Every finding on record at Redwood Health & Rehab

Based on record review and resident and staff interviews, the facility failed to treat Resident #1 with dignity and respect when Nurse #1 engaged in a verbal argument with Resident #1 utilizing profanity and yelling at Resident #1. This deficient practice affected 1 of 3 residents reviewed for dignity (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included heart failure, absence of right leg above knee, and unspecified arthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact and was not coded for behaviors. Resident #1's active care plan, last revised on 4/1/26, had a focus area regarding Resident #1 having behaviors of rejecting care and services. The goal included Resident #1's behaviors will not cause her or other residents any distress through the review period. Interventions included approaching with a calm quiet voice, diverting attention, and removing Resident #1 from the situation and taking her to an alternative location as needed, explaining all procedures to Resident #1 before starting and allowing her time to adjust to changes, and monitoring behavior episodes and attempting to determine the underlying cause with consideration to location, time of day, and persons involved. An Investigation Report dated 6/3/26 and sent to the Division of Health Service Regulation (DHSR) indicated that Resident #1 reported on 5/28/26 at approximately 5:30 PM that Nurse #1 alleged that on the evening of 5/27/26, Nurse #1 who was responsible for her care was verbally abusive toward her when she requested her pain medication. Resident #1 reported that Nurse #1 used derogatory and insulting statements, spoke to her in a scolding manner, and entered her personal space by getting close to her face during the interaction in front of other residents and staff. The Investigation Report revealed Resident #1 claimed she was upset but did not have mental anguish due to the altercation. Another resident's family member was listed as the witness and the Investigation Report additionally revealed Nurse #1 was reported to Board of Nursing in North Carolina and was immediately suspended pending investigation. The allegation of abuse was substantiated, and Nurse #1 was terminated on 6/1/26. The Investigation Report indicated all employees at the facility received abuse training. The Investigation Report was signed by the Administrator on 6/3/26. A written statement from Family Member #1 dated 5/27/26 at 5:17 PM revealed he witnessed Resident #1 following Nurse #1 in the hallway while yelling and making inappropriate, offensive, and racially derogatory comments towards Nurse #1 to include black b**** and dirty black b****. The statement indicated Nurse #1 initially attempted to disengage from Resident #1 and walked away but Resident #1 continued yelling and following Nurse #1 and Nurse #1 became visibly upset and began verbally engaging with and cursing at Resident #1. Family Member #1's statement included that Nurse #1 stated something to the effect of take your one-legged a** back to your room. You don't need to be out here. Call whoever the f*** you want, I don't f****** care. The statement indicated Resident #1 stated she wanted to beat up the nurse and Nurse #1 moved closer to Resident #1 and stated Let's do this. You can't get out of your f****** chair, you one-legged b****, so you can't do anything. Family Member #1 reported Nurse #1 was in Resident #1's face while yelling and cursing. He reported in his statement that Resident #1's behavior was inappropriate and offensive, however, Nurse #2's response was clearly inappropriate, and she should have walked away and sought assistance. A telephone interview with Family Member #1 was conducted on 6/16/26 at 12:50 PM. He stated he was visiting his loved one in her room when he heard a commotion which included shouting going on out in the hallway near the nurse's station. Family Member #1 stated he got up and went out into the hallway to see what was going on. He stated Resident #1 was chasing down Nurse #1 in her power chair and Nurse #1 was trying to get away from her. Family Member #1 stated Resident #1 caught up with Nurse #1 at the nurse's station and parked her chair there blocking access to leave the station on one side. He stated Resident #1 was calling Nurse #1 the N word and a nasty b**** person. Family Member #1 stated Nurse #1 kept telling Resident #1 her medications were not due to be given yet and she couldn't give them to her. He stated he went back into his loved one's room and when he came back out, Nurse #1 was yelling back inappropriate words at Resident #1 and apparently had enough. Family Member #1 stated Nurse #1 should not have yelled and spoken to Resident #1 in that way, but she seemed to be pushed towards it. He stated the incident went on for approximately 10-20 minutes and Nurse #2 came and stated you don't want to do this to Nurse #1 and Resident #1 was removed to another area. Family Member #1 said the incident was very bad and Resident #1 could move very quickly in her motorized chair and Nurse #1 could not get away from her. An interview with Resident #1 was conducted on 6/16/26 at 1:31 PM and revealed she went to get her evening medications on 5/27/26 and Nurse#1 started a big ordeal about she didn't have to give her the medications if she didn't want to. Resident #1 stated she wanted to get her medications and go to bed early. Resident #1 stated that she informed Nurse #1 that she could not threaten her like that and she would call the Administrator and let him know what happened as he looked after her like family. Resident #1 stated Nurse #1 slammed her medications down on the side of the nurse's cart and said, Do you want these or not? Resident #1 stated she didn't want to get into more of an altercation with Nurse #1 and she called the Administrator and went back to her room. Resident #1 stated the incident on 5/27/26 made her very upset and scared immediately after the incident. A written statement dated 5/29/26 at 10:06 AM from Nurse #1 revealed she was performing shift change duties on 5/27/26 at around 7:00 PM when she was informed by Nurse #2 that Resident #1 was due at 9:00 PM for her narcotic pain medication. Nurse #1 stated Nurse #2 warned her that Resident #1 would ask for her medication early. She stated as soon as she completed shift change duties, Resident #1 came to the nurse's station and asked for a different nurse, and she asked who Nurse #1 was. Nurse #1's statement revealed she introduced herself to Resident #1 and Resident #1 became verbally aggressive and started demanding her evening narcotic medication. Nurse #1's statement indicated she remained calm and explained that due to safety and regulatory requirements, she could not give Resident #1 her medication earlier than the scheduled administration time. Nurse #1 revealed in her statement that Resident #1 continued to be verbally abusive to her and Nurse #1 continually tried to de-escalate this situation and then Resident #1 stated I will call the police on you and I've done it before. Nurse #1 stated Resident #1 started engaging other residents in the incident and then Resident #1 went to Nurse #2 who had moved to the other unit to work and confronted her about the last time she had administered the narcotic medication to Resident #1. The statement indicated Resident #1 came back to her unit and Nurse #1 gave her the scheduled medication at 8:00 Pm and Resident #1 went back to her room and stated she had the Administrator's number, and she guaranteed Nurse #1 that she would be fired the next day. A telephone interview with Nurse #1 on 6/16/26 at 1:55 PM revealed she had received report from Nurse #2 and was warned by Nurse #2 that Resident #1's medications which included a narcotic was scheduled for 9:00 PM but Resdeint #1 would ask for them earlier. Nurse #1 stated Nurse #2 left the unit and Resident #1 immediately came up and started asking for her medication. Nurse #1 stated it was too early for her medication as they were scheduled at 9:00 PM. Nurse #1 indicated she walked away from Resident #1, but Resident #1 kept following her and she got louder when she started demanding her medications. Nurse #1 stated Family Member #1 came out of his loved one's room and said, Why are you cussing this nurse. Nurse #1 stated Resident #1 kept escalating the situation and she could not get away from her. Nurse #1 stated she had a couple of other residents that she needed to monitor closely due to condition changes and Resident #1 was preventing her from completing her tasks. Nurse #1 stated after more than an hour of Resident #1 being relentless, Nurse #1 stated she was irritated and gave Resident #1 her medications. Nurse #1 stated she had been a nurse for 30 years and had a bad day and she lost it with Resident #1. A statement from Nurse # 2 dated 5/28/26 revealed she heard Nurse #1 call Resident #1 a one-legged b**** and that she didn't give a f*** about being fired. Nurse #2 revealed in her statement that Nurse #1 stated Resident #1 was a drug addict and she didn't give a f*** who the Administrator was and that she would walk out of this b**** right now. Nurse #2's statement indicated Family Member #1 and other residents heard the altercation and that Family Member #1 told her he was scared to have his loved one cared for by Nurse #2. Nurse #2 continued that Resident #1 was distressed and Nurse #2 convinced her not to call the police. A telephone interview with Nurse #2 on 6/16/26 at 2:59 PM revealed she was working on the other unit on the evening of 5/27/26 when the incident between Resident #1 and Nurse #1 occurred. She stated a few residents came and got her on the unit and when she arrived at the other unit, she heard Nurse #1 and Resident #1 cursing each other out. She stated she removed Resident #1 from the unit and Resident #1 stated she was going to call the Administrator on her phone. Nurse #2 stated she saw Resident #1 speaking to the Administrator on the phone, but she did not know which details she shared with him. A telephone interview with the Director of Nursing (DON) was conducted on 6/18/26 at 10:20 AM. She stated she was made aware of the 5/27/26 incident between Nurse #1 and Resident #1 on 5/28/26. She understood that Nurse #1 made some inappropriate statements toward Resident #1 after she asked for her medications early in the evening of 5/27/26. The DON stated she had the expectation that all staff would notify either herself or the Administrator of any type of abuse and that Nurse #1 should have let Resident #1 know of the medication timeframe and continued her medication pass. The DON stated that nurses had to follow the provider's orders for scheduled medications. A telephone interview with the Administrator on 6/23/26 at 4:13 PM revealed he left the faciity on 5/27/26 and then received a phone call from Nurse #2 that Resident #1 was upset, and she wanted to speak to him. He stated Resident #1 told him another resident called her a one-legged white t**** wh***. The Administrator stated Resident #1 did not get along with the other resident and it was not unusual for them to get upset with each other. He asked Resident #1 what she wanted him to do and she stated she was going to go to her room for the evening. The next day, he followed with the other resident who did not mention the incident and in the evening when he was ready to leave for the day, he found a statement under his door from Nurse #2 explaining the incident on 5/27/26 between Resident #1 and Nurse #1. The Administrator stated he expected the Nurse #1 to walk off the unit and disengage during the altercation with Resident #1 and that did not happen. He indicated the entire incident could have all been avoided if Nurse #1 had just walked away from Resident #1.

Based on record review, resident, Pulmonologist Office Receptionist, Nurse Practitioner (NP) and staff interviews the facility failed to ensure a resident attended a scheduled pulmonary follow-up visit with the pulmonologist for 1 of 1 resident reviewed for quality of care (Resident #2). The findings included:Resident #2 was admitted to the facility on [DATE]. His diagnoses included acute respiratory failure with hypoxia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact. A review of resident #2's Electronic Medical Record (EMR) revealed a scheduled pulmonologist appointment on 6/9/26 at 1:20 PM. An interview with Resident #2 on 6/16/26 at 2:29 PM revealed he had a follow-up appointment with the pulmonologist on 6/9/26 from his hospitalization earlier in the year and no one from the facility took him to the appointment that the NP ordered because no one at the facility knew anything about it. He stated he hadn't been anywhere out of the facility for a while and was unaware if the appointment had been rescheduled. An interview with the Medical Transporter on 6/16/26 at 2:41 PM revealed she had been employed at the facility since the beginning of March 2026. She stated the Nurse Practitioner (NP) requested a follow-up appointment on 4/24/26 with the pulmonologist for Resident #2, but she was on medical leave and was unaware of the appointment request. The Medical Transporter stated typically when nursing received an order for a new doctor's appointment, the nurse on duty approved it and a copy of the appointment would be given to her, and another copy would be given to the Receptionist at the front desk. She stated she set up all appointments she knew about before her medical leave and was not aware of any other staff member covering her job duties while she was gone. The Medical Transporter stated after Resident #2 missed his appointment, she was made aware by the Director of Nursing (DON) on 6/10/26 and she rescheduled the appointment for 7/23/26. A telephone interview with the Pulmonologist Office Receptionist occurred on 6/17/26 at 11:02 AM. She revealed Resident #2 was a no-show for his appointment on 6/9/26 and confirmed Resident #2 had an appointment on their schedule for 7/23/26 and it was scheduled by the facility on 6/10/26. A telephone interview with the NP on 6/17/26 at 11:13 AM revealed Resident #2's pulmonologist appointment was a follow up from a hospitalization earlier in the year. He stated Resident #2 had some respiratory concerns including pneumonia and a pleural effusion earlier in the year and the pulmonologist wanted these concerns monitored after the hospitalization. The NP stated when he ordered a medical appointment for any resident, he would fill out a communication log sheet with the resident's name and consultation information, and he would put the communication log sheet in the box to communicate with the Medical Transporter. He stated he had the expectation that the DON or nursing staff would communicate with the Receptionist at the front desk or the Medical Transporter as well. The NP stated he understood that during the Medical Transporter's absence, new consults were getting scheduled and some appointments were missed. He stated all nursing staff should communicate with the Receptionist and the Medical Transporter when processing a medical appointment order. He stated he spoke with the DON a week ago and asked her to streamline the communication process with nursing staff for medical appointments. A telephone interview with the Receptionist occurred on 6/17/26 at 1:45 PM and revealed she was not aware of an appointment for Resident #2 on 6/9/26. She stated all appointments were scheduled and coordinated with outside transportation before the Medical Transporter went out on medical leave. The Receptionist stated she typically received a list of medical transports daily, some were driven by the Medical Transporter, and some were driven by a contracted wheelchair transport company. A telephone interview with the DON on 6/18/26 at 10:20AM revealed Resident #2's pulmonologist appointment on 6/9/26 was on the book for an outside wheelchair transport company because Resident #2 had to be transported in a reclining wheelchair. She stated the wheelchair transport company was supposed to pick up Resident #2 and they did not. The DON stated she called the wheelchair transport company, and they did not have transportation available for Resident #2. She stated a new appointment for Resident #2 was scheduled for 7/23/26. The DON stated that when a medical provider in the facility ordered a medical consult appointment, nursing staff reviewed the order and then a printed form for the appointment would be filled out and given to the Medical Transporter to put in the transportation book. She stated the Receptionist was covering for the Medical Transporter while she was out on leave and the DON was sure there was a transport communication request given to the outside wheelchair transportation company to request a ride for Resident #2. A review of a facility transportation request sheet dated 4/27/26 at 1:30 PM revealed an email request for wheelchair transportation for Resident #2 on 6/9/26 for a 1:20 PM appointment at the pulmonologist office location. The form indicated it had been scanned to email but did not contain an email from the facility to the wheelchair transportation company or a response from the wheelchair transportation company confirming the appointment. A telephone interview with the Wheelchair Transportation Company Owner was attempted on 6/23/26 at 10:13 AM but he refused to provide any information regarding Resident #2's medical transportation request for a pulmonology appointment on 6/9/26. A telephone interview with the Administrator on 6/23/26 at 4:13 PM revealed Resident #2 did miss his appointment on 6/9/26 and he did not find out about the missed appointment until the following day when Resident #2's Responsible Party (RP) contacted him. The Administrator stated the Medical Transporter was out on medical leave when the order was made and the facility started reviewing all medical appointments for residents since 6/9/26 to ensure there were no more missed appointments. He stated Resident #2 had a rescheduled pulmonologist appointment in July.

Based on observations and staff interviews, the facility failed to discard dented canned goods stored for use, failed to dry divided plates prior to stacking, and failed to discard a wet cardboard box of pound cakes covered in frozen condensation. These practices occurred in 1 of 1 walk-in freezer, 1 of 1 dishwashing area, and 1 of 1 dry storage area and had the potential to affect food served to residents. The findings included:An initial tour of the main kitchen occurred on 5/4/26 at 9:58 AM with the Dietary Manager. The following concerns were identified:-A 108 ounce (oz.) can of applesauce with a large dent on the rim and side, a 6.62 pound (lb.) can of mandarin oranges with a small dent on rim, and a 7 lb. can of vanilla pudding with a small dent on the rim were stored in the dry storage area for use.-A cardboard box containing 12-pound cakes was stored under the main cooling fan in the walk-in freezer; the box was dark in appearance and covered in frozen condensation.-Six divided plates were stacked wet (wet-nested) in the dishwasher area.An interview with the Dietary Manager on 5/7/26 at 2:05 PM revealed she in-serviced the kitchen staff on proper drying of dining supplies, inspecting cans for dents, and proper storage in the freezer. The Dietary Manager stated the staff sometimes would not pay attention and would forget correct kitchen practices. She stated the cardboard box in the walk-in freezer belonged to the Activities department and she found sometimes those boxes were not placed in the right spot in the walk-in freezer to prevent the condensation from dripping on the box. The Dietary Manager stated Activity staff had access to the freezer and the box was placed in the incorrect spot on the shelf. She stated she wanted dented cans to be pulled from rotation to send back to the distributer for credit. An interview with the Administrator on 5/7/26 at 2:50 PM revealed he had the expectation for staff to properly store items in the walk-in freezer and divided plates needed to be stored correctly. He indicated kitchen staff who assist with unloading the food distribution truck would be educated on proper can storage in the dry storage area.

Based on observations, record review, and Nurse Practitioner, resident and staff interviews, the facility failed to provide clinical assessment and treatment when a resident first reported that he was burned after he accidentally spilled his cup of hot noodles on himself for 1 of 3 residents reviewed for quality of care (Resident #70). Findings included: Resident #70 was admitted to the facility on [DATE] and readmission on [DATE] with diagnosis that included multiple sclerosis, paraplegia, muscle weakness, and contracture of muscles to lower extremities. Review of physician order dated 7/25/24 revealed Hydrocodone (pain reliever used to treat moderate to severe pain) 5-325 milligrams (MG) one (1) tablet by mouth every 12 hours as needed for pain. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively intact and had been assessed as being independent for eating, personal hygiene, mobility, and transfers. Resident #70 also required minimal assistance for toileting, supervision assistance for dressing, and partial assistance for showering. Resident #70 was also as coded as use of manual wheelchair for mobility. An interview with Resident #70 on 5/06/26 at 2:15 PM revealed on the evening of 4/30/26 sometime after supper probably between 6:00 PM to 7:00 PM he was putting his fork into a cup of hot noodles, and his hand accidentally hit the cup and spilled the cup of noodles onto him. He stated he immediately started to clean himself up, removed his wet clothes, dried himself off and draped a gown over himself. He revealed at first he could tell his skin on the lower right side of his stomach and his right upper thigh appeared red but then a few minutes later the areas appeared more irritated and were burning a little, so he went out to the hall and found Medication Aide #1 on the medication cart. Resident #70 stated that he told Medication Aide #1 about what had happened and that he had burned himself and she asked him why he did not tell the first shift nurse and that he should have told them and that he could tell the second shift nurse (Nurse #4) who was covering both halls. He revealed he then asked for his as needed pain medication due to the pain from his burn being a level 8 out of 10 (numeric scale for pain with 0 being no pain and 10 being the worst pain) and Medication Aide #1 administered him his pain medication which helped with the pain. He stated later that evening he spoke with Nurse #4 and told her about what had happened and that he had been burned, and she also asked him why he did not notify the first shift nurse and that he should have notified the first shift nurse and then walked away. Resident #70 stated at first he was shocked Nurse #4 had not even asked to look at his burns but his pain medication had started working, and he was not feeling any pain or discomfort from his burns, so he did not mention it again until he notified the first shift nurse (Nurse #3) the following morning on 5/01/26. He revealed once he told Nurse #3 about what had happened and about the burns, Nurse #3 immediately assessed his burns, contacted the NP and provided treatment. Resident #70 stated the NP followed up with him later that same day and continued with his same treatment, instructed him to notify staff if he saw any signs of drainage or infection, and reminded him if he was feeling any pain to request his pain medication as needed. An interview conducted with Nurse Aide (NA) #2 on 5/06/26 at 3:15 PM revealed he typically worked second shift (3:00 PM to 11:00 PM), had been scheduled to work second shift on the evening of 4/30/26, and was assigned to Resident #70's hall. NA #2 stated he did not recall Resident #70 telling him during his rounds that night about him spilling his noodles or about the burns and if Resident #70 had told him he would have notified the nurse. An interview with Medication Aide #1 on 5/06/26 at 3:25 PM revealed she typically worked second shift (3:00 PM to 11:00 PM) and was scheduled on the evening of 4/30/26 and assigned to work the medication cart for Resident #70's hall. She stated on the evening of 4/30/26 sometime between 7:00 PM and 8:00 PM while working the medication cart, Resident #70 approached her and stated that earlier he had gotten burned when he accidentally spilled his cup of hot soup noodles on himself. She revealed she asked him if he had told the first shift nurse what happened and Resident #70 stated no, the first shift nurse had already left by the time he had got everything cleaned up. Medication Aide #1 stated that she told him he should have notified the first shift nurse and that the second shift nurse on the 200 hall was also covering his hall and for him to tell her. She revealed Resident #70 had an order for as needed pain medication due to his medical conditions and requested his pain medication for a pain level of 8 out of 10 due to burning himself. She stated that she administered Resident #70 his pain medication. Medication Aide #1 revealed she never assessed or provided treatment for Resident #70's burns that night and did not recall whether she informed Nurse #4 about the burns. She stated she did recall seeing Resident #70 speaking with Nurse #4 later that evening but could not hear what they were speaking about and was never told that night of any new orders for medications or treatments. Medication Aide #1 revealed she remembered completing rounds on Resident #70 later that evening and he stated his pain was good and the medication was effective. Review of the April 2026 Medication Administration Record (MAR) revealed on 4/30/26 at 8:38 PM Resident #70 was administered Hydrocodone 5-325 MG 1 tablet by mouth every 12 hours as needed for pain by Medication Aide #1 for a pain level of 8 out of 10. Pain medication was effective. A telephone interview conducted with Nurse #4 on 5/11/26 at 2:30 PM revealed she typically worked as a second shift nurse (7:00 PM to 7:00AM) and was scheduled to work on the night of 4/30/26. She stated she was scheduled as the nurse and working the cart on the 200 halls but was overseeing Medication Aide #1 who was working Resident #70's hall. She revealed she was familiar with Resident #70 and might have spoken to him that night but did not recall him ever telling her about him accidentally spilling his cup of hot soup noodles onto himself causing him to get burned. She stated she believed that had she been told she would have assessed Resident #70, called the physician, and documented the incident. Nurse #4 revealed she spoke with Medication Aide #1 that night about resident blood sugars but never about Resident #70 getting burned. Review of nursing progress note written by Nurse #3 dated 5/01/26 revealed Resident #70 showed Nurse #3 scald wounds sustained previous night when hot soup noodles accidentally spilled onto his right thigh (8 inch by 3-inch wound and a 3 inch by 1-inch wound) and lower right side of abdomen (6 inch by 2-inch wound). Nurse #3 notified NP and wound nurse and received treatment orders. Nurse #3 thoroughly washed wound and applied new treatment orders. Review of incident report written by Nurse #3 dated 5/01/26 revealed Resident #70 showed Nurse #3 scald wounds sustained previous night when hot soup noodles accidentally spilled to his right thigh (8 inch by 3-inch wound and a 3 inch by 1-inch wound) and lower right side of abdomen (6 inch by 2-inch wound). Nurse #3 notified NP and wound nurse and received treatment orders. Nurse #3 thoroughly washed wound and applied new treatment orders. An interview with Nurse #3 on 5/06/26 at 3:35 PM revealed he typically worked first shift (7:00 AM to 7:00 PM) and was scheduled to work on the morning of 5/01/26 and assigned to Resident #70's hall. He stated on the morning of 5/01/26 sometime between 8:00 AM and 9:00 AM he was administering Resident #70 his morning medications when Resident #70 informed him that the previous evening he was attempting to eat a cup of hot soup noodles and accidentally hit the cup with his hand and spilled the hot soup noodles onto himself and had gotten burned. He revealed Resident #70 stated that after he cleaned himself up, he went to the second shift Medication Aide #1 and informed her what had happened and that he had gotten burned and that she asked Resident #70 why he didn't tell the first shift nurse before they left and that he would need to tell the second shift nurse. He revealed Resident #70 requested his as needed pain medication for the pain from his burns and Medication Aide #1 administered the medication and it was successful. Nurse #3 stated Resident #70 later informed the second shift nurse (Nurse #4) who was covering that hall and that she also asked why he did not inform the first shift nurse what happened and that he should have informed first shift but that she never physically assessed him or treated the burns or contacted the physician. Nurse #3 revealed after hearing this he immediately assessed Resident #70 and found that he had a burn to his lower right abdomen that was red and appeared as if a blister had popped and what he believed to be two wounds to his right upper thigh that appeared the same. He stated he immediately notified the NP and received new treatment orders. He revealed he then washed Resident #70's wounds, applied the new treatments, administered his as needed pain medication for a pain level of 5 out of 10, entered treatment orders into system, completed incident report, and documented incident in progress notes. Nurse #3 stated that he did check on Resident #70 a little while later and observed the dressings were intact and his pain medication was successful with no complaints of pain. Review of physician progress note written by the NP dated 5/01/26 revealed Resident #70 reported he had spilled hot soup noodles on himself by accident last night and sustained burns to his right abdomen and right upper thigh. Upon exam, Resident #70 was assessed to have stage 2 burns (partial-thickness burn is a burn that affects the outer layer of the skin (epidermis) and part of the underlying dermis) to his right lower abdomen and right upper thigh that had been treated and was currently dressed with dry dressing with no evidence of drainage, infection or swelling. Wound Care NP would assess burns during routine rounds next week to make further recommendations. Resident #70 endorsed mild pain at burn site and advised he had an order for as needed pain medication that could be administered for burn pain. Continue new orders for thermal wound care to right upper thigh and right lower abdomen. Review of physician order written by NP for Resident #70 dated 5/01/26 revealed thermal wound care to right upper thigh and right lower abdomen with betadine paint (fast drying topical treatment used to kill germs and prevent infection in skin wounds), Dermasyn (provides moist environment for maximum healing to skin wounds and burns) ointment and covered with dry dressing. Review of physician progress note written by the NP dated 5/04/26 revealed Resident #70 was seen for follow-up of recent second-degree thermal wound to right upper thigh and right lower side of abdomen to assess healing and assure no evidence of wound infection. Upon exam, abdominal wound was noted to be open with a deep red base and areas of yellow crusting. Given the location of wounds in areas more prone to increased moisture and friction, there was concern for potential secondary infection. Recommended treatment plan revealed the following: discontinue current treatment orders for both burns due to potential for impaired healing, initiate Clindamycin (antibiotic used to treat or prevent serious bacterial infections) 300 MG one (1) tablet by mouth 3 times daily for 7 days for wound infection, apply Silvadene (topical antibiotic cream used to treat serious skin infections associated with second-third degree burns) cream 1% to affected areas once a day (day shift) for wound care, increase as needed pain medication from every 12 hours to every 8 hours as needed, placed consult request for Wound Care NP evaluation on 5/06/26 (routine weekly rounds) for further assessment and recommendations, continue wound hygiene and monitor closely for any signs or symptoms of infection. Review of physician orders written by NP for Resident #70 dated 5/04/26 revealed the following:Hydrocodone Acetaminophen 5-325 MG one (1) tablet by mouth every 8 hours as needed for treatment of pain.Clindamycin 300 MG 1 tablet by mouth 3 times daily for 7 days for wound infectionSilvadene cream 1% applied to affected area (right upper thigh and right lower abdomen) once a day (day shift) for wound care An interview conducted with the NP on 5/06/26 at 10:15 AM revealed he was familiar with Resident #70. He stated on the morning of 5/01/26 he received a telephone call from Nurse #3 stating the previous evening Resident #70 had accidentally spilled a cup of hot soup noodles on himself and had some burns to his lower right abdomen and right upper thigh and they appeared red and as if blister had opened. He revealed he gave orders to clean both burns and treat with betadine, medicated cream, and cover with dry dressing and to administer Resident #70's as needed pain medication if needed and that he would be in to assess burn that morning. The NP stated on 5/01/26 he assessed Resident #70's burns and felt they were stage 2 and continued with the current treatment order to be completed daily during day shift. He revealed Resident #70 stated only some mild pain from the burns and he reminded him that he had an order for pain medication every 12 hours that he could request as needed. The NP stated he followed up with Resident #70's burns on 5/04/26 and they appeared a little worse with a red base and yellow crustiness so he changed the treatment order to an antibiotic cream specifically for burns to be administered daily during day shift, ordered an antibiotic to prevent infection, and changed his as needed pain medication to every 8 hours as needed instead of every 12 hours due to new treatment orders. He revealed Resident #70 was also evaluated today by the Wound Care NP and they agreed to keep the treatment order the same and will continue to see him weekly until the burns have healed. The NP stated as of right now there were no signs of infection present in Resident #70's burns and he has not complained of any severe pain and has only requested his as needed pain medication sporadically with a documented pain level of 5 and medication seemed to be working effectively. He revealed he was not notified and to his knowledge neither was the on-call service notified of Resident #70's incident or his burns on the evening the incident occurred and although in his opinion it would not have changed the degree of the burn he still would have liked to have been notified or at least on-call to have been notified so they could have had an initial assessment of the burn after it occurred and treatment recommended. Review of Wound Care NP progress note dated 5/06/26 revealed Resident #70 being seen for initial evaluation. He received burns from accidental spilling of hot soup noodles onto right thigh and right abdomen, both areas with dermis (middle layer of skin) and scabbed areas, some trace erythema (redness) on edges, and received antibiotic. Resident #70 reported some drainage, but none seen on assessment. Wound to right thigh measured 16 centimeters (cm) by 4.5 cm by 0.1 cm and wound to right abdomen measured 6 cm by 3 cm by 0.1 cm. Continue current treatment course. An interview and observation with Resident #70 on 5/06/26 at 2:15 PM revealed he believed his burns were starting to heal, nursing staff were providing his treatment daily, the NP continued to follow-up with him weekly, and he had also been seen and treated by the Wound Care NP. Resident #70 stated he had some mild to moderate pain from the burns from time to time but once he received his as needed pain medication the pain would stop. Observation of Resident #70 burns on his lower right abdomen and right upper thigh revealed both areas covered with dry dressing, dated, and initialed. An interview conducted with the Director of Nursing (DON) and Regional Nurse Consultant on 5/07/25 at 3:30 PM revealed both were familiar with Resident #70. The DON stated she was not made aware of the incident with Resident #70 and the burns until 5/04/26 due to being out of town and then was only notified that Resident #70 had spilled his cup of hot soup noodles on himself by accident and received burns to his stomach and thigh. The DON revealed she was not aware of staff being told after the incident occurred on 4/30/26 and not assessing or treating the burns until the following morning. The Regional Nurse Consultant stated that she was made aware of the incident on 5/01/26 while at the facility and had spoken with Resident #70 who had told her a similar version of how he had accidentally spilled the cup of hot soup noodles onto him and caused him to get burned but could not recall him telling her the specifics about the staff and not providing care. She stated when she saw Resident #70 on 5/01/26 his wounds had been treated, and he had no complaints of pain. The Regional Nurse Consultant stated she expected that nursing staff should immediately report to their supervisor any incidents involving residents as soon as they are made aware, nursing staff should physically assess any reports of resident injury as soon as they are made aware, nursing staff should notify the physician of any incidents as soon as they are made aware, and nursing staff should always document any incidents involving residents as soon as possible. The DON agreed with the expectations from the Regional Nurse Consultant and stated that Medication Aide #1 should have assured that Nurse #4 was notified of the incident and Nurse #4 should have physically assessed Resident #70's burns, notified the physician for further recommendations, applied any treatments as ordered, and documented the incident. An interview conducted with the Administrator on 5/07/26 at 4:00 PM revealed he was familiar with Resident #70. The Administrator stated he believed he was made aware on 5/01/26 of Resident #70 accidentally spilling his cup of hot soup noodles onto himself causing him to get burned and having to receive treatments for his burns. He revealed he was not aware that Resident #70 had told Medication Aide #1 and Nurse #4 the previous night when the incident happened and that he was not physically assessed or provided care until the following morning. He stated nursing staff were aware to notify their supervisors immediately when notified of any type of incident or injury involving a resident, to immediately physically assess residents once they were notified of an incident or injury, to notify the physician for further recommendations and treatment orders, and to complete incident reports and document the reported incidents or injury in a timely manner. The Administrator stated Medication Aide #1 should have made sure Nurse #4 was aware of Resident #70's incident and his burns and once notified Nurse #4 should have physically assessed Resident #70 immediately, notified the physician for further treatment recommendations, completed an incident report and documented the incident and injury in a nursing progress note.

Based on observation, record review, and interviews with the Responsible Party (RP), staff, Nurse Practitioner (NP), and hospice staff, the facility failed to ensure effective communication and coordination of care occurred with the hospice provider. On 6/29/25, Resident #101, who was under the care of hospice, fell in his room and was assessed by Nurse #1, assisted back to bed and then sent to the Emergency Department (ED) for evaluation. The hospice on call provider was not notified by facility staff before Emergency Medical Services (EMS) was called. This deficient practice affected 1 of 4 sampled residents reviewed for coordination of hospice services (Resident #101).The findings included:The Hospice Facility and Services Agreement contract dated 4/30/19 stated, With respect to the management of the resident's terminal illness, the facility shall notify Hospice immediately of any significant change in the Patient's status (mental, social, emotional, or physical), clinical complication that suggest a need to alter the plan of care; a need to transfer the Patient out of the Facility; or the Patient's death regardless of the time or the day since a Hospice staff member is available (24) twenty four hours a day, every day.Resident #101 was admitted to the facility on [DATE] under hospice services with diagnoses which included protein-calorie malnutrition (when the body does not receive enough protein and calories to maintain proper health and functioning), and ascorbic acid deficiency (a deficiency caused by low vitamin C levels).Resident #101's care plan dated 4/21/25 revealed a focus area for hospice services with expected decline in condition due to terminal progressive disease related to protein calorie malnutrition. Interventions included notifying the Medical Director and hospice of complications as indicated.Resident #101's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired and received hospice care. Resident #101 required substantial and maximal assistance to set up assistance from staff for all Activities of Daily Living (ADL).A review of Resident #101's physician's orders revealed an order dated 4/24/25 for hospice due to protein-calorie malnutrition. The order read to notify Hospice 24 hours a day, seven days a week of any change in condition or question/concern.A review of a document entitled Interact Transfer Form dated 6/29/25 and signed by Nurse #1 revealed Emergency Contact #2 was called and notified of the transfer to the hospital. The reason for transfer to the ED was due to altered mental status. A nursing progress note dated 6/30/25 and written by Nurse #1 revealed after a fall on 6/29/25, Resident #101 appeared lethargic and was observed head to toe with no wounds or bruises noted and Resident #101 was assisted back to his bed. Resident #101 was restless and repeatedly stated he was having difficulty breathing. A pulse oximetry (a non-invasive test that measures the oxygen saturation level in the blood and heart rate) reading was obtained and noted to be in the low 60s (normal range is between 95% and 100%) and oxygen was applied immediately. The nursing progress note continued that due to Resident #101's continued lethargy and low oxygen saturation, EMS was contacted and he was transported to the hospital via ambulance for further evaluation and treatment. The note indicated that the RP and nurse supervisor were notified. There were no physician orders documented to send Resident #101 to the ED for evaluation on 6/29/25.A telephone interview with Nurse #1 occurred on 5/7/26 at 12:37 PM. She stated she couldn't remember exact details from 6/29/25 but did generally recall Resident #101. Nurse #1 stated the Former Nurse Supervisor that night called EMS, and she stayed with Resident #101 in the meantime. She stated Resident #101's oxygen saturation was low and just because he used hospice services didn't mean he didn't need to be treated although she did not specifically recall if Resident #101 utilized hospice services. Nurse #1 stated she did not call hospice or the NP, but the Former Weekend Supervisor did. A telephone interview with the Former Weekend Supervisor on 5/8/26 at 1:23 PM revealed he was not assigned to Resident #101 on the night of 6/29/25 and that Nurse #1 was. He stated he did not assist with calling EMS for Resident #101 but knew he was sent out of the facility for evaluation at the ED. The Former Weekend Supervisor stated he did not remember many details about what happened on 6/29/25 but knew he did not complete any paperwork or make any calls to hospice, the on-call service for the NP, or the RP regarding Resident #101. A phone interview with Hospice Nurse #1 on 5/6/26 at 3:40 PM revealed the hospice agency was not contacted about Resident #101's fall on 6/29/25. She stated Resident #101 was documented in their EMR as not wanting any aggressive treatment. Hospice Nurse #1 stated she reviewed the coordination notes in their system call log and it revealed no calls or notes regarding Resident #101 that night. Hospice Nurse #1 stated they became aware of his hospitalization the following day on 6/30/25 because Resident #101's RP called stating he was sent to the hospital and did not know which one. She stated generally hospice should be called for any change in condition. Hospice Nurse #1 stated their on-call service would track the call, coordinate with the RP or family to see what their wishes were and typically a nurse from the hospice agency would be sent out to evaluate. She stated a MOST form was signed on 7/2/25 after Resident #101's hospitalization on 6/29/25 indicating no further hospitalizations.In a telephone interview with Resident #101's RP on 5/6/26 at 1:16 PM she revealed Resident #101 did not want to go to the hospital for treatment. She stated Emergency Contact #2 was called instead of her on 6/29/25. The RP stated she had recently become Emergency Contact #1 for Resident #101 due to a change in health status concerning Emergency Contact #2. She stated the facility called Emergency Contact #2 and stated Resident #101 was being sent to the ED for evaluation. The RP stated the facility did not call hospice for any orders or evaluation of Resident #101 and as a result, a MOST (Medical Orders for Scope of Treatment) form was signed indicating Resident #101 did not want to be hospitalized when he returned from the ED. The RP stated she also placed a sign in Resident #101's room indicating his wishes to not be hospitalized again.A review of Resident #101's Electronic Medical Record (EMR) revealed Emergency Contact #2 was labeled as Emergency Contact #2, but listed first on the form and Emergency Contact #1 was labeled as Emergency Contact #1, but listed second on the form.A review of Resident #101's hospital records dated 6/30/25 revealed Resident #101 was sent by EMS for treatment after a fall with a fever and low oxygen saturation. Resident #101 was found to have a fractured rib, pneumonia, and osteomyelitis (a bone infection) in one toe. Broad spectrum antibiotics were initiated but were stopped due to comfort measures wishes as directed by the RP. Resident #101's hospital records also revealed hospice was contacted by hospital staff and confirmed only comfort measures were desired at that time per the RP and Resident #101 would be discharged back to the facility when transport became available. Resident #101 was discharged from the hospital back to the facility 7/01/25.An additional review of Resident #101's EMR revealed a MOST form signed on 7/2/25 indicating Comfort Measures. Keep clean, warm and dry. Use medication by any route, positioning, wound care, and other measures to relieve pain and suffering. Use oxygen, suction, and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital unless comfort needs cannot be met in current location.A telephone interview with the Former Director of Nursing (DON) on 5/8/26 at 2:20 PM revealed that generally, if the nurse on duty was not familiar with any resident, she would expect them to call the provider and provide care for the resident's safety. She stated she did not recall the exact details of Resident #101's fall and transfer to the ED on the night of 6/29/25 but stated unless his EMR stated to not call 911 due to hospice services, she expected Nurse #1 to call the provider and let hospice know. The Former DON was not sure when hospice was contacted for Resident #101 but stated she recalled doing some education to the nursing staff about hospice coordination. A telephone interview with the former Administrator on 5/11/26 at 1:45 PM revealed he did not recall Resident #101 or the coordination of care the night of 6/29/25 but stated the Former DON expected providers to be called and indicated education for staff was probably completed on hospice coordination by the Former DON.

Based on record review, observations and interviews with residents, Responsible Party, and staff, the facility failed to ensure the call light system was functioning properly for 3 of 27 residents who required assistance for activities of daily living (Resident #5, Resident #19, and Resident #48). The findings included:a. Resident #5 was admitted on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was assessed as moderately cognitively impaired.An observation of the call light for Resident #5's room and an interview with the resident occurred on 5/4/26 at 11:00 AM. The light in the hallway above the Resident #5's door did not light up when the call light was pressed. Resident #5 stated he was not aware the call light was not working and had been waiting for a staff member to provide ice water and take money to get a soda for him out of the drink machine. He stated he might have to yell if he needed assistance since his call light was not working. There was not a manual hand bell present for Resident #5's use. An interview with Unit Manager #1 occurred on 5/4/26 at 11:10 AM. She stated she was not aware there was an issue with Resident #5's call light. Unit Manager #1 went to Resident #5's room to test call light. She stated she had no idea the call light was not working and provided a hand bell to Resident #5 and immediately notified maintenance to address the issue. b. Resident #19 was admitted to the facility on [DATE]. The significant change MDS assessment dated [DATE] revealed Resident #19 was moderately cognitively impaired. An observation of the call light for Resident #19's room and an interview with Resident #19 occurred on 5/4/26 at 11:50 AM. When Resident #19's call light was pressed it did not light up in the hallway above the door. Resident #19 stated he did not know that the bell was not working. There was no hand bell present in Resident #19's room. c. Resident #48 was admitted to the facility on [DATE]. The admission MDS assessment dated [DATE] revealed Resident #48 was moderately cognitively impaired. An observation of Resident #48's call light and interview with Resident #48's Responsible Party (RP) occurred on 5/4/26 at 11:45 AM. When the bell was pressed, the light in the hallway did not turn on. Resident #48's RP stated she was not aware the call light was not working. There was no hand bell present in Resident #48's room.An interview with Nurse #2 on 5/4/26 at 11:03 AM revealed it was her first day at the facility and she did not know there was any issue with the call lights not lighting up in the hallway. An interview with Nurse Aide (NA) #1 on 5/4/26 at 11:05 AM revealed she did not know there was any issue with the call lights not lighting up in the hallway.An interview with the Maintenance Director occurred on 5/7/26 at 9:24 AM. He stated he was notified by Unit Manager #1 of call lights not lighting up in the hallway on 5/4/26. He was not aware of the call lights not functioning for Resident #5, Resident #19, and Resident #48's rooms before 5/4/26 and no staff had reported any issues. A follow-up interview with the Maintenance Director on 5/7/26 at 1:10 PM was conducted. The Maintenance Director stated any staff member could place a request in the online system for maintenance. He stated staff would frequently stop Maintenance staff members in the hallway with requests. The Maintenance Director stated the Maintenance department did random call light checks often and the nonfunctioning call lights were not identified before 5/4/26. An interview with the Maintenance Assistant on 5/7/26 at 1:35 PM revealed the Maintenance staff did random rounds to check on the call lights in resident rooms, but he was not aware of any of the call lights not working before 5/4/26.An interview with the Director of Nursing (DON) was conducted on 5/8/26 at 4:03 PM. She stated she was not aware of the call lights not working in Resident #5, Resident #19, and Resident #48's rooms before 5/4/26 but stated if there was a concern regarding call lights not working after hours, staff could borrow a call light from an empty room and put a request in the online maintenance request system. The DON stated nursing staff could also give any resident a physical hand bell to use, alert the staff of the use of the physical hand bell, and then put in a request in the online maintenance request system. An interview with the Administrator on 5/7/26 at 2:58 PM revealed he did not know the call lights in Resident #5, Resident #19, and Resident #48's rooms were not working before 5/4/26 and he had the expectation that all staff would make a request to fix call lights in the online maintenance request system as soon as the issue was identified.

Based on observation, record review, and staff interviews, the facility failed to secure an opened bottle of antacid for 1 of 1 Resident (Resident #90) and failed to store 3 unopened eye drops at the proper temperature per manufacturer's instructions for 1 of 4 medication cart (100 halls medication cart) review for medication storage. The findings included: a. Resident #90 was admitted to the facility on [DATE]. A review of Resident #90's medication records revealed he had never been assessed nor approved for self-administration of medication since admission. A review of the physician's orders revealed Resident #90 did not have an order to receive liquid Pepto Bismol (an over-the-counter medication primarily used to relieve upset stomach symptoms such as nausea, heartburn, indigestion, and diarrhea). The significant change in status Minimum Data Set (MDS) dated [DATE] coded Resident #90 with moderately impaired cognition During a medication storage observation conducted on 04/21/25 at 11:33 AM, an opened bottle of liquid Pepto Bismol containing approximately 7 fluid ounces was seen left unattended on top of Resident #90's bedside table and ready to be used. An interview was conducted with Resident #90 on 04/21/25 at 11:35 AM. He stated his wife brought the Pepto Bismol for him about 3 days ago and left it in his room. He denied he had used this medication so far. He was unsure whether any staff were aware of this medication when providing care but so far none of them had said anything. During an interview conducted on 04/21/25 at 11:42 AM, Nurse #1 stated when she did medication pass for Resident #90 in the morning of 04/21/25, she did not notice the bottle of liquid Pepto Bismol left unattended in his room. She acknowledged that none of the medications should be left unattended in the resident's room. An interview was conducted with Nurse Aide #1 (NA) on 04/21/25 at 12:14 PM. She stated that she provided care for Resident #90 in the morning of 04/21/25, but she did not notice he had an opened bottle of Pepto Bismol left unattended in his room. Otherwise, she would report the incident to the nurse. b. Review of the manufacturer's package insert for Latanoprost eye drops revealed an unopened bottle should be stored under refrigeration between 36 to 46 Fahrenheit (F) and protected from light. Once opened, Latanoprost may be stored at room temperature up to 77 F for up to six weeks. During a medication storage audit conducted on 04/22/25 at 2:21 PM for the 100 hall medication cart in the presence of Nurse #2, three unopened bottles of Latanoprost 0.005% eye drop (medication used to treat glaucoma) were found in the medication cart at room temperature and ready to be used. Each bottle had a hand-written opening date of 04/20/25 but the plastic seal for all three bottles remained intact. An interview was conducted with Nurse #2 on 04/22/25 at 2:25 PM. She confirmed all three bottles of Latanoprost eye drops in 100 hall medication cart were unopened. She explained she had been off for the last 2 days and did not know who had placed the Latanoprost eye drops in the medication cart. She acknowledged that unopened Latanoprost eye drops should be stored in the refrigerator until they were ready to be used. During an interview conducted on 04/22/25 at 2:48 PM, the Director of Nursing (DON) expected all the nursing staff to be more attentive to resident's living environment to ensure the facility free of unattended medications. It was her expectation for all the nursing staff to store the medications according to the manufacturer's guidelines. An interview was conducted with the Administrator on 04/23/25 at 5:10 PM. He expected all the nursing staff to follow manufacturer's guidelines in medication storage and keep the facility free of unattended medications.

Based on record review and staff interviews, the facility failed to maintain accuracy and consistency of advance directive throughout the medical record for 1 of 1 resident (Resident #62) reviewed for advance directives. The findings included: Resident #62 was admitted to the facility on [DATE]. A review of Resident #62's care plan initiated on [DATE] indicated his advance directive was a full code. Interventions included receiving cardiopulmonary resuscitation (CPR) through the next review period. A review of Resident #62's electronic health records (EHR) indicated a physician's order dated [DATE] for Do Not Resuscitate (DNR). A review of the advance directive binder at the nurses' station dated [DATE] indicated Resident #62 was coded as DNR. During an interview conducted on [DATE] at 1:00 PM, Nurse #3, who was assigned to Resident #62, stated when a code was called, she would check the advanced directive in the EHR or the hard chart in the nurses' station to confirm whether the resident was a full code or a DNR. After reviewing Resident #62's care plan, Nurse #3 stated it could cause confusion as the care plan was inconsistent with the current code status. She acknowledged that the care plan for Resident #62 should be updated in a timely manner. An interview was conducted with MDS Coordinator #1 on [DATE] at 1:15 PM. She stated she was responsible for updating the code status for the care plan whenever it was changed. She explained she audited all residents' advanced directives routinely to ensure consistency with the care plan and did not know why Resident #62's care plan was missed. She attributed the error as an oversight and acknowledged Resident #62's care plan needed to be updated in a timely manner to avoid confusion. During an interview conducted on [DATE] at 1:29 PM, the Director of Nursing stated nursing staff would mainly check the code status in EHR instead of the care plan when a code was called. It was her expectation for the MDS Coordinator to update the care plan for advance directives in a timely manner whenever a change had been made. An interview was conducted with the Administrator on [DATE] at 5:10 PM. He expected the MDS coordinator to update the care plan in a timely manner when the code status had been changed to avoid confusion.

Based on observation, record review and staff interview, the facility failed to implement Transmission-Based Precautions (TBP) when two Nurse Aides provided incontinence care for Resident #55 and did not wear a gown for 2 of 5 staff members observed for infection control practices (Nurse Aide #3, Nurse Aide #4). The findings included: Review of the facility's policy for Transmission- Based Precautions (TBP) dated 10/27/20 revealed the TBP will be implemented for the prevention of transmission of multidrug-resistant organisms. Three categories of precautions were listed on the policy including Contact Precautions, Droplet Precautions and Airborne Precautions. Contact precautions included the following: 1. Personal Protective Equipment (PPE) a. Staff and visitors will wear gloves when entering the room for all interactions that may involve contact with the resident and/or the residents' environment. b. Staff and visitors will remove gloves and perform hand hygiene prior to leaving the resident's room. c. Staff and visitors will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves were removed. d. Staff and visitors will wear a gown when entering the room for all interactions that may involve contact with the resident and/or the residents' environment. e. Staff and visitors will remove the gown and perform hand hygiene prior to leaving the resident's room. f. Staff and visitors will avoid touching potentially contaminated surfaces with clothing after the gown is removed. A physician order dated 04/22/25 for Resident #55 revealed an order for contact precautions due to Enterobacter cloacae complex (a group of closely related bacterial species known for causing various infections) in her urine. An observation was conducted on 04/23/25 at 3:00 PM of Resident #55's room. The observation revealed signage posted on Resident #55's door for Enhanced Barrier Precautions (EBP). A three-compartment container was observed on the outside of the resident's door with gown, gloves and mask in the compartments. An observation of incontinence care conducted on 04/23/25 at 3:36 PM revealed Enhanced Barrier Precaution (EBP) signage on Resident #55's door. Nurse Aide (NA) #3 and NA #4 entered Resident #55's room and provided incontinence care wearing only gloves for the duration of the task. NA #3 and NA #4 were observed changing Resident #55's bed sheet, incontinence brief and bottom sheet. The staff members had a wash basin and were observed washing Resident #55's peri area. An interview was conducted with NA #3 on 04/23/25 at 3:45 PM. During the interview she stated she was unaware Resident #55 was on Transmission Based Precautions (TBP). An interview was conducted with NA #4 on 04/24/25 at 9:16 AM. During the interview she stated she did not wear a gown while providing care for Resident #55 because she didn't know the resident was on TBP. On 04/23/25 at 4:04 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated she was also in charge of Infection Prevention in the facility. She stated there should have been signage on Resident #55's door indicating for staff to wear a gown and gloves while performing incontinence care. The interview revealed the physician order was placed into the electronic system by the Assistant Director of Nursing (ADON), and he should have placed a sign on the door at the time the order was put in. The DON stated the staff should have worn gown and gloves while providing care for Resident #55. On 04/24/25 at 12:00 PM an interview was conducted with the ADON. He stated there was already an Enhanced Barrier Precaution sign on Resident #55's door for her roommate so he thought he did not have to put another sign on the door. He stated he did not realize that staff wouldn't know Resident #55 was on contact precaution isolation. After realizing the issue, the ADON stated he should have put a contact precaution sign on Resident #55's door. On 04/24/25 at 12:32 PM an interview was conducted with the Administrator. During the interview she stated a contact precaution sign should have been on Resident #55's door if she had a physician order stating those precautions were required.

Based on record reviews and staff interviews, the facility failed to maintain an accurate and consistent electronic medication administration record (eMAR) for 1 of 1 resident review for documentation accuracy (Resident #152). The findings included: Resident #152 was admitted to the facility on [DATE] with diagnoses including opioid dependence. A review of physician order dated 04/17/25 revealed Resident #152 had an order to receive 1 tablet of oxycodone-acetaminophen (Percocet) 5/325 milligrams (mg) by mouth once every 4 hours as needed (PRN) for pain at his right hip. Review of the eMAR dated 04/21/25 revealed Resident #152 had received 1 tablet of Percocet 5/325 mg at 8:15 AM and 4:24 PM. On 04/22/25, the eMAR indicated Resident #152 had received 1 tablet of Percocet 5/325 mg at 7:45 AM and 2:25 PM. Review of the nurse's progress notes dated 04/21/25 and 04/22/25 revealed none of the nursing staff had documented any notes related to Resident #152's need for PRN Percocet. Review of the controlled substance declining sheet indicated Resident #152 had received 1 tablet of Percocet 5/325 mg 3 times respectively on 04/21/25 at 8:00 AM, 4:15 PM, and 10:00 PM. On 04/22/25, the controlled substance declining sheet revealed Resident #152 had received 1 tablet of Percocet 5/325 mg 3 times respectively at 7:45 AM, 2:25 PM, and 10:00 PM. The Percocet signed out for Resident #152 on 04/21/25 at 10:00 PM and 04/22/25 at 10:00 PM by Nurse #4 were not charted in the eMAR. An interview was conducted with Resident #152 on 04/23/25 at 12:59 PM. He confirmed he had received his PRN Percocet on 04/21/25 and 04/22/25 around 10 PM and stated the medication was administered by Nurse #4. During a phone interview conducted on 04/24/25 at 9:50 AM, Nurse #4 stated he worked second shift on 04/21/25 and 4/22/25. He recalled Resident #152 had asked for his PRN Percocet and confirmed he had administered the pain medication to Resident #152 around 10 PM both night. Typically, he would sign out narcotic in the controlled substance declining sheet first. After it was administered, he would chart it in the eMAR. He was surprised to learn that he did not chart both entries in the eMAR and attributed it to distractions. He acknowledged that all medication administration that involved controlled substance should be documented in the controlled substance declining sheet and eMAR. During an interview conducted with the Director of Nursing on 04/23/25 at 1:28 AM, she acknowledged that Resident #152's Percocet that were administered by Nurse #4 should be charted in the controlled substance declining sheet and eMAR as well. It was her expectation for all the controlled substances to be accounted for and documented accurately in a timely manner. An interview was conducted with the Administrator on 04/23/25 at 5:10 PM. He expected nursing staff to document all the controlled substances accurately and consistently in the controlled substances declining sheet and eMAR.

Based on observation and staff interviews, the facility failed to cover facial hair during food service for 1 of 4 dietary staff observed (Dietary Manager #1). This deficient practice had the potential to affect food served to residents. The findings included: During a follow up tour of the kitchen on 4/22/2025 at 7:30 AM, Dietary Manager #1 was observed in the kitchen area with a short, neatly trimmed beard with no facial hair covering. As the tray line for breakfast began, Dietary Manager #1 was observed at the steam table and began to assist with plating food. This surveyor called Dietary Manager #1 away from the steam table and asked if he used facial hair covering. He immediately obtained one and put it on. He stated he usually wore a facial hair covering. Dietary Manager #1 stated he was from a different facility, had come to pick up chemicals from the kitchen and had not planned to stay at the facility. He reported he had spoken to the Culinary Director by telephone, and she had requested he stay until she arrived at work. An interview on 4/24/2025 at 10:45 AM with the Culinary Director revealed that facial hair coverings were always required in the kitchen for staff with facial hair. She did not know why Dietary Manager #1 was not wearing a facial hair covering. An interview on 4/24/2025 at 11:45 AM with the Administrator indicated Dietary Manager #1 should have used a facial hair covering while in the kitchen.

Based on observations, record reviews, resident and staff interviews, the facility failed to provide podiatry care for 1 of 7 residents (Resident #57) reviewed for activities of daily living. The findings included: Resident #57 was admitted to the facility on [DATE] with diagnoses which included type II diabetes mellitus, lymphedema, and peripheral vascular disease. Resident #57's care plan had a focus area for diabetes mellitus, type II dated last revised on 9/19/24 and revealed an intervention for a referral to podiatrist and/or foot care nurse to monitor and document foot care needs and to cut long nails. Resident #57's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required substantial to maximal assistance with personal hygiene. There were no behaviors, and no rejection of care noted on the MDS. An observation of Resident #57 on 4/21/25 at 10:45 AM revealed Resident #57 was in her bed without a sheet or cover over her feet. Her toenails were jagged and pointed and the length varied with some nails around .5 to one inch in length on both feet. An interview with Resident #57 on 4/21/25 at 10:45 AM was conducted. She explained she was required to see the podiatrist due to her diabetes diagnosis and she was supposed to be seen by the podiatrist as her toenails were very long and painful. She indicated she had to keep her feet uncovered in bed as the pressure from the bed sheet made her toenails painful. Resident #57 explained she asked the nursing staff about seeing the podiatrist due to her long toenails and was told that she missed the podiatry clinic in March 2025 because she was in the hospital. Resident #57 indicated she was on the list for the next podiatry clinic, but did not know when that was supposed to occur. She could not recall which nursing staff member she discussed her toenails with. A review of the podiatry schedule was conducted. It revealed Resident #57 was seen on 5/15/24 and 11/13/24. The next podiatry clinic was to be held on 6/9/25 and 6/10/25. Resident #57 was on the list for the 6/9/25 podiatry clinic. Resident #57 was not seen by the podiatry clinic on 3/17/25 or 3/18/25 due to hospitalization . An interview on 4/23/25 at 1:49 PM with Nurse Aide #1 revealed she worked with Resident #57 earlier that morning. She stated Resident #57 reported to her that her toenails were very long and had been painful. Nurse Aide #1 stated she did not typically work with Resident #57 but reported her concerns regarding her painful toenails to Nurse #2. An interview with Nurse #2 was conducted on 4/23/25 at 1:55 PM. She stated she had been at the facility for about a year and a half. She explained Resident #57 was very alert and would communicate her needs to staff. Nurse #2 stated Resident #57 asked her on 4/22/25 when the podiatrist was coming to the facility, and she told her the schedule. She stated she was not made aware her toenails were painful and had not seen how long her toenails were. An interview with the Director of Nursing (DON) on 4/24/25 at 10:43 AM revealed Resident #57 was on the list for the podiatry clinic in June 2025. She stated she was not aware Resident #57 had indicated her nails were painful after she missed the March 2025 podiatry clinic due to hospitalization . The DON explained Resident #57 could be seen by an outside provider before the next onsite podiatry clinic and she would speak to her about that option. An interview with the Administrator on 4/24/25 at 12:34 PM was conducted. He expected Resident #57 to receive the podiatry care she needed whether onsite or at another provider.

Based on observation, record review, and interviews with resident and staff, the facility failed to ensure dependent residents could access the light switch located behind the bed for 1 of 1 residents reviewed for accommodation of needs (Resident #157). The findings included: Resident #157 was admitted to the facility on [DATE]. Review of Resident #157's medical records revealed she had resided in the current room since 04/09/25. The admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #157 with severely impaired cognition. The MDS indicated walking between locations inside the room for more than 10 feet was not attempted by Resident #157 during the assessment period due to medical condition or safety concerns. During an observation conducted on 04/21/25 at 11:19 AM, the switch for the light fixture that was located behind Resident #157's bed on the wall approximately 5 feet from the floor and 6 feet from the bed and was attached with a broken cord approximately 3 inches in length. Resident #157 was unable to reach the switch cord from the bed if needed. An interview was conducted with Resident #157 on 04/21/25 at 11:20 AM. She stated she had a stroke recently and was bedbound. She could not recall when the switch cord was broken. She stated she did not have any control of the light fixture behind her bed as she could not stand up to reach the broken switch cord on the wall. She had to rely on nursing staff to control the light fixture and she was tired of asking for help repeatedly. She wanted the maintenance staff to fix the switch cord to accommodate her needs as soon as possible. During a joint observation conducted with the Maintenance Director and Nurse #1 on 04/21/25 at 12:50 PM, the switch cord for the light fixture behind Resident #157's bed remained inaccessible from her bed. Nurse #1 and the Maintenance Director acknowledged that the switch cord needed to be fixed immediately. An interview was conducted with the Maintenance Director on 04/21/25 at 12:54 PM. He stated he walked through the entire facility at least once per week to check for repair needs. He did not notice the switch cord for Resident #157's light fixture behind her bed was broken during his recent weekly walk through. In most cases, he depended on the staff to report repair needs via work orders electronically or verbal notifications. He checked the work order at least twice daily to ensure all repair needs were addressed in a timely manner. He could not explain why he missed the switch cord for Resident #157 and acknowledged that it had to be fixed immediately. During an interview conducted with Nurse #1 on 04/21/25 at 1:00 PM, she stated she provided care for Resident #157 in the morning, but she did not notice that her switch cord for the light fixture behind the bed was broken and inaccessible. She acknowledged that the broken switch cord needed to be fixed immediately to ensure Resident #157 had full control and accessibility to the light fixture behind the bed all the times. An interview was conducted with the Director of Nursing on 04/22/25 at 1:29 PM. She stated she expected the staff to be more attentive to residents' living environment, and to report repair needs to the maintenance department in a timely manner to accommodate residents' needs. It was her expectation for all the dependent residents to have full accessibility and control of the light fixture behind the bed all the times. During an interview conducted on 04/2325 at 5:10 PM with the Administrator, he expected nursing staff to pay attention to residents' homes and reported repair needs to the maintenance department in a timely manner.

Based on record review, resident and staff interviews, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for 1 of 1 resident reviewed for safe, clean, comfortable, homelike environment (Resident #71). The findings included: Resident #71 was admitted to the facility on [DATE] with diagnoses which included history of a right above the knee amputation (R AKA) and neoplasm of the brain. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #71 was cognitively intact. An interview with Resident #71 on 4/22/2025 at 10:43 AM revealed he was sent to the hospital from the facility on 1/21/2025. When he returned to the facility on [DATE], he found out his belongings had been packed up and removed from his room during his hospital stay. Resident #71 recalled the housekeeping manager brought 2 boxes to his room on 2/6/2025. The boxes were sealed with tape. After unpacking the boxes that evening, Resident #71 stated his Apple iPad Pro, a new bag of white sleeveless t-shirts, a few pairs of pants and his right leg prosthesis were not in either of the 2 boxes. Resident #71 stated it was concerning that his property was gone. Resident #71 indicated he was mostly upset about the loss of the iPad Pro. He stated he no longer used the right leg prothesis and the clothes were already replaced. Resident #71 stated that if the belongings had been packed up by the facility, then the facility should have returned the same items to him. Resident #71 reported the missing items to nursing staff on 2/6/2025 as soon as he realized the items were not in the boxes. He stated he spoke directly to the previous Administrator on 2/11/2025 to follow up on the missing items. Resident #71 filed a grievance with the facility on 3/26/2025 regarding the missing iPad Pro. Resident #71 stated the facility had recently placed a lock on his closet door. A review of the facility grievance report dated 3/26/2025 revealed that Social Worker #1 had met with Resident #71 to discuss the grievance regarding his lost property. Social Worker #1 documented that Resident #71 was unaware of the location of the iPad Pro and unsure when it was exactly misplaced. Social Worker #1 reminded Resident #71 that the matter regarding the iPad Pro had been previously discussed. Social Worker #1 re-educated Resident #71 regarding having pricey items in the facility. Social Worker #1 documented the grievance resolved on 3/28/2025. An interview on 4/22/2025 at 3:35 PM with NA #2 revealed she cared for Resident #71 routinely. She stated she had never seen Resident #71 with an iPad Pro and had signed statement regarding this for the previous Administrator. She stated she could obtain an empty iPad Pro box like the one Resident #71 had in his room. She reported she had never seen a right leg prothesis. NA #2 stated she was working the day Resident #71 was transferred to the hospital and she requested his family take his personal items with them. NA #2 stated housekeeping is responsible for packing up resident belongings. An interview on 4/22/2025 at 3:40 PM with Unit Manager B/Assistant Director of Nursing (ADON) revealed he knew Resident #71 very well. Resident #71 told him about the items missing from the 2 boxes. He did not know what had happened to Resident #71's property. An interview on 4/22/2025 at 3:51 PM with the Housekeeping Manager revealed he had packed up Resident #71's belongings on 2/6/2025 at approximately 2:00 PM. He stated he remembered this clearly because he had just taken the 2 boxes to his office when he received a text that Resident #71 was returning later that afternoon. The 2 boxes were never taken to the main storage area. The Housekeeping manager stated he packed Resident #71's clothes, a tablet, and a prosthetic leg. He stated he used very strong biohazard tape to seal the boxes and there is no way anyone could have tampered with the boxes. He stated he took the 2 boxes back to the room around 5:00 PM and asked Resident #71 if he would like him to unpack for him. He stated Resident #71 had family/visitors in the room and stated he would unpack himself. He stated he spoke with Resident #71 later regarding the missing items but did not know what had happened as the 2 boxes were sealed when he returned them. An interview on 4/22/2025 at 4:05 PM with Social Worker #1 revealed she assisted Resident #71 in filing a grievance with the facility regarding the missing property. She stated the matter had been handled by the previous Administrator. An interview on 4/23/2025 at 10:37 AM with the Administrator revealed that when residents go to the hospital, they should either take their valuables with them or leave them with the social worker. The Administrator stated he had been working at the facility 3 weeks and spoke with Resident #71 on his second working day regarding the missing items. The Administrator stated Resident #71 told him he may have lost the iPad between the hospital and the facility. The Administrator stated he felt the situation is resolved as Resident #71 lost the item and there was nothing the facility could do about it.

Based on staff interview and record review, the facility failed to electronically submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for quarter 1 of fiscal year (FY) 2023 (October - December 2023). The failure occurred for 1 of 5 quarters reviewed. The findings included: A review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database revealed the facility failed to submit the required PBJ Staffing Data for the first quarter of FY 2023. The Director of Nursing stated in an interview on 1/11/24 at 1:34 PM, that she was aware of the PBJ staffing reporting error due to lack of reporting to CMS but deferred to the Administrator as to why this error occurred. The Administrator stated in an interview on 1/11/24 at 1:51 PM that he was aware that the facility failed to electronically submit PBJ staffing data to CMS in the first quarter of FY 2023. The Administrator stated that the corporate office was responsible for submitting the PBJ staffing data for all the facilities in the corporation. He stated that during the first quarter of FY 2023, the corporation did not have a human resources department, so payroll tasks were outsourced to a 3rd party vendor at the time. The Administrator stated that the 3rd party vendor did not identify the facility as a focus for staffing data concerns, because the facility did not utilize agency staff and had more than sufficient staffing, and so he stated, somehow we fell off the map which he said caused the PBJ reporting error.

Based on interviews with staff and record review, the facility administration failed to provide effective leadership and oversight when the facility failed to enact their emergency operations plan to notify law enforcement of a missing resident. Resident #86 left the facility for a planned leave of absence but did not return to the facility as planned and did not communicate to the facility the Resident's whereabouts for 12 days. This failure occurred for 1 of 1 sampled residents reviewed. The findings included: This tag is crossed referred to: E OOO6: Plan based on all hazards risk assessment - Based on interviews with staff and record review, the facility failed to notify law enforcement per their emergency operations plan when Resident #86 left the facility for a planned leave of absence (LOA) but failed to communicate or return to the facility as planned. This failure occurred for 1 of 1 sampled resident reviewed for a LOA. An interview with the Administrator and Director of Nursing (DON) occurred on 1/10/24 at 03:03 PM. The DON stated that Resident #86 went on a planned LOA to attend a family funeral but did not return on 10/17/23 when expected. The DON stated two days after Resident #86 was supposed to have returned, the managers discussed Resident #86 during a meeting on 10/19/23. The facility reached out to her on 10/19/23, 10/20/23 and 10/22/23, but did not get an answer. The DON stated that the social services director spoke to the family on 10/24/23, but they did not know where she was. The Administrator stated that when Resident #86 called back on 10/30/23, he spoke to her, and Resident #86 said she was not going to return. The Administrator stated that the facility did not call 911 or consider her missing because the family said they thought she might be with some of her friends. The Medical Director was interviewed by phone on 1/11/24 at 9:56 AM. He stated that the facility made attempts to contact the Resident and her family while Resident #86 was on a LOA. However, in this case Resident #86 she was her own responsible party with intact cognition, so he was not sure that calling law enforcement would have made a difference. He further stated that the facility should have notified law enforcement per their emergency operations plan, but that he would need to review this plan for possible revision on how to handle such situations in the future.

Based on record review and staff interviews, the facility failed to ensure that the medical records contained dental visit notes for 1 of 4 residents reviewed for dental care (Resident #1). The findings included: 1. Resident #1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] assessed Resident #1 to be cognitively intact. Electronic medical records were reviewed. No dental visit notes were scanned into the system. The facility did not have hard copy records. The Social Worker (SW) was interviewed on 1/10/2024 at 12:23 PM. The SW reported she made appointments for routine and emergency dental services for the residents. When asked to provide dental visit notes for Resident #1, the SW reported she had to call the dentist office and they would email the visit notes to her. The SW provided a dental visit note dated 10/3/2022 for Resident #1 on 1/10/2024 and explained that she was not aware dental visit notes should be part of the electronic medical record. The Administrator was interviewed 1/11/2024 at 3:45 PM. The Administrator reported the dental records should have been sent to the facility after the visit to be manually uploaded into the system. The Administrator explained he was not certain why the dental records were not in the electronic medical record.

Based on observations, staff interviews and record review, the facility failed to post a Daily Staffing Record with the current facility name for 4 days of the survey (1/8/24 - 1/11/24) and failed to document the current facility name and accurate staffing data for 14 of 14 days of nurse staffing data reviewed. The findings included: 1a. An observation at 10:15 AM on 1/8/24 and at 8:45 AM on 1/9/24 through 1/11/24 of the posted Daily Staffing Record, revealed the name of the facility prior to the change in ownership was recorded. 1b. A review of 14 Daily Staffing Records (10/6/23, 10/14/23, 10/17/23, 10/23/23, 11/8/23, 11/14/23, 11/24/23, 11/27/23, 12/1/23, 12/7/23, 12/13/23, 12/22/23, 1/2/24 and 1/5/24) revealed the name of the facility prior to the change in ownership was recorded. 1c. A review of the Daily Staffing Records revealed licensed and unlicensed nursing staff was not recorded accurately for 14 days: - 10/6/23, the Daily Staffing Record documented 5 registered nurses (RN) provided 36 hours of nursing care, 7 licensed practical nurses (LPN) provided 60 hours of nursing care, and 23 nurse aides (NA) provided 172 hours of nursing care. The staff assignment sheet recorded 4 RN, 5 LPN and 21 NA. - 10/14/23, the Daily Staffing Record documented 5 RN provided 36 hours of nursing care, 7 LPN provided 48 hours of nursing care, and 31 NA provided 172.5 hours of nursing care. The staff assignment sheet recorded 3 RN, 4 LPN and 24 NA. - 10/17/23, the Daily Staffing Record documented 6 RN provided 48 hours of nursing care, 11 LPN provided 68 hours of nursing care, and 22 NA provided 165 hours of nursing care. The staff assignment sheet recorded 5 RN, 6 LPN and 24 NA. - 10/23/23, the Daily Staffing Record documented 4 RN provided 36 hours of nursing care, 9 LPN provided 64 hours of nursing care, and 23 NA provided 172.5 hours of nursing care. The staff assignment sheet recorded 3 RN, 5 LPN and 24 NA. - 11/8/23, the Daily Staffing Record documented 3 RN provided 24 hours of nursing care, 10 LPN provided 76 hours of nursing care, and 23 NA provided 172.5 hours of nursing care. The staff assignment sheet recorded 4 RN, 5 LPN and 24 NA. - 11/14/23, the Daily Staffing Record documented 6 RN provided 48 hours of nursing care, 11 LPN provided 76 hours of nursing care, and 21 NA provided 157.5 hours of nursing care. The staff assignment sheet recorded 4 RN, 6 LPN and 22 NA. - 11/24/23, the Daily Staffing Record documented 10 RN provided 72 hours of nursing care, 4 LPN provided 48 hours of nursing care, and 21 NA provided 157.5 hours of nursing care. The staff assignment sheet recorded 6 RN, 3 LPN and 22 NA. - 11/27/23, the Daily Staffing Record documented 10 LPN provided 72 hours of nursing care, and 22 NA provided 165 hours of nursing care. The staff assignment sheet recorded 6 LPN and 23 NA. - 12/1/23, the Daily Staffing Record documented 10 LPN provided 72 hours of nursing care, and 21 NA provided 157.5 hours of nursing care. The staff assignment sheet recorded 5 LPN, and 24 NA. - 12/13/23, the Daily Staffing Record documented 3 RN provided 24 hours of nursing care, 10 LPN provided 72 hours of nursing care, and 19 NA provided 157.5 hours of nursing care. The staff assignment sheet recorded 2 RN, 6 LPN and 20 NA. - 12/22/23, the Daily Staffing Record documented 7 RN provided 48 hours of nursing care, 7 LPN provided 60 hours of nursing care, and 20 NA provided 153 hours of nursing care. The staff assignment sheet recorded 4 RN, 5 LPN and 21 NA. - 1/2/24, the Daily Staffing Record documented 3 RN provided 24 hours of nursing care, 15 LPN provided 88 hours of nursing care, and 19 NA provided 142.5 hours of nursing care. The staff assignment sheet recorded 2 RN, 7 LPN and 21 NA. - 1/5/24, the Daily Staffing Record documented 2 RN provided 12 hours of nursing care, 12 LPN provided 96 hours of nursing care, and 21 NA provided 157.5 hours of nursing care. The staff assignment sheet recorded 1 RN, 8 LPN, 20 NA, and 3 Med Techs. The Staffing Coordinator was interviewed on 1/11/24 at 1:09 PM. She stated that she was responsible for completing the staff assignment sheets and completing updates to these records when the staffing pattern changed. The Staffing Coordinator stated that there were some staff that she did not include on the staff assignment sheets like the Assistant Director of Nursing (ADON), a RN, unless he was assigned a medication cart or herself because she was also the facility's Wound Nurse. She stated that the Director of Nursing (DON) was responsible for completing and posting the Daily Staffing Record. The DON stated in an interview on 1/11/24 at 1:34 PM that the facility changed ownership in March of 2023. She stated that since the change the facility has transitioned to a new staffing data system and that she was in the process of changing the report system used for the Daily Staffing Record. The DON stated that the Daily Staffing Record did not always include the ADON or the Wound Nurse since their responsibilities also included tasks which were not direct patient care. The DON stated that most of the time there were more staff in the facility than the posted Daily Staffing Record documented. She stated that she recorded on the Daily Staffing Record the staff she was expecting at the beginning of each shift, but at times staff showed up for work who were not scheduled and when she was aware this occurred, she updated the Daily Staffing Record to reflect the additional staff.

Based on observations and staff interviews, the facility failed to discard expired milk and food items (2% milk, boiled eggs, relish, and mustard), produce with signs of spoilage (small to medium tomatoes, lettuce, and onions) and unlabeled and undated food items (peanut butter and jelly sandwiches and turkey and cheese sandwiches) in 1 of 1 walk in refrigerators. Additionally, the facility failed to label and date drink items in 2 of 2 nourishment room refrigerators (A unit and B unit). This practice had the potential to affect the food served to the residents. The findings included: An initial tour of the kitchen was made on [DATE] at 10:30 AM with the Dietary Manager (DM). The following problems were observed with food stored in one of the kitchen's walk-in refrigerators: · 31 individual cartons of 2% milk in a blue crate with an expiration date of [DATE] · 5 ½ water sealed packs of 12 count boiled eggs with an expiration date of [DATE] · 1 used container of relish with an expiration date of [DATE] · 1 used container of mustard with an expiration date of [DATE] · ½ case of small to medium red tomatoes with white, fuzzy matter · 3 of 5 heads of lettuce with white, fuzzy matter · 6 of 11 mushy, white onions in a bag with white, fuzzy matter · 8 peanut butter and jelly sandwiches in a clear plastic wrap with no label or date · 5 turkey and cheese sandwiches in a clear plastic wrap with no label or date The DM was observed to remove these items from the walk-in refrigerator. An interview with the DM on [DATE] at 10:24 AM revealed that she was responsible for checking expiration dates, checking for spoilage, and labeling and dating items in the walk-in refrigerator. She explained she last checked the walk-in refrigerator on Friday ([DATE]). She stated that she completed these tasks daily and was running behind because of a call out. The DM was not certain why there were items that were expired, not labeled, and dated properly, and produce that showed signs of spoilage remained in the walk-in refrigerator. An interview with the Administrator on [DATE] at 10:50 AM explained that staff should use their knowledge and skill set to do the best job. He stated that the DM and dietary aides knew to check for expirations and to label and date items stored in the walk-in refrigerator daily. An observation of the Unit A (100 and 200 hall) nourishment room was completed on [DATE] at 3:03 PM revealed the following: · 1 unlabeled and undated plastic bottle with clear liquid observed in the freezer · 1 unlabeled and undated plastic bottle with brown liquid observed in the freezer An interview with the Nurse Aide #1 (NA) on [DATE] at 3:05 PM revealed that items should have a label, date, and resident's name. NA #1 was observed to remove items from the nourishment room. An interview with the Director of Nursing (DON) on [DATE] at 3:18 PM revealed that the DM and staff monitored the nourishment room. She stated that staff should not have items in the nourishment room and the nourishment room was for resident use only. An observation of the Unit B (300 and 400 hall) nourishment room was completed on [DATE] at 3:12 PM revealed the following: · 3 unlabeled and undated energy drink cans in a black plastic bag observed in the freezer An interview with the DON on [DATE] at 3:25 PM revealed that the DM checked the nourishment room daily and resident food should have a name, label, and a date on items. She stated that staff should not have items in the nourishment room.

Based on observations, an interview with the legal guardian, the physician, interviews with staff, and record review, the facility failed to implement elopement interventions to prevent Resident #2's unauthorized and unsupervised exit from the facility. Resident #2, with an appointed Department of Social Services (DSS) guardian of the person, assessed at risk for elopement and a diagnosis of Alzheimer's disease, exited the facility on 3/21/21 after 8:35 PM in her wheelchair with a wander guard management bracelet (WG) on her wheelchair that did not sound to alert staff and the facility exit door automatic lock system did not engage to prevent egress. Resident #2 propelled herself approximately 0.3 miles, to the pharmacy and was returned to the facility assisted by police at approximately 9:45 PM. This occurred for 1 of 2 sampled residents with an appointed DSS guardian reviewed for supervision to prevent accidents. The findings included: Resident #2 admitted to the facility 9/12/19 Diagnoses included Alzheimer's disease and paranoid [CONDITION(S)] disorder, among others. Resident #2's medical record documented a DSS guardian of the person as the legal guardian, and emergency contact. A [NAME] County (MC) Guardianship Policies Memo of Understanding, signed 9/20/19, recorded, in part, that MC DSS was appointed guardian of the person for Resident #2. The Clerk of Court gave MC DSS guardianship responsibilities and by law, MC DSS was required to make all decisions regarding the care and maintenance of Resident #2, which included a leave from the facility. Review of the medical record for Resident #2 revealed a nursing progress note dated 8/20/20 at 6:20 PM which recorded that Resident #2 was noted by the Unit Manager #1 (UM #1) with exit seeking behavior and verbalized a desire to leave the facility. A significant change Wandering Risk assessment dated [DATE] assessed Resident #2 at risk of elopement due to exit seeking behavior and verbally stating a desire to leave the facility. Resident #2's medical record documented a physician order dated 8/20/20 to place a WG to the back of her wheelchair, check for placement and function each shift, and change as needed. A nursing progress note dated 12/26/20 at 01:15 AM documented Resident #2 verbalized to Nurse #1 a desire to go home. A quarterly Wandering Risk assessment dated [DATE] assessed Resident #2 at high risk of elopement, due to a history of wandering behavior in the past month. The assessment noted that a WG was in place for Resident #2. A care plan, updated 2/14/21, identified that due to Alzheimer s disease, impaired cognitive function, impaired thought processes, difficulty making decisions and an expressed desire to be out of the facility unattended, Resident #2 was at risk for elopement. Interventions included staff to cue, reorient and supervise as needed, Resident #2 to inform staff when going out of the facility and for staff to apply a WG as ordered/tolerated. A quarterly minimum data set (MDS) assessment dated [DATE], assessed Resident #2 with adequate hearing, adequate vision, clear speech, able to understand and be understood, intact cognition, no behaviors during the review period, and no functional limitations. Review of the March 2021 medication administration record (MAR) revealed, nurse's initials were recorded daily each shift to indicate that the placement and function of Resident #2's WG was verified. Further review of the March 2021 MAR for Resident #2 documented by the UM #1 that on 3/21/21 Resident #2's WG was checked for function and placement to the back of her wheelchair during the 3 PM - 11 PM shift. The time was not documented. Nurse #1 completed an incident report dated 3/21/21 at 8:30 PM, which recorded that she was unable to locate Resident #2 in her room. Staff stated Resident #2 reported she was going to the vending machine. Resident #2 was not observed at the vending machine. Nurse #1 alerted staff verbally and with an overhead page to look for Resident #2. Staff searched inside/outside facility, but Resident #2 was not located. During staff search, a police officer came to the facility and notified that Resident #2 was with a police officer at the pharmacy near the facility. Resident #2 was returned to the facility, assessed by Nurse #1 without injury or pain. Vital signs were assessed as blood pressure 126/85, temperature 98, pulse 96, respirations 20, and oxygen saturations 94% via nasal cannula. Resident #2's description of the events included a statement that she was waiting for UM #1 to stop her, but nobody stopped her so she went outside, could not get back into the facility, so she went to local pharmacy for them to call the facility. Resident #2 then stated, she felt like it was all a joke. A review of Weather.com, revealed the outside temperature the evening of 3/21/21 was 45 degrees Fahrenheit and weather was partly cloudy. A physician progress note dated 3/24/21 documented a comprehensive monthly follow up that Resident #2 was without signs of [CONDITION(S)], mood disturbance, emotional symptoms or psychiatric exacerbation at the time of the assessment, alert and oriented to person and place, and clinically stable on continuous oxygen at 4 liters per minute. The physician noted that Resident #2 recently left the facility unattended and was picked up at the local pharmacy after making a phone call to the facility and returned to the facility without issue. Resident #2 reported to the physician she left because she thought there was a party outside. A psychiatric mental health nurse practitioner progress note dated 3/25/21, documented Resident #2 was seen for medication management of [CONDITION(S)] medications. During the session, Resident #2 presented with paranoid delusions, irrational thinking, poor insight, and poor judgement. She expressed she was not happy living at the facility because she felt the facility did not meet her mental health (MH) needs. Resident #2 stated she wanted to be at a MH facility. As a result, Resident #2 stated that she purposely went outside of the facility and went to the local pharmacy so that any random person would pick her up and take her away from the facility. Resident #2 also expressed that she planned to ask the social worker at an upcoming surgical appointment to help her with placement at another facility. A re-admission Wandering Risk assessment dated [DATE] assessed Resident #2 at low risk for elopement, no WG was indicated, due to the Resident's non-weight bearing and non-ambulatory status. Resident #2 was observed on 4/7/21 at 9:55 AM in her room across from the nursing station with therapy staff providing services. On 4/7/21 at 11:30 AM, Resident #2 was observed in her room and interviewed. Resident #2 stated in interview that she remembered when she left the facility and went to the local pharmacy. The day it occurred, she stated she thought someone was outside her door and wanted to hurt her. She went to the door and no one was there, so she then went up the hall to find someone to tell, but she could not find anyone, so she went to the front door of the building and just left. Resident #2 stated there was no one in the lobby and that when she left the facility, she did not hear an alarm. She further stated that if an alarm had sounded, she would have remembered that. Resident #2 stated that she went through the parking lot, she thought someone would come and bring her back, but that didn't happen, so she kept going all the way to the pharmacy, where an employee called the police and she was brought back to the facility. Resident #2 stated she spoke to the Director of Nursing (DON) on the phone when she got back to the facility and told her that she was not trying to leave, but that she just could not get back in the building. She rang the doorbell at the facility, but no one answered, so she went to the pharmacy to call so that staff would let her back in. Resident #2 stated she did not get hurt, she was not bothered by anyone and she did not have any pain when she got back. Resident #2 stated she did not currently have a WG in place. An observation with the Maintenance Director and the Administrator occurred on 4/7/21 at 2:32 PM of the facility's lobby and WG system at the front door and entrance to the nursing unit. The Maintenance Director tested a WG device to the WG system at the front door and the door which led to the nursing units. The WG device alarm sounded at both the front door, at the door which led to the nursing unit and the alarm was also heard on each nursing unit. Additionally, the front exit door automatically locked. An observation on 4/8/21 at 945 AM of the route from the facility to the local pharmacy revealed a two-lane road through a residential community with sidewalks shaded by trees on both sides of the road. The sidewalks leading to the local pharmacy was inclined approximately 10 - 15 degrees. The pharmacy was located at the corner of a four lane intersection. Nurse Aide (NA) #1 was interviewed on 4/8/21 at 3:30 PM and stated she was assigned to care for Resident #2 on 3/21/21, 3 PM - 11 PM shift. NA #1 stated she saw Resident #2 in her room on 3/21/21 around 8:00 PM or 8:30 PM when she provided Resident #2 with ice water, her WG was attached to her wheel chair like always and then the Resident went up the hall to the vending machine. NA #1 said about 30 - 40 minutes went by, no one saw her so staff started searching inside and outside the facility. NA #1 further stated she did not hear any alarms or doorbells that night and when Resident #2 returned to the facility her WG was still attached to her wheelchair, but it did not alarm. An interview with Medication Aide (MA) #1 occurred on 4/8/21 at 3:45 PM and revealed that he medicated Resident #2 on 3/21/21 around 8:35 PM. He stated that a little after that Nurse #1 came to him and said she was looking for Resident #2 to check her blood sugar. MA #1 stated he informed Nurse #1 that Resident #2 went to the vending machine about 20 - 30 minutes earlier, so staff checked the Resident's room and bathroom, but did not locate her. Then staff searched inside and outside the facility and then the facility received a call that Resident #2 was at the local pharmacy, so someone brought her back. MA #1 stated when Resident #2 returned, her explanation of what happened did not make sense and that he did not recall what she said. MA #1 further said Resident #2 had not expressed a desire to leave the facility before nor had she previously left the facility unattended. Nurse #1 stated in interview on 4/7/21 at 2:19 PM that she was the nurse assigned to Resident #2 on 3/21/21, on the 3 PM - 11 PM shift. Nurse #1 stated she observed the WG to Resident #2's wheelchair between 7:30 PM - 8:00 PM that day when she conducted nursing rounds, but that she only checked placement of the WG and not function. She further stated she did not have the monitoring tool to check the WG for function, she did not know where the tool was located because no one had shown her. Nurse #1 stated that she noticed Resident #2 was not in her room on 3/21/21 around 9:00 PM, she asked staff and staff said Resident #2 was observed going up the hall towards the vending machine. Nurse #1 said she went to the vending machine, but Resident #2 was not there, so she returned to the unit, notified staff verbally and via the overhead call system to begin a search to locate Resident #2. She stated that staff searched both inside and outside the facility but could not locate Resident #2. During the search, MA #1 came to Nurse #1 and told her that a police officer came to the facility asking if staff knew Resident #2 and informed staff that Resident #2 was at the local pharmacy with another police officer. Nurse #1 stated she left the facility and was assisted by the police to bring Resident #2 back to the facility. When Resident #2 returned, she was wearing pants, a long-sleeved shirt, shoes, and socks. Nurse #1 further stated that she thought Resident #2 was also wearing a jacket, but that she was not certain. Nurse #1 stated when Resident #2 returned, her WG was on her wheelchair, but it did not alarm when the WG passed through the WG monitoring systems at the front entry of the building or at the entrance to the nursing units. Nurse #1 then said she conducted a head to toe skin assessment for Resident #2 and checked her vital signs, with no injuries noted, Resident #2 denied pain and her vital signs were normal. Nurse #1 said Resident #2 was monitored every 15 minutes for location until she discharged to the hospital on 3/29/21 for a planned surgical appointment. Nurse #1 said that she did not hear a WG alarm sound or a doorbell ring during her shift on 3/21/21. She further stated, I would have heard it (alarm), I don't know if it (WG) was functioning. Nurse #1 stated that during her assessment of Resident #2, the Resident reported that she left the facility because she thought someone would stop her before she got to the front door, but no one did, so she kept going. An interview with UM #1 occurred on 4/12/21 at 11:40 AM. UM #1 stated that she came to the facility on [DATE]. UM #1 stated that she did not usually work weekends, but that sometimes she came into the facility to assist and check on residents when the staffing pattern included a nurse and a MA. UM #1 said on 3/21/21 sometime after dinner, possibly around 6:30 PM, she came to the facility, conducted a nursing round, observed Resident #2 with a WG to her wheel chair, verified its function using the monitoring tool on the medication cart and signed the MAR. An interview on 4/8/21 at 9:30 AM was conducted with a sales associate (SA) of the local pharmacy. The SA stated that he was SA in the local pharmacy on 3/21/21 when a customer came inside around 9:00 PM and told him there was a lady (Resident #2) outside who wanted to speak to an employee. The SA stated he notified his supervisor and went outside and saw a lady (Resident #2) seated in a wheelchair. The SA stated the lady (Resident #2) was wearing pants, a shirt, shoes, and a jacket and that it was a little cold outside that night. He stated the lady (Resident #2) asked him to call the police. The SA further stated that the lady (Resident #2) did not appear to be injured or hurt, she was calm and appeared appropriately dressed, so he asked her to come inside the pharmacy and wait at the front of the store while he called the police. The SA stated he called the police and they arrived about 10 - 15 minutes later. He stated that when the police arrived, two officers came and spoke to her (Resident #2), but he could not hear the conversation. One police officer waited inside the pharmacy while the other police officer left and came back. When the police officer returned, he informed the lady (Resident #2) that staff at the nursing home (NH) down the street were looking for her because they didn't know where she was. The police officers told her (Resident #2) they were going to take her back to the NH and then they took her with them and left. A telephone interview with the receptionist occurred on 4/9/21 at 12:45 PM. During the interview, the receptionist stated that she worked Monday - Friday, 8:30 AM - 5:00 PM and at times a receptionist covered the evenings, however a receptionist did not work on Sunday evening 3/21/21. The receptionist stated part of her responsibilities included to monitor the lobby area. She stated that if a resident with a WG approached the front doors, the WG alarm sounded and the front door locked. The receptionist stated that Resident #2 had a WG and enjoyed sitting outside at the front entrance, so at times the Resident was assisted outside by staff. The receptionist would inform her nurse and the Resident was monitored by staff while she was outside. The receptionist also stated that about a year ago, Resident #2 was witnessed to propel outside in the parking lot, unattended, so after that, a WG was placed. The physician was interviewed by phone on 4/8/21 at 1:40 PM and stated that he spoke to Resident #2 on 3/24/21 which he documented in a progress note. Resident #2 described the incident on 3/21/21 to the physician by saying she thought there was a party down the street and she was missing out. Resident #2 stated she left the facility to find the party. The physician stated that once Resident #2 got out of the facility, he believed she got confused and went to the local pharmacy to get help. He described Resident #2 as having a history of [CONDITION(S)], mild [CONDITION(S)] with intermittent confusion and delusional behavior at times. The physician stated Resident #2 had a DSS guardian which was needed for her medical decisions due to her psychiatric state, but that Resident #2 did not need a one to one sitter; she did not need constant monitoring. The physician stated that in his opinion, Resident #2 just got confused but was not in danger, the incident did not pose a safety issue for her, she left the facility and returned all within a couple of hours and she was returned safely without incident or injury. An interview with the Maintenance Director occurred 4/7/21 at 2:11 PM. The Maintenance Director stated he began employment at the facility on 2/22/21 and worked Monday - Friday. He stated that since his employment, he conducted daily checks of the facility's WG system, Monday - Friday. He stated that he used a WG monitoring device to verify that the monitoring system did alarm and the front door automatically locked within a 10-foot radius of the WG antenna. He stated the WG alarm when sounded, could be heard throughout the facility. He further stated that he was not sure who checked the WG system on Saturday or Sunday. A follow up interview with the Maintenance Director occurred on 4/8/21 at 11:35 AM. During the interview he provided written guidance from the vendor service for the WG system. The guidance recorded that the alarmed doors typically had a maximum 8-foot radius from the WG antenna based on the adjustment and radio frequency interference of the WG device. The vendor service recorded that best practice for placement of the WG tags was to place the WG on the resident's wrist or ankle. The Maintenance Director described that in his experience, the WG system functioned best when the WG was placed on the resident rather than the wheelchair in case the resident got separated from the wheelchair, but that if the WG was placed on the wheelchair, it should still alarm if the WG was working. Review of documentation provided by the Maintenance Director during the interview revealed he last checked the WG system on Friday, 3/19/21 prior to the elopement of Resident #2. He stated that no concerns were identified. On 4/8/21 at 3:06 PM, the Administrator and DON were interviewed. The interview revealed that in the past, Resident #2 sat at the front of the facility with her bags for hours, but that she never said she was going to leave the facility, only that she wanted to be somewhere else, refused to wear a WG and had cut it off before. The Administrator and DON stated they received a phone call from staff to inform that Resident #2 left the facility and returned. The DON stated that she spoke to Resident #2 via phone on 3/21/21 after she returned to the facility and the Resident stated that she wasn't trying to go anywhere, she wasn't leaving, but rather going to the local pharmacy to call the facility to get back in. Resident #2 reported that she informed NA #1 that she wanted to go sit outside, so she let NA #1 know and went to the front of the facility, after about 10 minutes, Resident #2 stated she wanted to come back in, rang the bell but no one answered so she went down the street to the local pharmacy to call the facility to get back in. The Administrator stated he was not certain why Resident #2's WG did not sound and that he could not confirm that the WG function was checked on 3/21/21. He stated that a power surge could have affected her WG or Resident #2 could have manipulated it. He stated that when Resident #2 returned the WG did not sound at the front door, staff reported they did not hear an alarm during the shift, nor did staff hear a doorbell. The interview further revealed that the Administrator and DON spoke to Resident #2 in person the next day, 3/22/21 and she provided the same course of events as given during the phone interview on 3/21/21. The Administrator stated that in the facility's investigation, they could not corroborate that Resident #2 told a staff member that she was going to sit outside. The Administrator stated Resident #2 was safe to sit outside without staff supervision, but that if she wanted to leave the grounds, staff preferred that she inform staff so that staff could coordinate that with her DSS guardian. A phone interview with the DSS guardian occurred on 4/12/12 at 8:22 AM. She stated that she routinely received calls from Resident #2, it was difficult to get direct answers from her and keep her on task during a conversation. The DSS guardian stated she was aware that Resident #2 was assessed at risk for elopement and had a WG placed on her wheelchair because at one point she refused to wear the WG on her person due to complaints of discomfort. The DSS guardian further stated she was aware that Resident #2 had previously requested to move back home to a MH facility but that was not an appropriate placement for her due to her required skilled level needs. She described Resident #2 with behaviors that included chronic paranoia about the people around her, fixated on people, circumstances and had irrational perceptions. During the interview, the DSS guardian stated she received a phone call from Resident #2 on Monday, 3/22/21. During this call, Resident #2 asked if she had heard what happened over the weekend. Resident #2 went on to describe that she got into her wheelchair and rolled to the local pharmacy around 9:00 or 10:00 PM the night before. Resident #2 further stated that she thought someone was behind her and that she didn't realize she was going so far. She thought someone would stop her, but she got all the way to the pharmacy. Facility staff came and got her and brought her back. Resident #2 then apologized and said she would not leave the facility again. The DSS guardian stated that Resident #2 did not dwell on this incident and moved on to discuss her upcoming planned surgery. The DSS guardian stated that Resident #2 had been adjudicated incompetent and due to her personality disorder, sometimes her perception could not be substantiated, so the guardian stated she needed to verify her statement. The DSS guardian stated that Resident #2 denied being injured, confirmed that she was safe and currently back in the facility. The DSS guardian stated that she asked Resident #2 how she got out of the facility, but the Resident did not answer her directly. The DSS guardian stated she contacted the facility to verify this incident. The facility provided a corrective action plan with a completion date of 3/22/21 which included the following information: 1) Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. ·Skin assessment was immediately completed on resident #2 by the nurse to identify any injuries and no injuries were noted. (10:00 pm 3/21/2021) ·15 minutes safety checks-initiated for resident #2 and remain in place. (10:00 pm 3/21/2021) ·Maintenance Director checked all doors and WanderGuard system to ensure proper functioning. Systems were functioning properly. (7:00 am 3/22/2021) ·Supervisor made regular checks to the front of the building until Maintenance Director arrived to check the system the next morning. (10:00 pm 3/21/2021 - 7:00 am 3/22/2021) ·A new WanderGuard assessment was completed for all current residents with a WanderGuard bracelet by members of nursing team. (3/22/2021) ·Care plans reviewed for all residents with WanderGuard bracelets by MDS nurse. (3/22/2021) ·QAA Committee met on 3/22/2021 to develop and approve action plan related to this incident. 2) Address how the facility will identify other residents having the potential to be affected by the same deficient practice. ·All residents with WanderGuard bracelets have the potential to be affected. 3) Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. ·Staff nurses and medication aides were educated on proper placement of the WanderGuard bracelet and function of the WanderGuard system by DON and ADON. This education was completed on 3/22/2021 for facility employees. Any agency nurse is provided with education packet prior to beginning their first shift by a nursing supervisor on duty. This education was added to the new hire packet and new hires will be educated prior to beginning their first shift. ·The Maintenance Director or designee will complete daily WanderGuard and door systems checks to ensure ongoing proper function of the system. Any issues identified as needing corrective action will be addressed immediately and reported to the QAA Committee. ·Nursing will monitor residents with WanderGuard bracelets for placement and function every shift. ·DON will monitor MAR to validate WanderGuard placement and function five times a week for 1 month then weekly for 2 months. ·Administrator will monitor compliance with daily door checks weekly via TELS system. 4) Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. ·Administrator and DON will report results of on-going monitoring monthly to QAA Committee. The QAA Committee will assess the information to determine if compliance is being maintained and will make any changes or updates to the plan of correction as needed. On 4/20/21, the facility's corrective action plan, with a correction date of 3/22/21 was validated by the following, observations of wander guard placement and function to 100% residents in the facility identified at risk for elopement, interviews with family, legal guardian and staff, review of monitoring logs, documentation of wander guard placement and function and documentation of training.

Based on observations, record reviews, staff, Respiratory Therapist, former Medical Director, current Medical Director, and Pulmonologist interviews the facility's Administration failed to provide leadership and oversight to the facility staff to ensure that a physician ordered non-invasive mechanical ventilator was applied (Resident #1). The facility's Administration also failed to provide leadership and oversight to the facility staff to ensure that the respiratory needs of (Resident #9, #10, and #11) did not exceed the capabilities that the facility was equipped to handle. This affected 4 of 5 sampled residents (Resident #1, #9, #10, and #11). Immediate Jeopardy began on [DATE] when the facility Administration failed to provide oversight and management to ensure that physician ordered respiratory devices were applied. On [DATE] the staff failed to connect Resident #1 to his physician's orders [REDACTED]. The facility continued to provide non-invasive mechanical ventilation to Resident #9, #10 and #11 until they were discharged from the facility on [DATE]. The facility management was not aware that the non-invasive mechanical ventilators were being used in manner in which the facility staff was not equipped to handle effectively. Immediate jeopardy was removed on [DATE] at 2:20 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place were effective. The findings included: 1. This tag is cross referred to F695: Based on record review, staff, respiratory therapist, former Medical Director, current Medical Director, and Pulmonologist interviews, the facility failed to apply oxygen and a non-invasive mechanical ventilator as ordered by the physician for 1 of 3 residents sampled for respiratory services (Resident #1). When Resident #1 was found by staff without the physician ordered devices he was deceased . An interview was conducted with the Director of Clinical Services (DCS) on [DATE] at 12:47 PM. The DCS stated that she has worked with this facility since (MONTH) of (YEAR) and stated that no one had shared with her the specifics of the unit where Resident #1 resided or the equipment that was being used on that unit. An interview was conducted with the Vice President of Operations (VPO) on [DATE] at 12:16 PM. The VPO stated she had recently been reassigned to the facility in (MONTH) of (YEAR). She stated that the Administrator at the time had given her a tour of the facility but she had no knowledge of the devices that were being used on the unit. 2. Resident #9 readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #9 was mildly cognitively impaired and required extensive assistance of 2 staff members with activities of daily living. The MDS further indicated Resident #9 had no behaviors or rejection of care. The MDS indicated that Resident #9 required oxygen, suctioning, and had a [MEDICAL CONDITION]. No ventilator use was identified on the MDS. Review of Medication Administration Record [REDACTED]. The time indicated was 9:00 PM and the staff had initialed it indicating the device had been applied. There was no time indicating what time the device was removed. An interview was conducted with Respiratory Therapist (RT) #1 on [DATE] at 12:52 PM. RT #1 stated that the unit where Resident #9 resided was a specialty unit that accepted residents that had a [MEDICAL CONDITION] and required a ventilator 8 hours or less at night. RT #1 stated that Resident #9 required the non-invasive mechanical ventilator at night to manage her [MEDICAL CONDITION] and had been at the facility for well over a year or so. RT #1 stated that in (MONTH) of (YEAR) the facility had put a temporary hold on admitting residents with [MEDICAL CONDITION]'s that required the use of the non-invasive mechanical ventilator. Then around (MONTH) or (MONTH) of (YEAR) they stated that they could resume admissions of those resident that required the ventilators but as long as they were only required for 8 hours a day or less. RT #1 stated that if they required the non-invasive mechanical ventilator more than 8 hours a day then the resident could not admit to the facility or would have to be discharged to a traditional ventilator unit. He explained that if there was no RT on the unit at bedtime than the nurse on the unit would place Resident #9 on the non-invasive mechanical ventilator and then the RT that was on duty in the morning would generally take her off. The RT further explained that there was no way to track the exact time that Resident #9 was actually on the non-invasive mechanical ventilator. The rule was she usually would go on at bedtime and come off in the morning. Review of Resident #9's ventilator log along with the RT verified the following days Resident #9 had been on the non-invasive mechanical ventilator greater than 8 hours. · [DATE]: the non-invasive mechanical ventilator was turned on 12:15 AM and turned off 9:13 AM (8 hours and 58 minutes) · [DATE]: the non-invasive mechanical ventilator was turned on 10:17 PM and turned off at 7:20 AM (9 hours and 3 minutes) · [DATE]: the non-invasive mechanical ventilator was turned on 10:07 PM and turned off at 9:42 AM (11 hours and 35 minutes) · [DATE]: the non-invasive mechanical ventilator was turned on 12:07 AM and turned off at 8:32 AM (8 hours and 25 minutes) · [DATE]: the non-invasive mechanical ventilator was turned on 11:26 PM and turned off at 9:35 AM (10 hours and 9 minutes) Resident #9 was discharged from the facility on [DATE]. An interview was conducted with the current Medical Director (CMD) on [DATE] at 11:41 AM. He stated he was new to the facility and this was only his 3rd at the facility. The CMD stated he was not familiar with the equipment that was used in the facility like the non-invasive mechanical ventilators, he left the management of those devices up to the pulmonologist who visited the facility on a weekly basis. The CMD stated that he was not aware that the facility was not equipped to handle residents that required greater than 8 hours of ventilator support or he would have questioned it before he came to work at the facility. An interview was conducted with the pulmonologist on [DATE] at 2:52 PM. The Pulmonologist stated that Resident #9 had a [MEDICAL CONDITION] and could not be weaned from it. The pulmonologist stated that Resident #9 required the non-invasive mechanical ventilator at night and described the device as a superior form of ventilation. He added that any resident that required the non-invasive mechanical ventilator was ventilator dependent and the settings that Resident #9 required were not available on the traditional continuous positive airway pressure ([MEDICAL CONDITION]) or the Bi-level positive airway pressure (Bi-pap) machines. The pulmonologist stated that he had made no policy or procedural changes since he had been coming to the facility and that when he walked onto the unit and there were already patients established there. An interview was conducted with the Director of Clinical Services (DCS) on [DATE] at 12:47 PM. The DCS stated that she has worked with this facility since (MONTH) of (YEAR) and stated that no one had shared with her the specifics of the unit where Resident #1 resided or the equipment that was being used on that unit. An interview was conducted with the Vice President of Operations (VPO) on [DATE] at 12:16 PM. The VPO stated she had recently been reassigned to the facility in (MONTH) of (YEAR). She stated that the Administrator at the time had given her a tour of the facility but she had no knowledge of the devices that were being used on the unit. An interview was conducted with the Director of Nursing (DON) on [DATE] at 12:07 PM. The DON stated that Resident #9 required the use of non-invasive life support and that it was usually on when Resident #9 went to bed to assist her with breathing. The DON stated that most of the time the RT would apply them at bedtime and remove then in the morning. She added that if there was no RT on duty the nurses were trained to place Resident #9 on her the non-invasive mechanical ventilator and if necessary to remove her from the device as well. A follow up interview was conducted with the DON on [DATE] at 10:52 AM. The DON stated that when she came to work at the facility in (MONTH) (YEAR) she was told the specialty unit where Resident #9 resided accepted patients that had tracheostomies and required the non-invasive mechanical ventilators when they were transitioning home. She stated it was portrayed to her as a short term unit where residents came to be decannulated (removal of the [MEDICAL CONDITION]) and then discharged home. The DON stated that to her knowledge the non-invasive mechanical ventilator were ventilator machines that had the capability to function as a [MEDICAL CONDITION] and Bi-pap machine. The DON stated that when she began working at the facility she was told that Resident #9 could not be decannulated but opted to stay here at the facility because she had no help in the community. She added that as long as the residents were on the non-invasive ventilator devices less than 8 hours then the facility did not require any special license to operate and Resident #9 was fine to stay in the facility because she was only on the non-invasive mechanical ventilator at night. 3. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #10 was cognitively intact for daily decision making. The MDS further indicated Resident #10 required extensive assistance with bed mobility, transfers, toileting and hygiene and had no behaviors or rejection of care. The MDS also indicated Resident #10 required oxygen, suctioning, and had a [MEDICAL CONDITION]. No ventilator use was identified on the MDS. A review of a physician's history and physical dated [DATE] indicated Resident #10 remained ventilator dependent and would be followed closely by pulmonology and respiratory therapy in regard to his chronic [MEDICAL CONDITION] and need for mechanical ventilation at night. A review of a physician's orders [REDACTED]. A review of a Medication Administration Record [REDACTED]. The time indicated was 9:00 PM and the staff had initialed it indicating the device had been applied. There was no time indicating what time the device was removed. During an interview on [DATE] at 12:52 PM Respiratory Therapist (RT) #1 explained the unit where Resident #10 lived was a specialty unit that accepted residents that had a [MEDICAL CONDITION] and required a ventilator 8 hours or less at night. RT #1 stated that Resident #10 had recently been admitted to the facility and required the non-invasive mechanical ventilator at night to manage his [MEDICAL CONDITION]. RT #1 explained in (MONTH) of (YEAR) the facility had put a temporary hold on admitting residents with [MEDICAL CONDITION]'s that required the use of the non-invasive mechanical ventilator. He further explained around (MONTH) or (MONTH) of (YEAR) he was told by the former Administrator they could resume admissions of those residents that required the ventilators as long as they only required the mechanical ventilator for 8 hours a day or less. RT #1 stated if a resident required the non-invasive mechanical ventilator more than 8 hours a day then the resident could not be admitted to the facility or they would have to be discharged to a traditional ventilator unit. He explained if there was no RT on the unit at bedtime the nurse on the unit would place Resident #10 on the non-invasive mechanical ventilator and then the RT that was on duty in the morning would generally take him off. The RT further explained the general rule was Resident #10 usually went on the ventilator at bedtime and came off in the morning. During an observation with RT #1 on [DATE] at 3:45 PM of Resident #10's ventilator log contained inside the monitor for the ventilator RT #1 verified the following days Resident #10 had been on the non-invasive mechanical ventilator greater than 8 hours. [DATE]: the non-invasive mechanical ventilator was turned on at 11:57 PM and was turned off at 8:28 AM (8 hours and 31 minutes) [DATE]: the non-invasive mechanical ventilator was turned on at 10:07 PM and was turned off at 9:42 AM (11 hours and 35 minutes) Resident #9 was discharged from the facility on [DATE]. During an interview on [DATE] at 2:52 PM, the Pulmonologist explained Resident #10 had [MEDICAL CONDITION] and he determined Resident #10 might not be a good candidate for decannulation (removal of his [MEDICAL CONDITION]). He stated Resident #10 required the non-invasive mechanical ventilator at night and described the device as a superior form of ventilation. He added that any resident who required the non-invasive mechanical ventilator was ventilator dependent and the settings that Resident #10 required were not available on the traditional continuous positive airway pressure (C-pap) or the Bi-level positive airway pressure (Bi-pap) machines. The Pulmonologist stated he had made no policy or procedural changes since he had been coming to the facility and when he walked into the unit there were already patients established there. During an interview on [DATE] at 11:41 AM, the current Medical Director (CMD) stated he was new to the facility and today was only his third visit at the facility. The CMD explained he was not familiar with the non-invasive mechanical ventilators and he left the management of those devices up to the Pulmonologist who visited the facility on a weekly basis. The CMD stated he was not aware the facility was not equipped to handle residents that required greater than 8 hours of ventilator support or he would have questioned it before he came to work at the facility. During an interview on [DATE] at 12:47 PM, the District Director of Clinical Services (DDCS) stated she had worked with the facility since (MONTH) of (YEAR) and stated no one had shared with her the specifics of the unit where Resident #10 lived or the ventilator equipment that was being used on that unit. During an interview on [DATE] at 12:16 PM, the Vice President of Operations (VPO) stated she had recently been reassigned to the facility in (MONTH) of (YEAR). She further stated the Administrator at the time had given her a tour of the facility but she had no knowledge of the non-invasive mechanical ventilators that were being used on the unit. During an interview on [DATE] at 12:07 PM, the Director of Nursing (DON) stated Resident #10 required the use of non-invasive life support and that it was usually put on when Resident #10 went to bed to assist him with breathing. The DON further stated most of the time the RT would apply the non-invasive mechanical ventilators at bedtime and remove then in the morning. She explained if there was no RT on duty the nurses were trained to place Resident #10 on his non-invasive mechanical ventilator and could remove him from the non-invasive mechanical ventilator. During a follow up interview on [DATE] at 10:52 AM the DON explained when she came to work at the facility in (MONTH) (YEAR) she was told the specialty unit where Resident #10 lived accepted residents who had tracheostomies and required the non-invasive mechanical ventilators when they were transitioning to go home. She stated it was portrayed to her as a short term unit where residents came to be decannulated (removal of the [MEDICAL CONDITION]) and then discharged home. The DON further stated to her knowledge the non-invasive mechanical ventilators had the capability to function as a C-pap and Bi-pap machine. The DON explained as long as residents were on the non-invasive ventilator devices less than 8 hours then the facility did not require any special license to operate. She stated she did not make the decision to accept residents who required a non-invasive mechanical ventilator but RTs worked with the Pulmonologist and they made decisions to accept residents who required non-invasive mechanical ventilation. 4. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission MDS dated [DATE] indicated Resident #11 was cognitively intact for daily decision making. The MDS also indicated Resident #11 required minimal assistance with transfers but extensive assistance with bed mobility, dressing, toileting and hygiene and had no behaviors or rejection of care. The MDS also indicated Resident #11 required oxygen, suctioning, and had a [MEDICAL CONDITION]. No ventilator use was identified on the MDS. A review of a Pulmonologist progress note dated [DATE] indicated Resident #11 needed the non-invasive mechanical ventilator to live. A review of a physician's orders [REDACTED]. A review of a Medication Administration Record [REDACTED]. The time indicated was 9:00 PM and the staff had initialed it indicating the device had been applied. There was no time indicating what time the device was removed. During an interview on [DATE] at 12:52 PM Respiratory Therapist (RT) #1 explained the unit where Resident #11 lived was a specialty unit that accepted residents that had a [MEDICAL CONDITION] and required a ventilator 8 hours or less at night. RT #1 stated that Resident #11 had been recently admitted to the facility and required the non-invasive mechanical ventilator at night to manage his [MEDICAL CONDITION]. RT #1 explained in (MONTH) of (YEAR) the facility had put a temporary hold on admitting residents with [MEDICAL CONDITION]'s that required the use of the non-invasive mechanical ventilator. He further explained around (MONTH) or (MONTH) of (YEAR) he was told by the former Administrator they could resume admissions of those residents that required the ventilators as long as they only required the mechanical ventilator for 8 hours a day or less. RT #1 stated if a resident required the non-invasive mechanical ventilator more than 8 hours a day then the resident could not be admitted to the facility or they would have to be discharged to a traditional ventilator unit. He explained if there was no RT on the unit at bedtime the nurse on the unit would place Resident #11 on the non-invasive mechanical ventilator and then the RT that was on duty in the morning would generally take him off. The RT further explained the general rule was Resident #11 usually went on the ventilator at bedtime and came off in the morning. During an observation with RT #1 on [DATE] at 3:45 PM of Resident #10's ventilator log contained inside the monitor for the ventilator RT #1 verified there were no dates when Resident #11 had been on the non-invasive mechanical ventilator greater than 8 hours. Resident #9 was discharged from the facility on [DATE]. During an interview on [DATE] at 2:52 PM, the Pulmonologist explained Resident #11 kept going back and forth to the hospital because of changes in his condition and he required non-invasive mechanical ventilation at night. He described the non-invasive mechanical ventilators as a superior form of ventilation. He explained any resident who required the non-invasive mechanical ventilator was ventilator dependent and the settings that Resident #11 required were not available on the traditional continuous positive airway pressure (C-pap) or the Bi-level positive airway pressure (Bi-pap) machines. The Pulmonologist stated he had made no policy or procedural changes since he had been coming to the facility and when he walked into the unit there were already patients established there. During an interview on [DATE] at 11:41 AM, the current Medical Director (CMD) stated he was new to the facility and today was only his third visit at the facility. The CMD explained he was not familiar with the non-invasive mechanical ventilators and he left the management of those devices up to the Pulmonologist who visited the facility on a weekly basis. The CMD stated he was not aware the facility was not equipped to handle residents that required greater than 8 hours of ventilator support or he would have questioned it before he came to work at the facility. During an interview on [DATE] at 12:47 PM, the District Director of Clinical Services (DDCS) stated she had worked with the facility since (MONTH) of (YEAR) and stated no one had shared with her the specifics of the unit where Resident #10 lived or the ventilator equipment that was being used on that unit. During an interview on [DATE] at 12:16 PM, the Vice President of Operations (VPO) stated she had recently been reassigned to the facility in (MONTH) of (YEAR). She further stated the Administrator at the time had given her a tour of the facility but she had no knowledge of the non-invasive mechanical ventilators that were being used on the unit. During an interview on [DATE] at 12:07 PM, the Director of Nursing (DON) stated Resident #11 required the use of non-invasive life support and that it was usually put on when Resident #11 went to bed to assist him with breathing. The DON further stated most of the time the RT would apply the non-invasive mechanical ventilators at bedtime and remove then in the morning. She explained if there was no RT on duty the nurses were trained to place Resident #10 on his non-invasive mechanical ventilator and could remove him from the non-invasive mechanical ventilator. During a follow up interview on [DATE] at 10:52 AM the DON explained when she came to work at the facility in (MONTH) (YEAR) she was told the specialty unit where Resident #10 lived accepted residents who had tracheostomies and required the non-invasive mechanical ventilators when they were transitioning to go home. She stated it was portrayed to her as a short term unit where residents came to be decannulated (removal of the [MEDICAL CONDITION]) and then discharged home. The DON further stated to her knowledge the non-invasive mechanical ventilators had the capability to function as a C-pap and Bi-pap machine. The DON explained as long as residents were on the non-invasive ventilator devices less than 8 hours then the facility did not require any special license to operate. She stated she did not make the decision to accept residents who required a non-invasive mechanical ventilator but RTs worked with the Pulmonologist and they made decisions to accept residents who required non-invasive mechanical ventilation. Credible Allegation of Compliance F835 Administration 1. The Resident identified to be affected by the alleged deficient practice. At 9:30pm on [DATE] Nurse #1 administered medication to resident #1. Resident #1 experienced no distress or change in his baseline condition. Resident #1 swallowed his medication and drink without problems. At 9:50pm Nurse Aide #1 and Nurse Aide #3 assisted resident #1 in preparing for bed. Nurse Aide #1 and Nurse Aide #3 transferred resident #1 via sit to stand lift from the chair to the bed. NA #1 placed resident #1's call light and urinal within reach. NA#1 and NA #3 exited room. At 10:45pm NA#1 exited another resident's room and noted resident #1's call light was on. NA #1 noted that resident #1 had his right leg off of the bed and the call bell in his hand. NA #1 went around the bed to address the call light. Resident #1's tongue was protruding from his mouth. NA #1 stated resident's color was gray. NA #1 went to the door of resident #1's room and yelled for help. NA #3 ran to the nurses' station to get help. At 10:47pm Nurse #1 and Nurse #2 responded to resident #1's room. Nurse #1 placed resident #1 on the respiratory assistive device. Resident #1 noted to be unresponsive. Nurse #2 exited resident #1's room to obtain the crash cart. At 10:55pm Nurse #1 checked resident's advanced directives and noted resident #1 was a DNR. At 11:00pm Nurse #1 and Nurse #2 assessed resident #1's vital signs and Vital signs were absent. At 11:03pm the Director of Nursing was notified of resident #1's death. A 24 hour report was sent to the NC Health Care Registry, NCDHHS by the Administrator on [DATE] reporting this event. The police were notified by the Administrator on [DATE]. The NC Board of Nursing was notified via email on [DATE] by the Director of Nursing. A Root Cause Analysis was conducted by the Interdisciplinary Team (IDT) on [DATE] and it was determined that the Nurse #1 did not apply oxygen [MEDICAL CONDITION] and Astral ventilation was not initiated for Resident #1 immediately after the NA # 1 assisted Resident to bed. There was no Respiratory Therapist (RT) on duty to assist Nurse #1 with completion of respiratory related tasks which led to Nurse #1 failing to follow the physician orders [REDACTED]. The IDT determined this event was the result of a lack of RT staffing on 2nd shift. Further Root Cause Analysis was conducted regarding the admission of residents with tracheostomies requiring ventilation assistance. Education was conducted with the Administrator, Director of Nursing, Respiratory therapist and facility Sales Representative by the Division Team regarding admission requirements for residents with tracheostomies on [DATE]. This education required that no residents with tracheostomies requiring ventilation would be admitted to the facility thereafter. Since [DATE], 4 residents exceeding this criteria, have been admitted in error and 1 resident received physician's orders [REDACTED]. 2. Residents with the potential to be affected by the alleged deficient practice. Residents with tracheostomies requiring ventilation assistance have the potential to be affected by the alleged deficient practice. On [DATE] an audit was completed by the Director of Nursing and Nurse Managers, of residents with tracheostomies requiring ventilation assistance to ensure oxygen and Astral/Trilogy devices were applied according to the physician's orders [REDACTED]. On [DATE] an audit was completed by the Director of Nursing and Nurse Managers, of residents with tracheostomies requiring ventilation assistance to ensure care plans were updated to reflect interventions including [MEDICAL CONDITION] care, oxygen administration and donning and doffing the Astral/Trilogy device. On [DATE] Residents #8, #9, #10 and #11 were identified with tracheostomies utilizing respiratory equipment that requiring ventilation assistance was transferred to hospital setting. 3. Systemic Measures On [DATE] the facility Administrator was suspended by the Region Vice President of Operations (RVPO). An Interim Administrator was established with supervision to be provided by the RVPO at least 3 times per week to ensure adherence to the plan of correction. The change of administrator form was faxed to the NCDHHS on [DATE] by the RVPO. On 3//,[DATE], the District Director of Clinical Services provided education to the Interim Administrator regarding all aspects of the plan of correction. On [DATE] the District Director of Clinical Services provided education to the Interdisciplinary Team (IDT) regarding the facility's admission capabilities with a focus on resident requiring respiratory assistance. This education includes the following: -Specific types of respiratory referrals and levels of respiratory support required -Admission criteria regarding referrals with tracheostomies which includes the District Director of Clinical Services approval prior to offering placement -No ventilation assistance will be provided via Astral/Trilogy or other devices The Director of Nursing and Nurse Managers re-educated licensed nurses and nurse aides on Abuse and Neglect Prevention beginning on [DATE]. Beginning [DATE] No staff will be allowed to work until the training is complete. This education also included ensuring staff awareness that failure to provide respiratory equipment and services such as [MEDICAL CONDITION] care and oxygen administration as ordered by the physician, can constitute resident neglect. The NHA and DON will have a no tolerance approach to any deviation from the policy. On [DATE] Respiratory Therapist/Nurse Managers re-educated licensed nurses using the facility's policy for Respiratory/[MEDICAL CONDITION] Care to include suctioning, applying t-collar, and completing a respiratory assessment. On [DATE] the Director of Nursing and Nurse Managers re-educated licensed nurses regarding following the care plan of residents with tracheostomies requiring ventilation assistance to ensure care planned interventions including oxygen administration and donning and doffing devices providing ventilation assistance are in place. On [DATE] the Nurse Managers re-educated the Nurse Aides on reporting observations of residents with tracheostomies requiring oxygen administration to include notification of the nurse when oxygen is not applied as required. No licensed nurses or nurse aides will work before receiving education after [DATE]. New hires (licensed nurses and nurse aides) will be educated by the Nurse Manager on the facility's policy for Respiratory/[MEDICAL CONDITION] Care during the orientation process. All licensed nurses and nurse aides will be educated annually, by the Nurse Manager, for continued proficiency in respiratory/[MEDICAL CONDITION] care utilizing the facility's policy for Respiratory/[MEDICAL CONDITION] Care. The Director of Nursing or Nurse Managers will review new admissions daily during the clinical meeting to validate physician ordered respiratory equipment is available and applied according to the physician's orders [REDACTED]. The Director of Nursing or Nurse Managers will audit 10 residents requiring respiratory equipment weekly for 12 weeks to ensure respiratory equipment applied according to the physician's orders [REDACTED]. The Director of Nursing or Nurse Managers will audit 10 residents requiring respiratory equipment weekly for 12 weeks to ensure care planned interventions related to respiratory equipment are in place. The Director of Nursing will report the results of this morning during the weekly QAPI meeting and the committee will make recommendations as needed. The facility will no longer admit residents with tracheostomies that require the use of the Trilogy, Astral or other systems that provide ventilation assistance. All referrals with tracheostomies will be reviewed by the District Director of Clinical Services (DDCS) and placement will be offered for only those approved by the DDCS. 4. The facility Administrator is responsible for implementing this acceptable plan of correction. Date of Compliance: [DATE] Immediate jeopardy was removed on [DATE] at 2:20 PM when nursing staff interviews revealed they had received education on the application of respiratory devices, use of

Based on record review, staff, respiratory therapist, former Medical Director, current Medical Director, and Pulmonologist interviews, the facility failed to apply oxygen and a non-invasive mechanical ventilator as ordered by the physician for 1 of 3 residents sampled for respiratory services (Resident #1). When Resident #1 was found by staff without the physician ordered devices he was deceased . Immediate Jeopardy began on [DATE] when staff failed to connect Resident #1 to his physician's orders [REDACTED]. Immediate jeopardy was removed on [DATE] at 2:20 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff education and ensure monitoring systems put into place are effective for applying respiratory devices as ordered. The findings included: Review of the manufacturer's instructions for the Astral (non-invasive mechanical ventilation) device read in part, The Astral device provides mechanical ventilation to both ventilation dependent and non-dependent patients. The indications for use read in part, the Astral devices provides continuous or intermittent ventilator support for patients weighing more the 11 pounds who require mechanical ventilation. The Astral device is intended to be used in home, institution/hospital and portable applications for both invasive and non-invasive ventilation. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired at the facility on [DATE]. Review of a care plan initiated [DATE] and revised on [DATE] read in part, Resident #1 had a [MEDICAL CONDITION] (Trach) related to a respiratory illness. The goals of the stated care plan were Resident #1 would have clear and equal breath sounds bilaterally through the review date. Resident #1 would have no signs or symptoms of infection by the review date. The interventions included: oxygen [MEDICAL CONDITION] (initiated [DATE]), Resident #1 was to be placed on a non-invasive mechanical ventilator (initiated on [DATE]) at night as ordered, suction as needed (initiated on [DATE]). Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #1 was mildly cognitively impaired for daily decision making and required limited to extensive assistance from staff with activities of daily living. The MDS further revealed no behaviors or rejection of care were noted. Resident #1 also required oxygen and suctioning and had a [MEDICAL CONDITION] during the assessment reference period. Ventilator use was not indicated on the MDS. Review of a physician order [REDACTED]. Review of a physician order [REDACTED]. Review of Treatment Administration Record (TAR) dated [DATE] through [DATE] revealed, RT/Nursing to place on non-invasive mechanical ventilator at bedtime. The time for application was 9:00 PM. There was no time indicated that Resident #1 was to be removed from the non-invasive mechanical ventilator. Review of a RT note dated [DATE] at 10:06 AM read, Nurse #1 informed RT #1 that Resident #1 had passed away in the night. When asked what happened Nurse #1 stated that the Nursing Assistants (NAs) put Resident #1 to bed around 10:15 PM and they returned to Resident #1's room again at 10:55 PM and found Resident #1 deceased . RT #1 asked Nurse #1 if Resident #1 was placed on [MEDICAL CONDITION] collar with oxygen bled in or was he placed on his nocturnal non-invasive mechanical ventilator as ordered. Nurse #1 stated she had not gotten there yet due to her medication pass so she was unsure if he was on his [MEDICAL CONDITION] collar or his non-invasive mechanical ventilator at the time of event. RT #1 checked the non-invasive mechanical ventilator event log and it stated that it was powered on at 10:51 PM and stopped at 10:57 PM. There was no as needed (PRN) RT on shift at the time of the event. This note was signed by RT #1. An interview was conducted with NA #1 on [DATE] at 3:43 PM. NA #1 stated she routinely cared for and was familiar with Resident #1. She also confirmed that she was caring for him on [DATE] on 2nd shift. NA #1 stated it was a routine night on the unit for Resident #1 and at 9:50 PM NA #3 assisted her with placing Resident #1 in the bed. After Resident #1 was placed in the bed and care was provided, Resident #1 was handed his call bell, urinal, and oxygen tubing. She stated that Resident #1 was able to put his own oxygen on and she handed him the tubing but was not sure if he placed it on himself or not. NA #1 stated they then left the room and returned ,[DATE] minutes later when the call light was on. They entered Resident #1's room and noticed he was not breathing. NA #1 stated she could not recall if he had on his oxygen or not, she was so upset that he was not breathing. NA #3 summoned Nurse #1 to the room and confirmed that he was not breathing and had a Do Not Resuscitate (DNR) order. NA #1 stated she left the room because she was so upset. An interview was conducted with NA #3 on [DATE] at 3:27 PM. NA #3 confirmed that she routinely cared for and was familiar with Resident #1 and was caring for him on [DATE] on 2nd shift. NA #3 stated that Resident #1 had been his usual self all shift. He was up in his wheelchair on the unit and had his oxygen in place via his [MEDICAL CONDITION] and had been to the dining room for dinner. NA #3 stated that at approximately 9:50 PM to 10:00 PM with assistance from NA #1 they placed Resident #1 in the bed. NA #3 stated that she had removed his oxygen to put him to bed but could not recall if she had replaced it or not. Approximately ,[DATE] minutes later NA #3 stated that Resident #1's call light was on and she and NA #1 entered his room to see what he needed. When they entered his room Resident #1 had grabbed the hand rail and turned himself and his legs were coming out of the bed. She stated that NA #1 put his legs back in the bed and as they turned to leave the room they noticed that his chest was not rising or falling and they ran to get Nurse #1. Nurse #1 came into the room and began checking his vital signs and Resident #1 appeared to take a deep breath at one point when Nurse #1 was in the room. NA #3 stated she was not sure if Resident #1 had been hooked up to his ventilator because Nurse #1 was responsible for that. NA #3 stated that after she had put Resident #1 to bed she had communicated to Nurse #1 that he was in the bed and ready for her to hook him up to his machine. An interview was conducted with Nurse #1 on [DATE] at 3:06 PM. Nurse #1 confirmed that she was working with Resident #1 on [DATE] on 2nd shift. Nurse #1 stated that Resident #1 had been his usual self on [DATE], he had been up in the wheelchair and had his oxygen in place at ,[DATE] liters via [MEDICAL CONDITION] collar. She stated that at approximately 10:55 PM on [DATE] NA #1 and NA #3 stated Resident #1 is in bed and his tongue is hanging out. Nurse #1 stated she ran to Resident #1's room and he was unresponsive. Nurse #1 directed the NAs to get the crash cart and she went to make sure he had a DNR order in place. She stated that before she left the room to check if Resident #1 had a DNR order she hooked up his non-invasive mechanical ventilator and turned it on and when she returned to the room and was sure he had a DNR order in place she turned the ventilator off. Nurse #1 stated that when she entered Resident #1's room he did not have his oxygen on and could not recall if it was accessible to him. She further stated she had not had time to place him on his non-invasive mechanical ventilator because she was passing medications. Nurse #1 stated that she had not yet had time to start her [MEDICAL CONDITION] care and that was generally when she would put him on the non-invasive mechanical ventilator. She stated that Resident #1 had alarms to his ventilator but because she had not hooked him up yet they were not on. Nurse #1 stated that she and Nurse #2 pronounced Resident #1 dead at 11:00 PM. An interview was conducted with Nurse #2 on [DATE] at 5:06 PM. Nurse #2 confirmed that she was working on the unit where Resident #1 resided on [DATE] on 2nd shift. She stated that late in the evening one of the NAs called Nurse #1 to Resident #1's room. Nurse #2 stated she accompanied Nurse #1 to Resident #1's room. Nurse #2 stated that when she entered Resident #1's room he was reclined in bed and seemed to have no life in him and could not recall if he had his oxygen in place or was hooked to the non-invasive mechanical ventilator. Nurse #2 stated she exited his room to grab a pulse oximeter and when she returned Nurse #1 had placed Resident #1 on the non-invasive mechanical ventilator and she checked for a pulse and could not find a pulse. Nurse #1 went to his chart and confirmed that Resident #1 had a DNR order and then Nurse #1 turned the ventilator off and they both auscultated lung sounds for ,[DATE] minutes. There was none and Resident #1 was pronounced dead. An interview was conducted with RT #1 on [DATE] at 12:52 PM. RT #1 stated Resident #1 had chronic [MEDICAL CONDITION] and was ventilator dependent at night. RT #1 stated that Resident #1 was very cognitively alert and would sporadically take himself off the ventilator but he was not able to put himself on it. He added that Resident #1 usually required between ,[DATE] liters of oxygen via his tracheotomy collar during the day but the RT was able to adjust that depending on the condition of the resident. RT #1 stated that he arrived to work on [DATE] at 5:20 AM and generally Resident #1 would be up in his wheelchair waiting for the RT to get him a new tank of oxygen and on this day he was not. RT #1 questioned Nurse #1 where Resident #1 was at. RT #1 stated she replied, He was deceased . RT #1 stated he questioned Nurse #1 what happened. He added Resident #1 was very stable and had not been sick, had no increased oxygen needs and was only suctioned maybe ,[DATE] times a day so he was shocked that he had passed away. Nurse #1 stated that at approximately 10:15 PM on [DATE] Resident #1 requested to go to bed so the NAs put him to bed and they went back to check on him at 10:55 PM and he was deceased . RT #1 stated he asked her if Resident #1 had been on his non-invasive mechanical ventilator or his [MEDICAL CONDITION] collar and she stated he was not on the non-invasive mechanical ventilator because she was still passing medications and had not had time to hook him up yet. He further indicated he checked the non-invasive mechanical ventilator log and discovered that the ventilator had been turned on and off within just a few minutes. RT #1 stated that there was no RT in the building that night and Nurse #1 should have stopped her medication pass and connected Resident #1 to his non-invasive mechanical ventilator as ordered. RT #1 stated that the nurses were trained to place residents on the non-invasive mechanical ventilator in the absence of a RT. An interview was conducted with the former Medical Director (FMD) on [DATE] at 4:41 PM. The FMD stated that she cared for Resident #1 until approximately [DATE] and was very familiar with him. The FMD stated that she had never seen Resident #1 without his oxygen and she honestly did not have to see him very often because he was as stable as he could be with a [MEDICAL CONDITION] and being ventilator dependent. The FMD stated that if Resident #1 did not have his oxygen or his ventilator on that certainly could have contributed to his death along with his [MEDICAL CONDITION], lung disease, and hypertension. The FMD stated that she would expect that Resident #1 would have his oxygen in place and would be hooked to his non-invasive mechanical ventilator as ordered. She stated that Resident #1 did very well during the day with his oxygen hooked via [MEDICAL CONDITION] collar but at night he required the extra support of the non-invasive mechanical ventilator which to her knowledge was a traditional ventilator. An interview was conducted with the Pulmonologist on [DATE] at 2:51 PM. The pulmonologist stated that Resident #1 was very stable and he did not have to visit him on routine basis. He stated that Resident #1 was very independent but had chronic [MEDICAL CONDITION] with permanent [MEDICAL CONDITION] and was dependent on a nocturnal non-invasive mechanical ventilator. The pulmonologist stated that Resident #1 required the non-invasive mechanical ventilator as back up ventilation at night and anyone that required the non-invasive mechanical ventilator was ventilator dependent. He added the non-invasive mechanical ventilator was not a continuous positive airway pressure ([MEDICAL CONDITION]) and was not a bi-level positive airway pressure ([MEDICAL CONDITION]). The pulmonologist stated it is superior form of ventilation. He added that Resident #1's setting were not available via [MEDICAL CONDITION] or [MEDICAL CONDITION] and confirmed that Resident #1 was non-invasively mechanically ventilated via the non-invasive ventilator at night. The pulmonologist stated that without an autopsy he could not confirm that the lack of oxygen or non-invasive mechanical ventilator contributed to Resident #1's death. An interview was conducted with the current Medical Director (CMD) on [DATE] at 11:41 AM. The CMD stated that this was only his 3rd time in the facility and he had met and visited with Resident #1 while he was sitting up in his wheelchair before his passing. The CMD stated he was not familiar with the equipment that was used in the facility like the non-invasive mechanical ventilators he left the management of those devices up to the pulmonologist who visited the facility on a weekly basis. The CMD stated that he expected the staff to follow the physician orders [REDACTED].#1 on his non-invasive mechanical ventilator as ordered and communicate any issues that arose to himself or the pulmonologist. An interview was conducted with the Director of Nursing (DON) on [DATE] at 12:07 PM. The DON stated that Resident #1 required the use of non-invasive life support and that it was usually on when Resident #1 went to bed to assist him with breathing. The DON stated that Nurse #1 had contacted her on the evening of [DATE] and stated that Resident #1 had passed away and was directed as what she needed to do. The DON stated that Nurse #1 did not communicate all the facts to her in regards to Resident #1's death. The DON stated that she expected Nurse #1 to apply Resident #1's non-invasive mechanical ventilator as ordered. She further stated that Resident #1 was able to apply his own oxygen tubing and has known Resident #1 to go long periods of time without his oxygen and it never bothered him before. The DON stated that when Resident #1 was in the bed he usually had his oxygen and non-invasive mechanical ventilator on so maybe the position of lying down had something to do with it. Review of Resident #1's Certificate of Death dated [DATE] revealed the immediate cause of death was [MEDICAL CONDITION]. Credible Allegation of Compliance F695 1. The Resident identified to be affected by the alleged deficient practice. At 9:30pm on [DATE] Nurse #1 administered medication to resident #1. Resident #1 experienced no distress or change in his baseline condition. Resident #1 swallowed his medication and drink without problems. At 9:50pm Nurse Aide #1 and Nurse Aide #3 assisted resident #1 in preparing for bed. Nurse Aide #1 and Nurse Aide #3 transferred resident #1 via sit to stand lift from the chair to the bed. NA #1 placed resident #1's call light and urinal within reach. NA#1 and NA #3 exited room. At 10:45pm NA#1 exited another resident's room and noted resident #1's call light was on. NA #1 noted that resident #1 had his right leg off of the bed and the call bell in his hand. NA #1 went around the bed to address the call light. Resident #1's tongue was protruding from his mouth. NA #1 stated resident's color was gray. NA #1 went to the door of resident #1's room and yelled for help. NA #3 ran to the nurses' station to get help. At 10:47pm Nurse #1 and Nurse #2 responded to resident #1's room. Nurse #1 placed resident #1 on the respiratory assistive device. Resident #1 noted to be unresponsive. Nurse #2 exited resident #1's room to obtain the crash cart. At 10:55pm Nurse #1 checked resident's advanced directives and noted resident #1 was a DNR. At 11:00pm Nurse #1 and Nurse #2 assessed resident #1's vital signs and Vital signs were absent. At 11:03pm the Director of Nursing was notified of resident #1's death A 24 hour report was sent to the NC Health Care Registry, NCDHHS by the Administrator on [DATE] reporting this event. The police were notified by the Administrator on [DATE]. The NC Board of Nursing was notified via email on [DATE] by the Director of Nursing. · A Root Cause Analysis was conducted by the Interdisciplinary Team (IDT) on [DATE] and it was determined that Nurse #1 did not apply oxygen [MEDICAL CONDITION] and Astral ventilation was not initiated for Resident #1 immediately after the NA # 1 assisted Resident to bed. There was no Respiratory Therapist (RT) on duty to assist Nurse #1 with completion of respiratory related tasks which led to Nurse #1 failing to follow the physician orders [REDACTED]. The IDT determined this event was the result of a lack of RT staffing on 2nd shift. Further Root Cause Analysis was conducted regarding the admission of residents with tracheostomies requiring ventilation assistance. Education was conducted with the Administrator, Director of Nursing, Respiratory therapist and facility Sales Representative by the Division Team regarding admission requirements for residents with tracheostomies on [DATE]. This education required that no residents with tracheostomies requiring ventilation would be admitted to the facility thereafter. Since [DATE], 4 residents exceeding this criteria have been admitted in error and 1 resident received physician's orders [REDACTED]. 2. Residents with the potential to be affected by the alleged deficient practice. · Residents with tracheostomies requiring ventilation assistance have the potential to be affected by the alleged deficient practice. · On [DATE] an audit was completed by the Director of Nursing and Nurse Managers, of residents with tracheostomies requiring ventilation assistance to ensure oxygen and Astral/Trilogy devices were applied according to the physician's orders [REDACTED]. · On [DATE] Residents #8, #9, #10 and #11 were identified with tracheostomies utilizing respiratory equipment that requiring ventilation assistance were transferred to hospital setting. 3. Systemic Measures · On [DATE] the District Director of Clinical Services provided education to the Interdisciplinary Team (IDT) regarding the facility's admission capabilities with a focus on resident requiring respiratory assistance. This education includes the following: -Specific types of respiratory referrals and levels of respiratory support required -Admission criteria regarding referrals with tracheostomies which includes the District Director of Clinical Services approval prior to offering placement. -No ventilation assistance will be provided via Astral/Trilogy or other devices. · On [DATE] Respiratory Therapist/Nurse Managers re-educated licensed nurses using the facility's policy for Respiratory/[MEDICAL CONDITION] Care to include suctioning, applying t-collar, and completing a respiratory assessment. · On [DATE] the Nurse Managers re-educated the Nurse Aides on reporting observations of residents with tracheostomies requiring oxygen administration to include notification of the nurse when oxygen is not applied as required. · No licensed nurses or nurse aides will work before receiving education after [DATE]. · New hires (licensed nurses and nurse aides) will be educated by the Nurse Manager on the facility's policy for Respiratory/[MEDICAL CONDITION] Care during the orientation process. · All licensed nurses and nurse aides will be educated annually, by the Nurse Manager, for continued proficiency in respiratory/[MEDICAL CONDITION] care utilizing the facility's policy for Respiratory/[MEDICAL CONDITION] Care. · The Director of Nursing or Nurse Managers will review new admissions daily during the clinical meeting to validate physician ordered respiratory equipment is available and applied according to the physician's orders [REDACTED]. · The Director of Nursing or Nurse Managers will audit 10 residents requiring respiratory equipment weekly for 12 weeks to ensure respiratory equipment applied according to the physician's orders [REDACTED]. · The Director of Nursing will report the results of the audits during the weekly QAPI meeting and the committee will make recommendations as needed. · The facility will no longer admit residents with tracheostomies that require the use of the Trilogy, Astral or other systems that provide ventilation assistance. All referrals with tracheostomies will be reviewed by the District Director of Clinical Services (DDCS) and placement will be offered for only those approved by the DDCS. 4. The Administrator is responsible for implementing this acceptable plan of correction. Immediate jeopardy was removed on [DATE] at 2:20 PM when nursing staff interviews revealed that they had received education on the application of respiratory devices, how to properly care for tracheostomies, and that residents that required non-invasive mechanical ventilation had been discharged from the facility.

Based on record review, staff, former Medical Director and current Medical Director interviews the facility failed to implement care plan interventions by not applying oxygen and a non-invasive mechanical ventilator as stated in the care plan for 1 of 3 residents sampled for respiratory services (Resident #1). When Resident #1 was found by staff without the devices he was deceased . Immediate Jeopardy began on [DATE] when staff failed implement Resident #1's care plan by not connecting him to his physician's orders [REDACTED]. Immediate jeopardy was removed on [DATE] at 2:20 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete educate and ensure monitoring systems put into place for implementing care plan interventions are effective. The findings included: Resident #1 readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan initiated [DATE] and revised on [DATE] read in part, Resident #1 had a [MEDICAL CONDITION] related to a respiratory illness. The goal of the stated care plan was Resident #1 would have clear and equal breath sounds bilaterally through the review date and Resident #1 would have no signs or symptoms of infection by the review date. Additional goals of the care plan read, Resident #1 would have no abnormal drainage around his [MEDICAL CONDITION] site and Resident #1 would have a temperature within normal limits through the review period. The interventions included: ensure [MEDICAL CONDITION] ties were secured at all times (initiated [DATE]), observe and document restlessness, agitation, confusion, and increased heart rate (initiated [DATE]), observe and document respiratory rate, depth, and quality every shift as ordered (initiated [DATE]), oxygen via [MEDICAL CONDITION] collar (initiated [DATE]), report any changes in respiratory status to the nurse (initiated [DATE]), Resident #1 was to be placed on the non-invasive mechanical ventilator (initiated on [DATE] revised on [DATE]) at night as ordered, suction as needed (initiated on [DATE]). No changes were made to the care plan with the revision on [DATE]. Review of a physician order [REDACTED]. Review of a physician order [REDACTED]. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #1 was mildly cognitively impaired and required limited to extensive assistance from staff with activities of daily living. The MDS further revealed no behaviors or rejection of care were noted. Resident #1 also required oxygen and suctioning and had a [MEDICAL CONDITION] during the assessment reference period. Ventilator use was not indicated on the MDS. Review of a Situation, Background, Assessment, and Recommendation (SBAR) dated [DATE] indicated that on [DATE] at 10:55 AM Resident #1 was found without signs of life. Resident #1 was assessed for vital signs and none were present. Advance directives were reviewed and Resident #1 was noted to be a Do Not Resuscitate (DNR). The Director of Nursing (DON) and family were notified of Resident #1's death. An interview was conducted with Nursing Assistant (NA) #1 on [DATE] at 3:43 PM. NA #1 stated she routinely cared for and was familiar with Resident #1. She also confirmed that she was caring for him on [DATE] on 2nd shift. NA #1 stated it was a routine night on the unit for Resident #1 and at 9:50 PM NA #3 assisted her with placing Resident #1 in the bed. After Resident #1 was placed in the bed and care was provided Resident #1 was handed his call bell, urinal, and oxygen tubing. She stated that Resident #1 was able to put his own oxygen on and she handed him the tubing but was not sure if he placed it on himself or not. NA #1 stated they then left the room and returned ,[DATE] minutes later when the call light was on and they entered room and noticed Resident #1 was not breathing. NA #1 stated she could not recall if he had on his oxygen or not she was so upset that he was not breathing. NA #3 summoned Nurse #1 to the room and confirmed that he was not breathing and was a DNR. NA #1 stated she left the room because she was so upset. An interview was conducted with NA #3 on [DATE] at 3:27 PM. NA #3 confirmed that she routinely cared for and was familiar with Resident #1 and was caring for him on [DATE] on 2nd shift. NA #3 stated that at approximately 9:50 PM to 10:00 PM with assistance from NA #1 they place Resident #1 in the bed. NA #3 stated that she had removed his oxygen to put him to bed but could not recall if she had replaced it or not. Approximately ,[DATE] minutes later NA #3 stated that Resident #1's call light was on and she and NA #1 entered his room to see what he needed. She stated that they noticed that Resident #1's chest was not rising or falling and they ran to get Nurse #1. Nurse #1 came into the room and checked his vital signs. She stated she could not recall if Resident #1 had his oxygen on or not. NA #3 stated she was not sure if Resident #1 had been hooked up to his ventilator because Nurse #1 was responsible for that. An interview was conducted with Nurse #1 on [DATE] at 3:06 PM. Nurse #1 confirmed that she was working with Resident #1 on [DATE] on 2nd shift. Nurse #1 stated that Resident #1 had been his usual self on [DATE], he had been up in the wheelchair and had his oxygen in place at ,[DATE] liters via [MEDICAL CONDITION] collar. She stated that at approximately 10:55 PM on [DATE] NA #1 and NA #3 stated Resident #1 is in bed and his tongue is hanging out. Nurse #1 stated she ran to Resident #1's room and he was unresponsive. Nurse #1 directed the NAs to get the crash cart and she went to make sure he had a DNR order in place. She stated that before she left the room to check if Resident #1 had a DNR order she hooked his oxygen to the ventilator and turned it on and when she returned to the room and was sure he had a DNR order she turned the ventilator off. Nurse #1 stated that when she entered Resident #1's room he did not have his oxygen on and she had not had time to place him on his non-invasive mechanical ventilator because she was passing medications. Nurse #1 stated that she pronounced Resident #1 dead at 11:00 PM. An interview was conducted with the former Medical Director (FMD) on [DATE] at 4:41 PM. The FMD stated that she cared for Resident #1 until approximately [DATE] and was very familiar with him. The FMD stated that she had never seen Resident #1 without his oxygen and she honestly did not have to see him very often because he was a stable as he could be with a [MEDICAL CONDITION] and being ventilator dependent. The FMD stated that if Resident #1 did not have his oxygen or his ventilator on that certainly could have contributed to his death along with his [MEDICAL CONDITION], lung disease, and hypertension. The FMD stated that she would expect that Resident #1 would have his oxygen in place and would be hooked to his non-invasive mechanical ventilator as ordered and as directed by the plan of care. An interview was conducted with the current Medical Director (CMD) on [DATE] at 11:41 AM. The CMD stated that this was only his 3rd time in the facility and he had met and visited with Resident #1 while he was sitting in up in his wheelchair before his passing. The CMD stated that he expected the staff to follow the plan of care and place Resident #1 on his oxygen and on his non-invasive mechanical ventilator as directed by the plan of care. An interview was conducted with the DON on [DATE] at 12:07 PM. The DON stated that Resident #1 required the use of non-invasive life support and that it was usually on when Resident #1 went to bed to assist him with breathing. The DON stated that she expected Nurse #1 to apply Resident #1's oxygen and non-invasive mechanical ventilator as ordered and as directed by the plan of care. She further stated that Resident #1 was able to apply his own oxygen tubing and has known Resident #1 to go long periods of time without his oxygen and it never bothered him before. The DON stated that when Resident #1 was in the bed he usually had his oxygen and non-invasive mechanical ventilator on so maybe the position of lying down had something to do with it. Credible Allegation of Compliance F656 Care planning 1. The Resident identified to be affected by the alleged deficient practice. At 9:30pm on [DATE] Nurse #1 administered medication to resident #1. Resident #1 experienced no distress or change in his baseline condition. Resident #1 swallowed his medication and drink without problems. At 9:50pm Nurse Aide #1 and Nurse Aide #3 assisted resident #1 in preparing for bed. Nurse Aide #1 and Nurse Aide #3 transferred resident #1 via sit to stand lift from the chair to the bed. NA #1 placed resident #1's call light and urinal within reach. NA#1 and NA #3 exited room. At 10:45pm NA#1 exited another resident's room and noted resident #1's call light was on. NA #1 noted that resident #1 had his right leg off of the bed and the call bell in his hand. NA #1 went around the bed to address the call light. Resident #1's tongue was protruding from his mouth. NA #1 stated resident's color was gray. NA #1 went to the door of resident #1's room and yelled for help. NA #3 ran to the nurses' station to get help. At 10:47pm Nurse #1 and Nurse #2 responded to resident #1's room. Nurse #1 placed resident #1 on the respiratory assistive device. Resident #1 noted to be unresponsive. Nurse #2 exited resident #1's room to obtain the crash cart. At 10:55pm Nurse #1 checked resident 's advanced directives and noted resident #1 was a DNR. At 11:00pm Nurse #1 and Nurse #2 assessed resident #1's vital signs and Vital signs were absent. At 11:03pm the Director of Nursing was notified of resident #1's death. A 24 hour report was sent to the NC Health Care Registry, NCDHHS by the Administrator on [DATE] reporting this event. The police were notified by the Administrator on [DATE]. The NC Board of Nursing was notified via email on [DATE] by the Director of Nursing. · A Root Cause Analysis was conducted by the Interdisciplinary Team (IDT) on [DATE] and it was determined that the Nurse #1 did not apply oxygen [MEDICAL CONDITION] and Astral ventilation was not initiated for Resident #1 immediately after the NA # 1 assisted Resident to bed. There was no Respiratory Therapist (RT) on duty to assist Nurse #1 with completion of respiratory related tasks which led to Nurse #1 failing to follow the physician orders [REDACTED]. The IDT determined this event was the result of a lack of RT staffing on 2nd shift. Further Root Cause Analysis was conducted regarding the admission of residents with tracheostomies requiring ventilation assistance. Education was conducted with the Administrator, Director of Nursing, Respiratory therapist and facility Sales Representative by the Division Team regarding admission requirements for residents with tracheostomies on [DATE]. This education required that no residents with tracheostomies requiring ventilation would be admitted to the facility thereafter. Since [DATE], 4 residents exceeding this criteria, have been admitted in error and 1 resident received physician's orders [REDACTED]. 2. Residents with the potential to be affected by the alleged deficient practice. · Residents with tracheostomies requiring ventilation assistance have the potential to be affected by the alleged deficient practice. · On [DATE] an audit was completed by the Director of Nursing and Nurse Managers, of residents with tracheostomies requiring ventilation assistance to ensure care plans were updated to reflect interventions including [MEDICAL CONDITION] care, oxygen administration and donning and doffing the Astral/Trilogy device. · On [DATE] Residents #8, #9, #10 and #11 were identified with tracheostomies utilizing respiratory equipment that requiring ventilation assistance was transferred to hospital setting. 3. Systemic Measures · On [DATE] the Director of Nursing and Nurse Managers re-educated licensed nurses regarding following the care plan of residents with tracheostomies requiring ventilation assistance to ensure care planned interventions including oxygen administration and donning and doffing devices providing ventilation assistance are in place. · On [DATE] the District Director of Clinical Services provided education to the Interdisciplinary Team (IDT) regarding the facility's admission capabilities with a focus on resident requiring respiratory assistance. This education includes the following: -Specific types of respiratory referrals and levels of respiratory support required -Admission criteria regarding referrals with tracheostomies, which includes the District Director of Clinical Services approval prior to offering placement. -No ventilation assistance will be provided via Astral/Trilogy or other devices · On [DATE] Respiratory Therapist/Nurse Managers re-educated licensed nurses using the facility's policy for Respiratory/[MEDICAL CONDITION] Care to include suctioning, applying t-collar, and completing a respiratory assessment. · On [DATE] the Nurse Managers re-educated the Nurse Aides on reporting observations of residents with tracheostomies requiring oxygen administration to include notification of the nurse when oxygen is not applied as required. · No licensed nurses or nurse aides will work before receiving education after [DATE]. · New hires (licensed nurses and nurse aides) will be educated by the Nurse Manager on the facility's policy for Respiratory/[MEDICAL CONDITION] Care during the orientation process. · All licensed nurses and nurse aides will be educated annually, by the Nurse Manager, for continued proficiency in respiratory/[MEDICAL CONDITION] care utilizing the facility's policy for Respiratory/[MEDICAL CONDITION] Care. · The Director of Nursing or Nurse Managers will review new admissions daily during the clinical meeting to validate physician ordered respiratory equipment is available and applied according to the physician's orders [REDACTED]. · The Director of Nursing or Nurse Managers will audit 10 residents requiring respiratory equipment weekly for 12 weeks to ensure care planned interventions related to respiratory equipment are in place · The Director of Nursing will report the results of these audits during the weekly QAPI meeting and the committee will make recommendations as needed. · The facility will no longer admit residents with tracheostomies that require the use of the Trilogy, Astral or other systems that provide ventilation assistance. All referrals with tracheostomies will be reviewed by the District Director of Clinical Services (DDCS) and placement will be offered for only those approved by the DDCS. 4. The Administrator is responsible for implementing this acceptable plan of correction. Immediate jeopardy was removed on [DATE] at 2:20 PM when nursing staff interviews revealed that they had received education on the implementation of care plan interventions specially related to respiratory devices.

Based on record review, staff, Respiratory Therapist, former Medical Director, Pulmonologist and current Medical Director interviews, the facility neglected to connect a resident to a non-invasive mechanical ventilator to provide oxygen as ordered by the physician for 1 of 3 residents sampled for respiratory services (Resident #1). When Resident #1 was found by staff without the physician ordered non-invasive mechanical ventilator he was deceased . The facility also neglected to perform incontinent care for a dependent resident for 1 of 3 residents sampled for activities of daily living (Resident #6). Immediate Jeopardy began on [DATE] when staff neglected to connect Resident #1 to his physician's orders [REDACTED]. Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff education and ensure monitoring systems put into place are effective for applying respiratory devices as ordered. The facility was cited at F600 for example #2 at a scope and severity level of D. Findings included: 1. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired at the facility on [DATE]. A review of a care plan initiated [DATE] and revised on [DATE] revealed in part, Resident #1 had a [MEDICAL CONDITION] (trach) related to a respiratory illness and the goals were Resident #1 would have clear and equal breath sounds bilaterally and would have no signs or symptoms of infection by the review date. The interventions indicated to provide oxygen [MEDICAL CONDITION] and suction as needed (initiated [DATE]) and Resident #1 was to be placed on a non-invasive mechanical ventilator at night as ordered (initiated on [DATE]). A review of a physician order [REDACTED]. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had mild cognitive impairment for daily decision making and required limited to extensive assistance from staff with activities of daily living. The MDS further revealed no behaviors or rejection of care and Resident #1 required oxygen and suctioning and had a [MEDICAL CONDITION] during the assessment reference period but ventilator use was not indicated on the MDS. A review of a Treatment Administration Record (TAR) dated [DATE] through [DATE] indicated RT/Nursing to place Resident #1 on non-invasive mechanical ventilator at bedtime and the time for application was 9:00 PM. A review of a Respiratory Therapy (RT) note dated [DATE] at 10:06 AM signed by RT #1 revealed Nurse #1 informed RT #1 that Resident #1 had passed away in the night. The note indicated RT #1 asked Nurse #1 what happened and Nurse #1 stated Nursing Assistants (NAs) put Resident #1 to bed around 10:15 PM and they returned to Resident #1's room again at 10:55 PM and found Resident #1 deceased . The note further indicated RT #1 asked Nurse #1 if Resident #1 was placed on [MEDICAL CONDITION] collar with oxygen bled in or was he placed on his nocturnal non-invasive mechanical ventilator as ordered. The note revealed Nurse #1 stated she had not gotten there yet due to her medication pass so she was unsure if he was on his [MEDICAL CONDITION] collar or his non-invasive mechanical ventilator. The note further revealed RT #1 checked the non-invasive mechanical ventilator event log which indicated the non-invasive mechanical ventilator was powered on at 10:51 PM and stopped at 10:57 PM. The note indicated there was no as needed (PRN) RT on shift at the time of the event. During an interview on [DATE] at 12:52 PM, RT #1 confirmed Resident #1 had chronic [MEDICAL CONDITION] and was ventilator dependent at night. He stated Resident #1 was cognitively alert and would sporadically take himself off the ventilator but he was not able to put himself on the ventilator. RT #1 explained he arrived to work on [DATE] at 5:20 AM and generally Resident #1 was up in his wheelchair waiting for the RT to get him a new tank of oxygen but on this day he was not. RT #1 stated he questioned Nurse #1 where Resident #1 was and Nurse #1 stated he was deceased . He explained Resident #1 was very stable and had not been sick, had no increased oxygen needs and was only suctioned maybe ,[DATE] times a day. RT #1 stated he questioned Nurse #1 what happened and she explained at approximately 10:15 PM on [DATE] Resident #1 requested to go to bed so the NAs put him to bed and they went back to check on him at 10:55 PM and he was deceased . RT #1 further stated he asked Nurse #1 if Resident #1 had been on his non-invasive mechanical ventilator or his [MEDICAL CONDITION] collar and she stated he was not on the non-invasive mechanical ventilator because she was still passing medications and had not had time to hook him up yet. He explained he checked the non-invasive mechanical ventilator log inside the monitor on the ventilator and discovered that the ventilator had been turned on and off within just a few minutes. RT #1 stated there was no RT in the building that night and Nurse #1 should have stopped her medication pass and connected Resident #1 to his non-invasive mechanical ventilator as ordered. RT #1 stated the nurses had been trained to place residents on the non-invasive mechanical ventilator in the absence of an RT. During an interview on [DATE] at 3:43 PM, NA #1 stated she routinely provided care for Resident #1 and confirmed she provided care for him on [DATE] on second shift. NA #1 explained at 9:50 PM NA #3 assisted her with placing Resident #1 in bed. She stated after Resident #1 was placed in bed and care was provided, she handed Resident #1 his call bell, urinal, and oxygen tubing. She further stated Resident #1 was able to put on his oxygen and she handed him the tubing but was not sure if he placed it on himself or not. NA #1 explained she and NA #3 left Resident #1's room and returned ,[DATE] minutes later when Resident #1's call light was on. She stated when she and NA #3 entered Resident #1's room she noticed he was not breathing but could not recall if he had on his oxygen or not. She explained NA #3 called Nurse #1 to the room and Nurse #1 confirmed Resident #1 was not breathing and had a Do Not Resuscitate (DNR) order and NA #1 stated she left the room. During an interview on [DATE] at 3:27 PM, NA #3 confirmed she provided care for Resident #1 on [DATE] on second shift. NA #3 explained at approximately 9:50 PM to 10:00 PM she and NA #1 placed Resident #1 in bed and she had removed his oxygen to put him to bed but could not recall if she had replaced it or not. NA #3 stated after she had put Resident #1 to bed she told Nurse #1 he was in the bed and was ready for her to hook him up to his machine. She further stated approximately ,[DATE] minutes later Resident #1's call light was on and she and NA #1 entered his room to see what he needed and Resident #1 had grabbed the hand rail with his hand and had turned himself so that his legs were off the side of the bed. She stated NA #1 put his legs back in the bed and as they turned to leave the room they noticed that his chest was not rising or falling so they ran to get Nurse #1. She explained Nurse #1 came into the room and checked his vital signs and Resident #1 appeared to take a deep breath at one point when Nurse #1 was in the room. NA #3 stated she was not sure if Resident #1 had been hooked up to his ventilator because Nurse #1 was responsible for that. During an interview on [DATE] at 3:06 PM, Nurse #1 confirmed she provided care to Resident #1 on [DATE] on second shift. Nurse #1 explained Resident #1 had been his usual self on [DATE] and had been up in a wheelchair and had his oxygen in place at ,[DATE] liters through a [MEDICAL CONDITION] collar. She stated at approximately 10:55 PM on [DATE] NA #1 and NA #3 told her Resident #1 was in bed and his tongue was hanging out. Nurse #1 explained she ran to Resident #1's room and he was unresponsive and she directed the NAs to get the crash cart. Nurse #1 stated when she entered Resident #1's room he did not have his oxygen on and could not recall if it was accessible to him and she hooked up his non-invasive mechanical ventilator and turned it on and then left the room to check to see if Resident #1 had a DNR order. She explained when she was sure he had a DNR order in place she returned to Resident #1's room and turned the ventilator off. She further explained she had not had time to place him on his non-invasive mechanical ventilator because she was passing medications. Nurse #1 stated she had not had time to provide [MEDICAL CONDITION] care and that was generally when she would have put him on the non-invasive mechanical ventilator. She further stated Resident #1 had alarms on his ventilator but because she had not hooked him up yet they were not on. Nurse #1 stated she and Nurse #2 pronounced Resident #1 deceased at 11:00 PM. During an interview on [DATE] at 5:06 PM, Nurse #2 stated she worked on second shift on [DATE] and late in the evening a NA called Nurse #1 to Resident #1's room. She explained she went with Nurse #1 to Resident #1's room and when she entered Resident #1's room he was lying in bed and seemed to have no life in him. She further stated she could not recall if he had his oxygen in place or if he was hooked to the non-invasive mechanical ventilator but she left the room to grab a pulse oximeter. She explained when she returned to Resident #1's room, Nurse #1 had placed Resident #1 on the non-invasive mechanical ventilator and checked for a pulse but could not find a pulse. She stated Nurse #1 left the room to check Resident #1's chart and then returned to the room and confirmed he had a DNR order and Nurse #1 turned the ventilator off. She further stated they both listened for lung sounds for ,[DATE] minutes but there were none and Resident #1 was pronounced deceased . During an interview on [DATE] at 4:41 PM, the former Medical Director (FMD) stated she had been Resident #1's physician until approximately [DATE] and had never seen Resident #1 without his oxygen. She explained she did not have to see him very often because he was stable with a [MEDICAL CONDITION] and non-invasive mechanical ventilator. She explained at night Resident #1 required the extra support of the non-invasive mechanical ventilator which to her knowledge was a traditional ventilator. The FMD stated if Resident #1 did not have his oxygen on or his ventilator connected that could have contributed to his death along with his [MEDICAL CONDITION], lung disease, and hypertension. The FMD further stated she would expect for Resident #1 to have his oxygen in place and for him to be hooked to his non-invasive mechanical ventilator as ordered. During an interview on [DATE] at 2:51 PM, the Pulmonologist stated Resident #1 was very stable and very independent but had chronic [MEDICAL CONDITION] with a permanent [MEDICAL CONDITION] and he was dependent on a nocturnal (at night) non-invasive mechanical ventilator. The Pulmonologist explained Resident #1 required the non-invasive mechanical ventilator as back up ventilation at night and anyone who required the non-invasive mechanical ventilator was ventilator dependent. He stated Resident #1 was dependent on the non-invasive mechanical ventilator at night to support his ventilations (breathing). During an interview on [DATE] at 11:41 AM, the current Medical Director (CMD) stated this was only his third time in the facility but he recalled he met with Resident #1 while he was sitting up in his wheelchair on a previous visit. The CMD stated he was not familiar with the noninvasive mechanical ventilators used in the facility and he left the management of those devices up to the Pulmonologist who visited the facility on a weekly basis. The CMD stated it was his expectation for staff to follow the physician orders [REDACTED].#1 on his non-invasive mechanical ventilator as ordered. He further stated it was his expectation for staff to communicate any issues to himself or the Pulmonologist. During an interview on [DATE] at 12:07 PM, the Director of Nursing (DON) stated Resident #1 required the use of non-invasive life support and it was usually placed on him when he went to bed to assist him with breathing. The DON explained Nurse #1 had contacted her on the evening of [DATE] and reported Resident #1 had passed away and she gave Nurse #1 directions as to what she needed to do. The DON stated that Nurse #1 did not communicate with her at that time all the facts in regards to Resident #1's death. The DON further stated it was her expectation for Nurse #1 to apply Resident #1's non-invasive mechanical ventilator as ordered by the physician. Review of Resident #1's Certificate of Death dated [DATE] revealed the immediate cause of death was [MEDICAL CONDITION]. Credible Allegation of Compliance F600 Neglect 1. The Resident identified to be affected by the alleged deficient practice. At 9:30pm on [DATE] Nurse #1 administered medication to resident #1. Resident #1 experienced no distress or change in his baseline condition. Resident #1 swallowed his medication and drink without problems. At 9:50pm Nurse Aide #1 and Nurse Aide #3 assisted resident #1 in preparing for bed. Nurse Aide #1 and Nurse Aide #3 transferred resident #1 via sit to stand lift from the chair to the bed. NA #1 placed resident #1's call light and urinal within reach. NA#1 and NA #3 exited room. At 10:45pm NA#1 exited another resident's room and noted resident #1's call light was on. NA #1 noted that resident #1 had his right leg off of the bed and the call bell in his hand. NA #1 went around the bed to address the call light. Resident #1's tongue was protruding from his mouth. NA #1 stated resident's color was gray. NA #1 went to the door of resident #1's room and yelled for help. NA #3 ran to the nurses' station to get help. At 10:47pm Nurse #1 and Nurse #2 responded to resident #1's room. Nurse #1 placed resident #1 on the respiratory assistive device. Resident #1 noted to be unresponsive. Nurse #2 exited resident #1's room to obtain the crash cart. At 10:55pm Nurse #1 checked resident's advanced directives and noted resident #1 was a DNR. At 11:00pm Nurse #1 and Nurse #2 assessed resident #1's vital signs and Vital signs were absent. At 11:03pm the Director of Nursing was notified of resident #1's death A 24 hour report was sent to the NC Health Care Registry, NCDHHS by the Administrator on [DATE] reporting this event. The police were notified by the Administrator on [DATE]. The NC Board of Nursing was notified via email on [DATE] by the Director of Nursing. A Root Cause Analysis was conducted by the Interdisciplinary Team (IDT) on [DATE] and it was determined that the Nurse #1 did not apply oxygen [MEDICAL CONDITION] and Astral ventilation was not initiated for Resident #1 immediately after the NA # 1 assisted Resident to bed. There was no Respiratory Therapist (RT) on duty to assist Nurse #1 with completion of respiratory related tasks which led to Nurse #1 failing to follow the physician orders [REDACTED]. The IDT determined this event was the result of a lack of RT staffing on 2nd shift. Further Root Cause Analysis was conducted regarding the admission of residents with tracheostomies requiring ventilation assistance. Education was conducted with the Administrator, Director of Nursing, Respiratory therapist and facility Sales Representative by the Division Team regarding admission requirements for residents with tracheostomies on [DATE]. This education required that no residents with tracheostomies, requiring ventilation would be admitted to the facility thereafter. Since [DATE], 4 residents exceeding this criteria, have been admitted in error and 1 resident received physician's orders [REDACTED]. 2. Residents with the potential to be affected by the alleged deficient practice. Residents with tracheostomies requiring ventilation assistance have the potential to be affected by the alleged deficient practice. On [DATE] an audit was completed by the Director of Nursing and Nurse Managers, of residents with tracheostomies requiring ventilation assistance to ensure oxygen and Astral/Trilogy devices were applied according to the physician's orders [REDACTED]. On [DATE] Residents #8, #9, #10 and #11 were identified with tracheostomies utilizing respiratory equipment that requiring ventilation assistance was transferred to hospital setting. 3. Systemic Measures The Director of Nursing and Nurse Managers re-educated licensed nurses and nurse aides on Abuse and Neglect Prevention beginning on [DATE]. Beginning [DATE] No staff will be allowed to work until the training is complete. This education also included ensuring staff awareness that failure to provide respiratory equipment and services such as [MEDICAL CONDITION] care and oxygen administration as ordered by the physician, can constitute resident neglect. The NHA and DON will have a no tolerance approach to any deviation from the policy. On [DATE] the District Director of Clinical Services provided education to the Interdisciplinary Team (IDT) regarding the facility's admission capabilities with a focus on resident requiring respiratory assistance. This education includes the following: -Specific types of respiratory referrals and levels of respiratory support required -Admission criteria regarding referrals with tracheostomies which includes the District Director of Clinical Services approval prior to offering placement. -No ventilation assistance will be provided via Astral/Trilogy or other devices On [DATE] Respiratory Therapist/Nurse Managers re-educated licensed nurses using the facility's policy for Respiratory/[MEDICAL CONDITION] Care to include suctioning, applying t-collar, and completing a respiratory assessment. On [DATE] the Nurse Managers re-educated the Nurse Aides on reporting observations of residents with tracheostomies requiring oxygen administration to include notification of the nurse when oxygen is not applied as required. No licensed nurses or nurse aides will work before receiving education after [DATE]. New hires (licensed nurses and nurse aides) will be educated by the Nurse Manager on the facility's policy for Respiratory/[MEDICAL CONDITION] Care during the orientation process. All licensed nurses and nurse aides will be educated annually, by the Nurse Manager, for continued proficiency in respiratory/[MEDICAL CONDITION] care utilizing the facility's policy for Respiratory/[MEDICAL CONDITION] Care. The Director of Nursing or Nurse Managers will review new admissions daily during the clinical meeting to validate physician ordered respiratory equipment is available and applied according to the physician's orders [REDACTED]. The Director of Nursing or Nurse Managers will audit 10 residents requiring respiratory equipment weekly for 12 weeks to ensure respiratory equipment applied according to the physician's orders [REDACTED]. The Director of Nursing will report the results of this morning during the weekly QAPI meeting and the committee will make recommendations as needed. The facility will no longer admit residents with tracheostomies that require the use of the Trilogy, Astral or other systems that provide ventilation assistance. All referrals with tracheostomies will be reviewed by the District Director of Clinical Services (DDCS) and placement will be offered for only those approved by the DDCS. 4. The facility Administrator is responsible for implementing this acceptable plan of correction. Date of Compliance: [DATE] Immediate jeopardy was removed on [DATE] at 2:20 PM when nursing staff interviews revealed they had received education on the application of respiratory devices, use of respiratory equipment and suctioning of residents. The interviews also confirmed staff had received training regarding how to properly care for tracheostomies and to provide care according to physician's orders [REDACTED]. 2. Resident #6 readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent comprehensive Minimum Data Set ((MDS) dated [DATE] revealed that Resident #6 was cognitively impaired and required extensive assistance of 1 staff member with toileting. The MDS further revealed that Resident #6 was frequently incontinent of bowel. No behaviors or rejection of care was noted during the assessment reference period. A continuous observation was made of Resident #6 on [DATE] from 10:09 AM to 10:31 AM. Resident #6 was observed to be resting in bed with a gown on that was pulled up exposing his lower abdomen and legs. There was fecal odor noted immediately upon entering Resident #6's room. There was a large pile of light brown colored soft non formed stool laying between Resident #6's legs that extended from the brief to mid-thigh region. There was also light brown colored soft non formed stool laying on Resident #6's abdomen just above the brief. To the left side of Resident #6's bed was a large pool of yellow liquid on the floor. Resident #6 indicated that he had defecated and urinated on himself and wanted a cup of coffee. Numerous staff members were noted to pass by Resident #6's room during the observation. During the continuous observation the facility's Social Worker (SW) knocked on Resident #6's door and entered the room and was observed to cover Resident #6's lower extremities with a blanket and exit the room. Nursing Assistant (NA) #2 was observed to enter Resident #6's room and turn around and exited the room. She returned a few minutes later with a bag of linen supplies, she entered Resident #6's room delivered the linen supplies and exited the room. Resident #6's roommate entered the room and noted the puddle of fluid on the floor and asked the housekeeper to mop it up. An interview was conducted with NA #2 on [DATE] at 10:32 AM. NA #2 confirmed that she was caring for Resident #6 and was very familiar with him and his needs. NA #2 indicated she was going to start an incontinent round at the other end of the hall and work her way towards Resident #6 and would be providing care to him in approximately 20 to 30 minutes. An observation of Resident #6 was made on [DATE] at 10:53 AM. Resident #6 was resting in bed with a blanket that covered his lower extremities. There was a strong fecal odor now detected out in the hall directly in front of Resident #6's room. Light brown colored soft non-formed stool was observed to be lying on his lower abdomen just above the brief and the pile of light brown colored non-formed stool continued to ooze down between his legs nearly reaching his knee that was exposed from under the blanket. An observation was made of NA #2 entering Resident #6's room on [DATE] at 11:19 AM to provide incontinent care. The fecal odor was now heavily prevalent in the hallway and in Resident #6's room. Upon entering Resident #6's room NA # 2 stated he had a huge blow out. NA #2 was observed to provide incontinent care to Resident #6 and to remove the linen from his bed that was heavily soiled with light brown colored fecal matter. No skin breakdown was noted to Resident #6's buttock areas, they were slightly red but the skin was intact. Under the sheet the mattress had a large ring that was darker in color indicating the blue mattress was wet. Again Resident #6 indicated that he had defecated and urinated all over himself. NA #2 was observed to dress Resident #6 and place him in his wheelchair. A follow up interview was conducted with NA #2 on [DATE] at 11:21 AM. NA #2 explained that she was working the whole hall by herself and was running behind. She stated that generally Resident #6 was up and dressed when she arrived to work but today he was not. NA #2 stated that she had provided incontinent care to him at around 8:00 AM prior to his breakfast tray arriving and she was just now getting back to him. NA #2 stated that when she delivered linen supplies to his room earlier she had not noted the fecal odor and only when she arrived to provide care to Resident #6 did she detect the fecal odor. An interview was conducted with the Unit Manager (UM) on [DATE] at 10:23 AM. The UM stated she had been in her current role since (MONTH) (YEAR). The UM explained that generally she had 4 to 5 NAs on her unit each day and yesterday was the same. She indicated that the unit was fully staffed on [DATE] and that NA #2 did not have the entire hall by herself. The UM explained that the 2 nurses on the unit and herself made rounds sporadically throughout the day looking for things that needed to be done like incontinent care. She added that some residents were able to alert the staff that they were incontinent and needed to be clean up but some residents including Resident #6 were routinely checked and changed. The UM stated that it was unacceptable that Resident #6 laid in bed that soiled for that long and that care should have been provided much sooner. An interview was conducted with the Charge Nurse (CN) on [DATE] at 12:38 PM. The CN stated that she was responsible for overseeing the NAs on the unit where Resident #6 resided. The CN stated that she rounded daily on the unit and looked for things like beds being made, call lights being answered, linens were clean, full trash cans, and making sure staff was offering fluids to the residents. The CN stated that on [DATE] to her knowledge the unit was fully staffed and NA #2 was not working the unit by herself. She added that it was unacceptable to her that NA #2 neglected to provide incontinent care and Resident #6 laid soiled for that long. She added she was not aware that the situation had occurred and would immediately address the issue with the staff including NA #2. An interview was conducted with the SW on [DATE] at 12:55 PM. The SW recalled entering Resident #6's room on [DATE] and covering his legs with a blanket. The SW stated she did not see that he was soiled and did not smell the fecal odor. She stated if she would have seen it or smelled she would have immediately went and got the NAs to clean him up. She stated I just noticed he was uncovered and I threw the blanket over his legs and exited his room. An interview was conducted with the Director of Nursing (DON) on [DATE] at 10:52 AM. The DON stated that she expected NA #2 to provide care as soon as possible and to never leave any resident heavily soiled for as long as Resident #6 was left soiled. She indicated that was unacceptable for Resident #6 to lay soiled for over an hour.

Based on observation, resident, staff, and nurse practitioner interviews, and record review, the facility failed to assess pain and stop during a dressing change when Resident #3 cried out in pain for 1 of 4 sampled residents who required dressing changes (Resident #3). The findings included: Resident #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's physician's orders [REDACTED]. Review of Resident #3's quarterly Minimum Data Set ((MDS) dated [DATE] revealed an assessment of moderately impaired cognition with the ability to understand and be understood by others. The MDS indicated Resident #3 received scheduled and as needed pain medication. The MDS indicated Resident #3 occasionally experienced moderate pain. Review of Resident #3's care plan revealed interventions for the gastrostomy tube site included provision of local care to the tube site as ordered. Review of a nurse practitioner's (NP) note dated 03/08/17 revealed a description of Resident #3's gastrostomy tube site. The NP documented a small amount of yellow/tan colored drainage with blood noted to the tube insertion site Review of a NP note dated 03/09/17 revealed Resident #3's gastrostomy tube site was red with no pus drainage. Observation on 03/19/17 at 3:21 PM revealed Nurse #1 washed her hands and donned gloves. Resident #3 was supine on an air mattress. Nurse #1 removed the 4 by 4 drain sponge around the gastrostomy tube, which was half wet with tan colored liquid. A white, thick paste was on the skin surrounding the gastrostomy tube approximately 2 inches in diameter. Nurse #1 reported the white substance was [MEDICATION NAME] protectant paste placed to protect Resident #3's red and sensitive skin. Nurse #1 discarded the soiled dressing, washed her hands and donned gloves. Continued observation on 03/19/17 at 3:24 PM revealed Nurse #1 began to wipe away the white substance with a dry 4 by 4 gauze pad. Resident #3 yelled out, that hurts and cried. Nurse #1 did not stop and did not ask Resident #3 about the complaint of pain. Nurse #1 began to wipe the skin with a new dry 4 by 4 gauze pad and was stopped by the surveyor. Nurse #1 placed a clean drain sponge on the site. Interview with Nurse #1 on 03/19/17 at 3:26 PM revealed she did not assess Resident #3 for pain during the dressing change. Nurse #1 reported she should have used soap and water when she began to remove the [MEDICATION NAME] protectant paste. Nurse #1 reported she should have stopped when Resident #3 began to complain of pain. Nurse #1 explained Resident #3's tube leaked and the skin was irritated. Nurse #1 reported she intended to administer Resident #3 pain medication and perform the dressing change later in the shift. Nurse #1 reported she made a mistake when she tried to remove the paste. Interview with Resident #3 on 03/19/17 at 3:30 PM revealed the skin hurt when touched and did not want the dressing change done for a-while. Interview with Resident #3 on 03/20/17 at 7:37 AM revealed she did not remember the dressing change which occurred on 03/19/17 and was confused. Observation on 03/20/17 at 11:22 AM revealed Nurse #2 used wound cleanser to remove the [MEDICATION NAME] protectant paste from the skin surrounding the gastrostomy tube. Resident #3 had no complaints of pain. Interview with the Nurse Practitioner on 03/21/17 at 8:18 AM revealed Resident #3's feeding tube leaked and the skin around the stoma was very sensitive. The NP explained Resident #3's gastrostomy tube site should be cleansed with soap and water or wound cleanser, rinsed, patted dry and covered with a clean dressing. The NP explained application of the [MEDICATION NAME] protectant paste should not be done since the zinc oxide in the paste is difficult to remove. Interview with the Director of Nursing (DON) on 03/21/17 at 8:29 AM revealed she expected staff to assess for pain before, during and after dressing changes. The DON reported Nurse #1 should have used soap and water and immediately stopped when Resident #3 complained of pain.

Based on staff and nurse practitioner interviews and record review, the facility failed to obtain a urine specimen, begin antibiotic therapy and assess 1 of 3 sampled residents with significant condition changes (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed an assessment of moderately impaired cognition. The MDS indicated Resident #1 was always incontinent of urine. Review of a nurse practitioner (NP) note dated 02/17/14 revealed nursing staff requested a visit due to an elevated temperature of 101.4 degrees Fahrenheit (F.) on 02/16/14 at 5:00 PM which decreased to 99.2 degrees after Tylenol (used to lower fever) adminstration. The NP documented an assessment of "lethargy, fatigue, chronic confusion and [MEDICAL CONDITION] times bounding." The NP documented Resident #1 was bedfast and if fluids were unable to be taken by mouth, intravenous fluids would be discussed with Resident #1's family members. Review of NP's orders dated 02/17/14 revealed direction to obtain an urinalysis with culture and sensitivity and begin [MEDICATION NAME] (an antibiotic) 1 Gram intramuscular injection daily which could be given with [MEDICATION NAME] (a topical anesthetic). A chest x-ray due to fever and encouragement of fluids were also ordered. This order was signed as received by Nurse #3. Review of Resident #1's February 2014 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation of [MEDICATION NAME] administration. Review of Resident #1's nursing notes dated 02/17/14 and 02/18/14 revealed there was no documentation of an assessment. There was no documentation of attempts to obtain a urine specimen. Review of Resident #1's situation, background assessment, request communication (SBAR) form dated 02/18/14 at 10:00 AM, completed by Nurse #1, revealed documentation of a heart rate of 108 and a temperature of 101.4 degrees F. The documentation described Resident #1 with facial drooping and symptoms of a [MEDICAL CONDITION] (TIA). Review of the NP's telephone order dated 02/18/14 revealed direction to transfer Resident #1 to the emergency room for evaluation of elevated temperature and possible TIA. Review of Resident #1's emergency room admission history and physical exam dated 02/18/14 revealed a [DIAGNOSES REDACTED]. and a heart rate of 108. Resident #1's urinalysis result dated 02/18/14, obtained in the emergency room , listed a turbid appearance with large amounts of blood and white blood cells. Resident #1 received intravenous antibiotics in the emergency room and was admitted to the hospital for treatment of [REDACTED]. A computed tomography (CT) scan of the head revealed there were no acute changes. Interview with Nurse #1 on 02/24/14 at 1:46 PM revealed Resident #1 was seen by the NP on 02/17/14 in response to an evening shift nurse request regarding an elevated temperature on 02/16/14. Nurse #1 reported Resident #1 began to sweat profusely with a facial droop the morning of 02/18/14. Nurse #1 reported she contacted the NP and transferred Resident #1 to the emergency room . Nurse #1 explained Resident #1 did not begin the [MEDICATION NAME] injections since a urine specimen had not been obtained. Nurse #1 explained Resident #1 would require a straight catherization to obtain a urine specimen. Nurse #1 reported she did not know the reason the urine specimen was not obtained but attempts would be documented in the nursing notes. Nurse #1 explained she received no special information regarding Resident #1 in report the morning of 02/18/14. Telephone interview with Nurse #2 on 02/24/14 at 3:55 PM revealed Nurse #3 informed her of the order to obtain Resident #1's urine specimen and begin antibiotic therapy. Nurse #2 explained she worked from 7:00 PM to 11:00 PM on 02/17/14. Nurse #2 reported she did not attempt to obtain the urine specimen since night shift usually obtained urine specimens. Nurse #2 reported she informed the night nurse, Nurse #4, of the need for a specimen and initiation of antibiotic therapy. Nurse #2 explained she did not remember if she assessed Resident #1 but the assessment would be documented in the nursing notes. Telephone interview with the NP on 02/24/14 at 4:13 PM revealed she did not receive notification Resident #1's urine specimen was not obtained and antibiotic therapy not initiated. The NP explained she expected staff to obtain the urine specimen upon receipt of the order and not wait until the night shift. The NP explained she would expect to be notified if the urine could not be obtained so she could direct staff to initiate the antibiotic therapy. The NP reported she expected staff to monitor Resident #1 which would include temperature measurements. Telephone interview with Nurse #3 on 02/24/14 at 4:55 PM revealed she took off the order to obtain the urine specimen at the end of her shift at 7:00 PM on 02/17/14. Nurse #3 reported she transcribed the [MEDICATION NAME] order and completed a laboratory requisition slip. Nurse #3 reported she informed Nurse #2 of the need to obtain the urine specimen and give the [MEDICATION NAME]. Nurse #3 could not recall if she assessed Resident #1 after the NP visit. Telephone interview with Nurse #4 on 02/25/14 at 7:55 AM revealed she worked from 11:00 PM on 02/17/14 to 7:00 AM on 02/18/14. Nurse #4 reported she was not aware of the order to obtain a urine specimen and begin antibiotic therapy for Resident #1. Nurse #4 explained she spoke to Resident #1 during the night and he did not appear ill. Interview with the Staff Development Coordinator (SDC) on 02/25/14 at 9:20 AM revealed she was the resource person in the absence of the Director of Nursing. The SDC explained the NP did not order the urine specimen as a stat (immediate) order so the night shift would be responsible for the specimen. The SDC reported the need for the specimen would be communicated orally and written on the 24 hour report. The SDC reported there was no documentation of attempts to obtain a specimen and could not provide the 24 hour report for review. The SDC reported there was no available documentation of vital sign measurements or assessments of Resident #1 from 02/17/14 until the transfer to the hospital on [DATE].. The SDC reported she expected staff to document attempts to obtain the urine specimen and assessments of Resident #1.

Based on record review and staff interviews the facility failed to monitor the urinary output and urine characteristics to prevent urinary tract infections for one (1) of three (3) sampled residents with urinary catheters. (Resident #3) The findings are: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had an admission order for staff to provide him with suprapubic catheter care every shift and as needed. Review of Resident #3's Minimum Data Set (MDS) of 10/24/11 revealed he had no cognitive deficits, had an indwelling catheter in place and required extensive assistance with toilet use and personal hygiene. The resident's Care Area Assessment (CAA) of 10/28/11 specified that he required catheter care due to having a suprapubic urinary catheter and was bedridden. Review of Resident #3's care plan of 10/28/11 revealed the resident had a history of [REDACTED]. A care plan goal specified the resident's risk for complications of infection would be minimized with interventions during the next ninety (90) days. Care plan approaches directed nursing staff to monitor the odor, color, clarity and amount of Resident #3's urine and to notify physician as needed. Review of Resident #3's "Nursing Daily Skilled Summary" revealed there was a designated area on this sheet for nursing staff to document their assessment of the resident's urine. Further review of this documentation revealed that nursing staff had not documented any assessment of Resident #3's urine on 11/14/11, 11/15/11, 11/16/11 and 11/18/11. On 11/17/11 a physician's orders [REDACTED]. Further review of Resident #3's medical record revealed the following nursing notes: Nursing note of 11/18/11 at 10:30 p.m.: Intravenous (IV) site showing signs of infiltration. Infusion stopped and physician notified. Will continue to monitor. Nursing note of 11/19/11 at 6:00 a.m.: IV attempted twice without success, fluids encouraged and no complaints voiced. Nursing note of 11/19/11 (note not timed): Resident #3 reported lower abdominal pain and had no urine output in his urinary catheter bag. The note specified that Resident #3's suprapubic urinary catheter was changed and 900 cubic centimeters (cc's) of yellow, cloudy urine was drained from the resident. The note further specified that Resident #3 was sent to the hospital for an unstable heart rate. This nursing note was signed by Licensed Nurse (LN) #2. Review of Resident #3's Hospital History and Physical of 11/19/11 revealed a [DIAGNOSES REDACTED]. Review of Resident #3's Hospital Discharge Summary of 11/29/11 revealed the following discharge diagnosis; "Sepsis from urinary source with Proteus and blood cultures and E. coli and Proteus in urine culture." On 03/28/12 at 11:15 a.m. an interview was conducted with LN #2. During this interview the nurse stated that she had cared for Resident #3 on 11/19/11 during the 7:00 a.m. to 3:00 p.m. shift. LN #2 explained that when she came on duty on 11/19/11 the nursing staff who worked the prior shift (11:00 p.m. to 7:00 a.m.) did not report to her that Resident #3 had experienced any problems with his suprapubic catheter (including blockages) or that he was not urinating. LN #2 stated that on 11/19/11 at approximately 8:30 a.m. Resident #3 complained of abdominal pain and she administered a medication to relief the pain. The nurse stated that while caring for Resident #3 she observed there was no urine in his suprapubic catheter's collection bag, so she obtained a physician's orders [REDACTED]. cloudy urine from his bladder. LN #2 stated that Resident #3's heart rate became unstable, so she then obtained orders for him to be sent to the hospital for evaluation. Interview on 03/28/12 at 1:10 p.m. with the facility's Director of Nursing (DON) revealed that if a resident had a urinary catheter nursing staff was expected to monitor the resident's urine output during the provision of care. The DON explained that nursing staff should report any concerns observed regarding the resident's urine including color, odor and if the resident had little or no output. The DON stated that Resident #3 was not on strict fluid intake and output monitoring, but nursing staff would have been expected to provide catheter care at least every shift as ordered. The DON also stated that nursing staff were to monitor the resident's urine each shift and the nurses were expected to document an assessment of the resident's urine on the "Nursing Daily Skilled Summary" sheet. The DON confirmed that nursing staff did not document any assessment of the resident's urine on 11/14/11, 11/15/11, 11/16/11 and on 11/18/11. The DON stated that if Resident #3 had little or no urine output on 11/19/11, during the 11:00 p.m. to 7:00 a.m. shift, the nurse on duty should have assessed the resident and reported this concern to the oncoming shift nurse (LN #2) and to the resident's physician for possible treatment. On 03/30/12 at 10:05 a.m. an interview was conducted with Resident #3's physician. The physician stated that when Resident #3 was admitted to the facility on [DATE] he had [DIAGNOSES REDACTED]. The physician explained that he did not believe Resident #3's condition warranted staff to perform strict monitoring of the resident's fluid intake and output, but staff were expected to monitor the resident's urine output for signs of dehydration and infection. The physician stated that he did not recall being informed that Resident #3 experienced any issues regarding decreased urine output or urine retention until the morning of 11/19/11. The physician confirmed that Resident #3 was diagnosed with [REDACTED].

Based on observations, staff interviews and record review, the facility staff failed to supervise and implement the facility's elopement policy for two (2) of eleven (11) sampled cognitively impaired residents at risk for wandering who exited the building unattended by staff (Resident #1 and Resident #11). Immediate jeopardy began on 10/22/11 when Resident #1 exited the building and facility property without staff supervision or knowledge. Immediate jeopardy was removed on 11/3/11 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) for Resident #1 and Resident #11 to ensure monitoring of systems put in place and completion of employee education. The findings are: Review of the facility's elopement policy dated 6/2007 revealed if an employee discovered a resident is missing from the facility, determination should be made to see if the resident is out on an authorized leave and if not; the Administrator and the Director of Nursing (DON) should be notified and a thorough search of the building and premises conducted. The Administrator, DON or designee will notify the resident's legal representative, physician, local law enforcement, state agency, if required, provide search teams with resident identification information and make an extensive search of the surrounding area. 1. Resident #1 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly elopement risk assessment on 9/26/11 revealed he was assessed as at risk for elopement. Review of Resident #1's annual Minimum (MDS) data set [DATE] assessed intact cognition with limited assistance of one person for transfers and ambulation. Review of Resident #1's care plan dated 9/28/11 revealed elopement identified as a problem with interventions which included redirection as needed and a safety monitoring device to the right wrist. physician's orders [REDACTED]. Review of a nursing note dated 10/22/11 at 6:00 PM by Licensed Nurse (LN) #1 revealed Resident #1's safety monitoring device check at 8:30 AM that morning showed active function. Resident #1 required redirection from another resident's room during the morning. Resident #1 left the facility unsupervised and without an alarm sounding. Resident #1 returned with a staff member after a search. Family members, the physician and facility management received notification. Resident #1 received a full physical assessment after the elopement and there were no injuries noted. The care plan was updated to include application of the safety monitoring device to the left wrist and one to one monitoring. Review of the security video taken on 10/22/11 revealed Resident #1 exited the building at 11:17:13 AM. Resident #1 attempted to open the door at the hinges then pressed the disabled door release button on the right side. The door opened automatically and Resident #1 ambulated out of the front door using a rolling walker. A dietary aide, identified by the Maintenance Director, entered the facility at 11:17:42 AM. Observation of Resident #1 on 11/1/11 at 9:26 AM revealed he ambulated independently with a rolling walker on the nursing unit. Resident #1 was unable to state the location of his room. The safety monitoring device was observed on his left wrist. Interview with Nursing Assistant (NA) #2 on 11/1/11 at 11:00 AM revealed she last saw Resident #1 after breakfast at approximately 10:00AM when he required redirection from another resident's room. NA #2 was at the nursing desk on 10/22/11 "around 11:30 AM" when a visitor approached inquiring the location of Resident #1. NA #2 explained she went to Resident #1's room which was at the beginning of the hall. When Resident #1 was not there, she went to another resident's room at the far end of the hall where Resident #1 had been redirected earlier that morning. NA #2 immediately reported to Licensed Nurse (LN) #1 that Resident #1 could not be located. NA #2 explained Resident #1's safety monitoring device was on that morning since no alarm sounded, she did not think he was out of the building. NA #2 revealed Resident #1 frequently walked with his walker in the facility so she expected he was in the dining room or on another hall. NA #2 explained Resident #1 required redirection to his room, but usually went on his own to the dining room. NA #2 reported she checked the rooms of the hall, the television room and the dining room. Interview with LN #1 on 11/1/11 at 12:30 PM revealed she had checked Resident #1's safety monitoring device for function around "8:30 AM." She was notified by NA #2 that Resident #1 was not in his room and could not be found on the unit "around 11:15 AM." LN #1 explained she was not too worried because no alarm sounded. LN #1 reported all staff on the unit checked all of the residents' rooms and closets at that time. LN #1 reported Resident #1 ambulated slowly with his walker and she thought he had left the unit, but was in the building. LN #1 reported after a search on the unit which took ten to twenty minutes, she notified LN #2, unit manager, of the inability to locate Resident #1. She explained she called Resident #1's family to see if they had taken him out without signing him out shortly after 11:30 AM. LN #1 reported Resident #1 returned to the facility with the Human Resources Coordinator (HRC) and his safety monitoring device sounded. Interview with the Staff Development Coordinator (SDC) on 11/1/11 at 1:20 PM revealed LN #2, unit manager, informed her Resident #1 could not be located. The SDC reported she knew the time of her notification was 12:25 PM. The SDC explained she directed the unit manager (LN #2) to implement the facility's elopement procedure which included police and administration notification. The SDC reported she also directed the elopement code to be announced over the speakers. The SDC recalled a search was in place outside of the building on the grounds at the time she was informed of the missing resident. Interview with the Maintenance Director on 11/1/11 at 1:50 PM revealed he received notification of Resident #1's elopement on 10/22/11 by the Director of Nursing (DON). The Maintenance Director explained Resident #1's safety monitoring device caused the alarm to sound upon his reentry to the building. The Maintenance Director explained when the safety monitoring device worked not only an alarm sounded but the exterior doors automatically locked. He explained that there would be a one to two second delay before the exterior door locked if a person was entering at the same time a resident with a safety monitoring device approached. Interview with the HRC on 11/1/11 at 4:12 PM revealed she heard the overhead page on 10/22/11 which announced a resident was missing. She reported she and the SDC left the facility in their private vehicles to search at 12:30 PM. The HRC explained she crossed the main road with stoplights and saw Resident #1 standing on the corner at the next two lane road, three-way intersection with stoplights. (This corner is 0.34 miles from the facility according to an Internet map. The main road is a four lane state highway with a speed limit of 35 miles per hour according to the transportation department. The temperature on 10/22/11 was a high of 66 degrees Fahrenheit according to an Internet weather organization.) The HRC reported she assisted Resident #1 into her van and returned to the facility. He told her it was a good day for a walk. The HRC added she asked other staff to return to the intersection to look for his walker. She reported the staff found Resident #1's walker next to the sidewalk away from the street. Interview with LN #2, unit manager, on 11/1/11 at 4:25 PM revealed LN #1 informed her Resident #1 was not able to be found on 10/22/11 "around 12:30 PM." LN #2 explained LN #1 told her all resident rooms were searched and the grounds were being checked. LN #2 notified the DON and directed staff to continue to search the grounds and independent living section. LN #2 reported the SDC and HRC began to search for Resident #1 in their private vehicles. LN #2 explained she called the police after notifying the DON and left a message with the emergency 911 number at approximately 12:30 PM. LN #2 explained the 911 operator told her the police would return the call. When the police returned the call "about 1:10 PM," Resident #1 was reentering the facility at the same time so no police involvement was requested. Interview with the dietary aide on 11/1/11 at 5:00 PM revealed she passed Resident #1 when he exited and she entered the facility on 10/22/11. The dietary aide explained she noticed Resident #1 leaving but thought he was going to sit outside and did not know he required supervision. The dietary aide explained Resident #1 did not appear confused and was dressed in slacks, shirt, jacket, socks, shoes and cap. She stated she did not notice a wrist band on Resident #1. She explained when she heard of the missing resident, she realized it was Resident #1 and reported seeing him earlier in the day. Interview on 11/2/11 at 8:15 AM with NA #1, who was assigned to Resident #1 on 10/22/11, revealed she assisted Resident #1 with dressing and bathing before breakfast on 10/22/11. NA #1 remembered seeing him in the hallway between 9:00 AM and 10:00 AM. NA #1 explained Resident #1 wandered in the facility and usually required redirection. NA #1 reported she assisted in the search on the hall but was not too concerned at first because there was no alert from the safety monitoring device. Interview with the DON on 11/2/11 at 8:25 AM revealed she received notification of the search for Resident #1 on 10/22/11 around 12:30 PM. The DON explained the search of the facility and grounds had been initiated by staff and she directed staff to notify the police. The DON reported Resident #1's safety monitoring device was checked and moved to the left wrist upon recommendation of the Maintenance Director. Interview with the DON on 11/2/11 at 11:35 AM revealed a search of the facility and property would be done before notification of the police and family. The notification of these parties would not necessarily be immediate since the resident missing could be still on the grounds. The DON explained she was notified when Resident #1 could not be found after a facility wide search. The facility presented a credible allegation of compliance which included: 1. Residents affected by the alleged deficient practice. The resident identified as leaving the Center on 10/22/11 at approximately 11:03 am was returned safely. A licensed nurse completed an assessment of the resident upon return to facility on 10/22/11 and there were no injuries. The resident was re-assessed for elopement risk on 10/22/11 by the Unit manager. The resident was placed on one on one monitoring by the direct care staff on 10/22/11 upon return to facility approximately 1:15 pm, and remained until the wander guard system was checked again by the Division Director of Facility Engineering for proper functioning on 10/24/11. The physician and family members were notified that the resident exited the building on 10/22/11 at approximately 1:15 pm. The resident's wander guard bracelet was checked for placement and functioning upon return to facility. Alarm sounded when resident returned to facility. The bracelet was moved to the left wrist due to recommendation by the Wander guard technician to have bracelet on same side as sensor. The Licensed Nurse checked the bracelet and door alarm using the tester and was noted to be functioning properly. The Maintenance Director checked the wander guard system, which includes the door module, range of door module, cables and wires and the alarm sound at the nurse's station on 10/22/11 at approximately 2 pm, and called the Wander Guard technician on 10/22/11 approximately 2:30 pm. All checks performed at that time indicated that the system was working properly. 2. Residents with the potential to be affected by the alleged deficient Practice: The Licensed Nursing staff reassessed 100% of current residents beginning 10/22/11 with completion on 10/24/11, using the elopement risk assessment to determine if they are at risk for elopement. There are eleven total residents identified to be at risk for elopement. The Licensed Nursing staff checked placement and function of wander guard bracelets for the residents identified at risk for elopement on 10/22/11. Licensed Nursing staff performed every fifteen-minute checks on 10/22/11 through 10/24/11 for those residents identified at risk for elopement. The wander guard system was checked by the Division of Facility Engineering on 10/24/11, and the system was working properly, so therefore, the every fifteen minute checks were discontinued. The Administrator and/or the Director of Nursing will discuss all attempted elopements during the morning meeting Monday through Friday and will discuss residents at risk for elopement weekly for one month. The licensed nurses will complete the Elopement Risk Assessment form for all residents upon admission, quarterly, annually, and with significant change of condition. The Director of Nursing and/or RN supervisors will evaluate each assessment and update care plans and certified nursing assistant assignment sheets, as necessary. The Director of Nursing and/or the Unit Managers will observe the residents identified at risk for elopement each day to assure that wander guard placement is verified and documented on the Treatment Administration Record (TAR) by the Licensed nursing staff. The Director of Nursing, Unit managers and RN Supervisors will review the TAR's daily to ensure that nurses have checked wander guard placement and have documented the same for the residents identified as an elopement risk. The wander guard bracelets are changed according to manufacturers recommendation, which is the expiration date stamped on the bracelet device. The Director of Nursing and/or the unit managers maintains a log and changes the bracelets according to the expiration date on the bracelet or if the bracelet does not function when tested . The night shift nurse will verify function of the wander guard bracelet each night by use of a testing device. The nurse will document on the TAR once every twenty-four hours in accordance with the Elopement Management Policy. The Maintenance Director checked the wander guard system, which includes the door module, range of door module, cables and wires and the alarm sound at the nurse's station on 10/22/11 at approximately 2 pm, and called the Wander Guard Corporation on 10/22/11 approximately 2:30 pm. All checks performed at that time indicated that the system was working properly. 3. Systemic Changes The Administrator, Director of Nursing, Maintenance director and other members of the management and nursing team has reviewed the Elopement Management Policy on 10/22/11 at an ad hoc Quality Assessment and Assurance Committee meeting and has determined that it is appropriate for the Center's use. The Licensed Nursing staff checked placement and function of wander guard bracelets for the residents identified at risk for elopement on 10/22/11. Licensed Nursing staff performed every fifteen-minute checks beginning 10/22/11, for those residents identified at risk for elopement through 10/24/11. All newly admitted residents will be assessed on the day of admission then weekly for a total of four weeks, by licensed nurses to determine whether they are at risk for elopement. Residents will be assessed by the licensed nurses using the Elopement Risk Assessment form. Residents will be reassessed quarterly, annually, and with significant change of condition. Based on these evaluations, care plans will be updated by the licensed nurse when identified to include intervention to address exit-seeking behavior. Licensed nurses will be responsible for assuring that physicians and family members are contacted of any identified changes within twenty-four hours. The Interdisciplinary Team will discuss all attempted elopements during the morning meeting Monday through Friday and will discuss residents at risk for elopement weekly for one month. The team includes the Administrator, Director of Nursing, Unit Mangers, and other members of the management and nursing team. The certified nursing assistants' assignment sheets will be updated by the Licensed nursing for each resident identified as having exit seeking behaviors. If such behaviors have occurred during the shift the nursing assistant will immediately report the behavior to the charge nurse for review and/or implementation of the facility elopement policy. The Maintenance Director and the Division Director of Facility Engineering checked the wander guard system again on 10/24/11 and determined that the system is functioning properly. The range limit was increased to approximately eight feet to allow the system to alarm once the resident was within approximately eight feet of the door. An additional alarm will be placed on the administrative hallway prior to entrance of the front lobby on 11/02/11. Current employees which includes nursing, housekeeping, dietary, therapy and management staff, have been re-educated by the Director of Nursing, Staff Development Nurse, Unit Managers and Weekend supervisor beginning October 22, 2011, regarding the door alarm system and the Elopement Policy and Procedure. All current staff has been in serviced as of 10/28/11, excluding seven prn therapy staff and one prn dietary staff. Staff will not be allowed to resume work until education is complete. The in service will be part of the new hire orientation for all newly hired employees. Elopement notebook, which includes pictures and any pertinent information about the resident identified at risk for elopement, will be kept at receptionist desk and each nursing station. Notebooks were reviewed and updated on 10/22/11 by the licensed nurses. Licensed nurses will update notebook when as necessary as changes occur. Notebook was reviewed with staff during the in service education beginning 10/22/11. The Director of Nursing and/or Unit Managers will audit TAR's daily for one week then weekly for one month, then monthly thereafter. The Director of Nursing or designee will trend the results of the audits and will discuss the results during the monthly Quality Assessment and Assurance Committee meeting. 4. Quality Assessment and Assurance Committee On 10/22/11 an ad hoc subcommittee of the Quality Assurance and Assessment Committee met to discuss and approve this plan. The Medical Director was informed and approved the plan on 10/22/11. The Committee will meet on a weekly basis for one month then monthly thereafter. Finding from the results of audits and oversight will be reported to the Committee on a monthly basis. The Committee will make recommendations for policy changes or further education where necessary. The Regional Clinical Director will review the meeting minutes monthly for three months. Immediate jeopardy was removed on November 3, 2011 at 5:00 PM with interviews of direct care, dietary, business office, housekeeping and licensed nursing staff who confirmed they received in-service training on the facility's elopement and safety monitoring device policy and procedures prior to reporting on duty. Interviews with facility staff revealed awareness of how to respond to a missing resident and implement the elopement procedure. Facility staff indicted awareness of the safety monitoring device function, wristband checks and location of wandering resident binders. Facility staff interviewed reported direction to notify a licensed nurse or department head immediately when a resident is missing. Interview with licensed nurses revealed awareness of the procedures. Record review of sampled residents revealed documentation of safety monitoring device checks. Observations of the sampled residents revealed safety monitoring devices located on left wrists or left ankles. 2. Resident #11 was admitted to the facility in September 2010. [DIAGNOSES REDACTED]. A safety monitoring device was placed on the Resident's right wrist on admission due to a statement in which she expressed a desire to leave the facility. Resident #11 had a prior history of elopement attempts from the facility in 2010. An annual minimum (MDS) data set [DATE] assessed Resident #11 with impaired cognition and daily decision-making skills. An elopement risk review dated 9/29/11 assessed Resident #11 at low risk for elopement for reasons to include no history of elopement within the prior six months and no verbal expressions to leave the facility. A care plan dated 9/29/11 identified Resident #11 at risk for elopement due to her dementia with approaches to include evaluation for placement of safety monitoring device and redirection as needed. On 10/24/11, the Resident's care plan was updated and a physician's orders [REDACTED]. from the facility. Additionally, on 10/24/11 an elopement risk review was completed. Resident #11 was again assessed at low risk for elopement for reasons to include no history of elopement within the prior six months and no verbal expressions to leave the facility. A nurse's note dated 10/30/11 at 4:00 PM written by licensed nurse #3 (LN #3) documented that Resident #11 was noted outside of the building in the parking lot in her wheel chair. No injuries were noted after an assessment. The nurse's note also documented that the Resident removed the safety monitoring device from her left wrist. The nurse's note continued that the safety monitoring device was replaced to the Resident's left ankle area on 10/30/11 upon her return to the facility. An elopement risk review was completed again on 10/30/11 and assessed Resident #11 at high risk for elopement due in part to her elopement from the facility on 10/30/11. On 11/1/11 the care plan was further updated and a physician's orders [REDACTED]. Review of the security video taken on 10/29/11 at 3:32 PM revealed Resident #11 self propelled to the facility's front door, then stopped and waited while another resident entered the facility. At 3:33 PM Resident #11 was observed to self propel out of the facility into the parking lot. At 3:34 PM Resident #11 was observed returned to the facility by a staff member. An interview on 11/2/11 at 5:17 PM with restorative aide #1 (RA #1) revealed that Resident #11 attempted to leave the facility in 2010 when the Resident stated "gotta go" and self propelled outside the front door of the facility after a visitor opened the front door; the alarm sounded and staff responded. RA #1 further stated that on 10/30/11 "between 2:30 and 3:00 PM", she heard a buzzing sound coming from the unit on the opposite side of the facility and then the buzzing stopped. Restorative aide #1 further stated she decided to check the front door of the facility. She observed Resident #11 self propelling down the left side of the building into the parking lot. The Resident was wearing a long sleeved shirt and pants, socks and shoes and said "Gotta go" when the Resident was approached. RA #1 checked the Resident, but a safety monitoring device was not found on Resident #11. RA #1 returned Resident #11 to the facility. An interview with nursing assistant #2 on 11/2/11 at 5:20 PM revealed she was familiar with Resident #11 and was assigned to care for her in the past. NA #2 stated that she was aware that Resident #11 would remove her safety monitoring device a lot. An interview with the director of nursing (DON) on 11/2/11 at 5:21 PM revealed that upon admission to the skilled nursing unit a safety monitoring device was placed on the Resident. Resident #11's care plan was updated December 2010 and a physician's orders [REDACTED]. The interview continued that when Resident #1 eloped from the facility on 10/22/11, all residents with wandering behavior were reassessed for risk of elopement and safety monitoring devices were all moved to the residents' left wrists, including Resident #11. The DON further stated that the safety monitoring device was placed on the Resident's left wrist on 10/24/11 despite her previous history of removing the safety monitoring device from her right wrist. When asked if Resident #11's ability to remove the safety monitoring device from her wrists was considered, the DON replied the safety monitoring devices were moved to the left wrist for all residents due to a recommendation from the facility's safety monitoring device vendor. The DON stated that on 10/30/11, Resident #11 was found in her wheel chair outside the facility in the parking lot by a staff member. The safety monitoring device was not located on Resident #11 when she was returned to the facility and still had not been found. A safety monitoring device was replaced on Resident #11 on her left ankle on 10/31/11 because of her ability to remove the safety monitoring device from her wrists. Review of an incident report dated 10/29/11 during the interview with the DON revealed Resident #11 was found at 3:30 PM outside in the parking lot area in her wheel chair. The safety monitoring device was replaced to the left ankle. The DON stated the date of the incident report should have been 10/30/11. An interview with LN #3 on 11/3/11 at 10:30 AM revealed that she checked the safety monitoring device for Resident #11 on 10/30/11 during med pass "between 8:00 and 9:00 AM" and it was on and functioning. LN #3 also stated that staff would often find Resident #11 on the other side of the facility at the entrance of the independent apartments where the Resident lived before admission to the facility. LN #3 stated she last observed Resident #11 on 10/30/11 "about 1 PM after lunch." LN #3 also stated that Resident #11 was found outside the facility about 3:30 PM on 10/30/11 without the safety monitoring device to her right wrist. LN #3 explained she was not sure how the Resident got the safety device off, but stated she had observed Resident #11 "fidget with it" in the past by moving the band up and down her forearm and towards her hand. Interview with the administrator on 11/3/11 at 11:40 AM revealed she was informed of the elopement for Resident #11 on 10/30/11 and discussed the incident during a staff meeting on the evening of 11/2/11. Staff was in the process of developing a plan for implementation to further prevent elopements in the future. Staff would need to be re-educated regarding elopements and to check placement more frequently. An interview with licensed nurse #4 (nurse supervisor) on 11/3/11 at 12:07 PM revealed that it was the responsibility of the nurse managers to apply safety monitoring devices to residents. LN #4 further stated that on 10/24/11 safety monitoring devices were replaced for all residents with a risk of elopement to the left wrist due to an elopement by Resident #1. LN #4 stated she applied the safety monitoring device to the left wrist on Resident #11 on 10/24/11 and checked to make sure it fit correctly. LN #4 also stated that LN #3 reported that Resident #11 would "play" with the band of her safety monitoring device by moving it up and down her arm and hand.

Based on staff interviews and medical record reviews, the facility failed to supervise one (1) of five (5) sampled residents who required staff assistance with toileting. (Resident # 2) The findings are: Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Admission assessment dated [DATE] for Resident # 2 revealed she was at risk for a fall due to confusion, had visual hallucinations and poor balance. A bed alarm was implemented on 09/02/10 for Resident # 2 because she attempted to get out of bed without assistance. Review of the initial plan of care dated 09/02/10 listed sensory need due to visual deficit, falls potential due to vision and weakness and required assistance with activities of daily living (ADL) function. One of the care plan intervention was to provide assistance as required for completion of ADL tasks. Review of Occupation Therapy Progress Notes dated 09/04/10 to 09/10/10 revealed Resident # 2 required moderate to maximum assistance with toileting. Resident # 2 required multiple verbal cues with moderate to maximum assistance for toileting. Review of the ADL report (used by the nursing assistants to provide care) dated 09/06/10 to 09/12/10 documented Resident # 2 required one person assistance with toileting. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was assessed with [REDACTED]. She was assessed as requiring one person assistance with toileting and transfers. Review of the nurses' notes for 09/13/10 at 4:50PM, the nurse aide (NA) #1 put the resident on the bedside commode and attached the call bell to Resident # 2' s shirt. The NA #1 instructed the Resident # 2 at 4:30PM to call for assistance after she was done toileting. The NA #1 came back to Resident # 2' s room to check on her at 4:35PM, she was found on the floor. The NA #1 notified the licensed nurse about the fall and Resident # 2 complained of head and right shoulder pain. The physician was notified on 09/13/10 and he ordered an x-ray of head, right shoulder and right hip. The x-ray on 09/13/10 revealed no fractures of the head, right shoulder or right hip. Resident # 2 still had complaints of right side pain and the physician ordered an x-ray of the rib cage on 09/15/10. A review of the x-ray report on 09/15/10 revealed Resident # 2 had a acute right rib fracture. During an interview with Licensed Nurse (LN) #1 on 09/16/10 at 4:00PM, she stated that NA #1 informed her on 09/13/10 that Resident # 2 was unattended on the bedside commode. When NA #1 returned to the room, the Resident #2 was found on the floor. Interview with the Director of Nursing (DON) on 09/16/10 at 4:38PM, revealed the NA #1 should not leave Resident # 2 unattended due to resident's poor cognition and visual impairments. She revealed Resident # 2 was at a high risk for falls due to her poor cognition. She revealed the nurse aides use a Resident Care Specialist assignment sheet that list safety interventions for each resident and Resident # 2 is listed as requiring assistance and at risk for falls. Telephone interview with NA #1 on 09/16/10 at 5:00PM, revealed this was her first time working with Resident # 2. She stated that she put Resident # 2 on the bedside commode in her room. She left Resident #2 on the bedside commode to check on another resident. She clipped the call bell to Resident # 2' s shirt and instructed her not to get up but to call for assistance. She left the room to check on another resident and when she came back, the resident was lying on the floor. She revealed she did not know Resident # 2 needed supervision during tolieting.She revealed the nurse aide assignment sheet did not state that Resident # 2 needed supervision during tolieting.