hip wound area measured at 6.5 cm x 2.9 cm x 0 cm. There was 95 % Eschar and 5% yellow slough, with no odor or drainage During an interview on 6/26/2014 at 12:45 PM, Nurse ' s Aide (NA) #1 who was assigned to the resident on 5/4/2014 reported when she was getting ready to change the resident she noticed a blister skin opening on the left hip, raw area size a quarter on the resident. She stated that she reported her observation to the treatment nurse. She further indicated that the resident sat on a wheel chair with a cushion that was raised in the front. NA #1 also stated that Resident # 54 had very little movement in the wheel chair and he could not reposition himself During an interview on 6/26/2014 at 2:00 PM, the treatment nurse stated that the resident had a cushion in his wheel chair, which was to prevent the resident from sliding out of the wheel chair. The treatment nurse further stated that NA #1 informed her on 5/4/2014 that Resident # 54 had an abrasion on the left hip. She (treatment nurse) began the treatment on the resident ' s left hip abrasion but did not investigate the cause of the abrasion. The treatment nurse added that she found out on 5/16/2014 that the resident ' s left hip worsening was caused by the contoured cushion which was on the wheel chair. The treatment nurse also reported that she did not remove the contoured cushion from the resident ' s wheel chair until on 6/13/2014 when he referred the resident to Rehab. When questioned why the cushion was not replaced on 5/16/2014 when it was found to cause the pressure ulcer, the treatment nurse stated she did not know the reason as to why she did not refer the resident to rehab on 5/16/2014. In an interview on 6/26/14 at 2:45pm, the Rehab manager stated they placed a new cushion in the resident ' s wheel chair on 6/16/2014 when the treatment nurse requested it two weeks ago. The Rehab Director further stated she ordered a new one to replace the one in the resident ' s wheel chair because the older cushion was causing the pressure ulcer on the resident ' s left hip. She further stated the cushion had collapsed in the middle and could not be used anymore. During an interview with wound doctor on 6/26/2014 at 6:41 PM, he reported the facility was using an improper cushion, which caused the pressure ulcer on the resident's left hip. He further reported the pressure ulcer on the resident's left hip was avoidable if the facility had used a proper cushion on the resident ' s wheel chair. The doctor also started the pressure ulcer on the resident's hip was consistent with the cushion which the resident was using on his wheel chair. During the interview with Director of Nursing (DON) on 6/26/2014 at 6:45 PM, she reported her expectation was that an investigation should have been done the day an abrasion was reported to the treatment nurse on 5/4/2014. The DON further added that she was not aware that the cushion had caused the pressure ulcer on the resident's left hip. She added if she would have been notified early about the cause of the pressure ulcer on the resident ' s left hip then she would have put in an intervention to prevent further deterioration of the pressure ulcer.

Based on record review and staff and resident interviews, the facility failed to assess and implement interventions for 1 of 3 residents (Resident #75) with weight loss. The findings include: Resident #75 was admitted to the facility on [DATE] and readmitted on [DATE] following a 5 day hospital stay. The resident ' s cumulative [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated the resident had short term memory deficits and moderate impairments in daily decision making. The resident required setup assistance only with meals. Record review indicated the resident ' s admission weight on 9/23/2010 was 101 pounds. The resident was started on med pass 2 ounces four times a day with meals on 9/23/2010, and the resident ' s compliance was documented daily on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of the resident ' s care plan initiated on 10/15/2010 indicated the resident was at risk for weight loss and fluid volume deficit. Approaches put in place included "provide 2 ounces med pass four times a day with meals". Med pass 2 ounces 4 times a day was discontinued on 5/04/2011 due to the resident 's refusal. The resident ' s care plan was not updated to reflect the change. The resident 's weight on 06/08/11 was 105 pounds. Records indicated the resident was admitted to a local hospital on [DATE] with admission [DIAGNOSES REDACTED]. The hospital discharge/transfer summary dated 6/15/2011 indicated discharge was discussed with the resident 's responsible party regarding diet that "they have to be on top of things in the nursing home to make sure she eats good ". The summary further indicated the nursing home would have a dietary consult secondary to poor intake. Review of facility admission orders [REDACTED]. The order was transcribed on 6/13/2011 to the June 2011 MAR. The resident 's readmission weight on 6/13/2011 was 98.90 pounds . Review of the resident 's clinical record indicated no dietary consult was done as ordered on [DATE]. The next recorded weight was 87.10 pounds on 6/20/2011. The facility Dietary Manager was interviewed on 7/6/11 at 3:45PM and indicated the weight on 6/20/11 was 87.10 pounds and that she keyed the weight into the system. She further reported she should have asked for a reweigh at that time, but she did not. She also indicated she did not follow up with the low weight and it was her responsibility to do so. In an interview with the facility Director of Nursing (DON) on 7/6/11 at 4:05PM, it was indicated she was not aware of the 87.10 pound weight until today's date. She indicated weekly audits were done by restorative staff which included the facility dietary manager, and the resident's low weight should have been reported and followed up. In an interview with the resident 7/6/11 at 4:15PM, the resident reported she did not like the supplement the facility gave, and there were times she refused it. She indicated the supplement made her feel nauseous. She did not recall if any other kind of supplement was suggested, nor did she recall why the supplement was given. The resident was weighed on 7/7/2011 at 9:30 AM by Nursing Assistant #2 (NA #2), a member of the restorative staff. The facility DON was present for the weighing. The weight was done with lift scale. The CNA calibrated the scale to zero prior to weighing. The resident was on her bed wearing a gown. The resident ' s weight was 90.5 pounds. In an interview with restorative NA #2 on 7/7/11 at 9:48AM, it was revealed "There are 4 of us who do the weights, we record them on our weight sheets in the weight books. We give the weights to the Dietary Manager who lets us know if a reweigh is needed. We use both the standing and the lift scale to weigh the residents". She further indicated resident #75 was weighed on both the lift scale and the standing scale depending on when she was weighed. Staff nurse #1 was interviewed on 7/7/11 at 10:40AM and indicated when orders were received from the hospital upon return to the facility, the nurse transcribed the orders to the MAR. She reported the process was " If orders are given for a dietary consult, the orders are transcribed to a resident 's MAR, and a referral/communication form is filled out and taken to dietary by the nurse who transcribes the order " . The staff nurse indicated she was not the nurse who transcribed admission orders [REDACTED]. On 7/07/2011 at 10:50 AM, the facility Dietary Manger indicated it was her responsibility to carry out dietary consults and further indicated no referral form was received in June or July 2011 for a dietary consult for resident #75. In an interview with the facility DON on 7/07/11 at 11:05 AM, it was reported staff was unable to locate a referral form for a dietary consult for Resident #75 done on 6/13/2011. The DON further indicated it was her expectation that orders for a dietary consult were carried out as soon as the orders were received. The DON also reported if there was an abnormal weight, the weight was turned over to the Dietary Manager and the Assistant Director of Nursing both who were in charge of monitoring residents' weights. She also indicated significant weight loss issues were brought to the Quality Assurance (QA) meetings, and that none were brought to the attention of QA for Resident #75 in June or July 2011.