Every finding on record at Sapphire Ridge Health and Rehabilitation

Based on record review, observations and staff interviews, the facility failed to date open containers of nutritional supplements and failed to remove nutritional supplements stored past the use by date in 2 of 3 nourishment room refrigerators (North and South Units). This practice had the potential to affect residents receiving nutritional supplements.Findings included:Observations of the nourishment room refrigerators on the North and South Units conducted on 05/06/26 at 10:29 AM through 10:41 AM with the Dietary Manager (DM) revealed:a. Stored in the North Unit nourishment room refrigerator was a one-quart sized nutritional shake with no date to indicate when it was opened. The manufacturer's label on the container read, use within 4 days after opening if refrigerated.b. Stored in the South Unit nourishment room refrigerator were two one-quart sized nutritional shakes dated 4/24 and 4/28. The manufacturer's label on the containers read, use within 4 days after opening if refrigerated. Also stored was one opened and undated 8-ounce sized diabetic nutritional shake. The manufacturer's label on the container read if opened use within 48 hours.At the completion of the observation, the DM was interviewed and stated dietary staff did not stock nutritional shakes in the nourishment room refrigerators. The DM stated the nurses were responsible for the nutritional shakes given to residents and for dating those when opened and discarding when past the use by date. The DM revealed dietary staff checked the nourishment room refrigerators twice a day and restocked and checked expirations dates on the snacks and drinks provided by the kitchen. During an interview on 05/06/26 at 1:55 PM, Nurse #1 explained that a physician's order was required for a resident to receive a nutritional shake, and nurses were responsible for administering those. Nurse #1 revealed when a nutritional shake was administered the nurse was responsible for writing the date it was opened and for ensuring nutritional shakes were used and discarded by the use by date on the manufacture's label.An interview was conducted on 05/07/26 at 3:02 PM with the Administrator. The Administrator stated it was the responsibility of the person who opened a nutritional shake to write the date it was opened on the container. She stated historically dietary staff checked the dates on food and drinks stored in the nourishment room refrigerators.

Based on record review, observations, resident and staff interviews, the facility failed to provide assistance with denture care for 1 of 4 dependent residents reviewed for activities of daily living (Resident #100).Findings included:Resident #100 was admitted to the facility on [DATE] with diagnoses which included stroke, dysphagia (difficulty swallowing), and dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #100's cognition was severely impaired, setup or clean-up assistance was needed with oral hygiene, had no natural teeth or tooth fragments (edentulous), and had no rejection of care or behaviors during the lookback period.A review of the Nurse Aide (NA) documentation for oral care/denture care revealed from 04/07/26 through 05/05/26 denture care was documented as provided three times for Resident #100 on 04/14/26, 04/25/25, and 04/26/26.The care plan dated 04/19/26 revealed Resident #100 was at risk for oral and dental health problems related to being edentulous and identified a deficit in his ability to perform activities of daily living self-care related to dementia and a stroke. The goals included to maintain the highest practicable level of independence in performing activities of daily living. The interventions included were to provide or assist with oral care at least twice daily using a soft toothbrush or foam swab and to provide cues or minimal assistance to complete activities of daily living as appropriate. Review of the Kardex (a care plan reference guide) utilized by NA staff specified they were to provide or assist Resident #100 with oral care at least twice daily using a soft toothbrush or foam swabs.An observation and interview with Resident #100 were conducted on 05/04/26 at 10:39 AM. Resident #100 stated he wore upper and lower dentures and showed his dentures had brown stains and a buildup of debris around the teeth and gums. Resident #100 stated he could brush his dentures if he had a toothbrush and toothpaste.An interview was conducted on 05/06/26 at 3:37 PM with NA #1. NA #1 revealed she was Resident #100's assigned NA during the day shift on 05/04/26, 05/05/26, and 05/06/26 and she had provided setup assistance with oral care. She explained she gave Resident #100 mouthwash and a basin for him to rinse his mouth because he had difficulty brushing his teeth. NA #1 revealed oral hygiene care was provided at least once during her shift and as needed. NA #1 stated Resident #100, did not have dentures, had his own teeth and confirmed she had not provided denture care. NA #1 revealed denture care meant dentures were soaked overnight, rinsed in morning, and adhesive was applied.A phone interview was conducted on 05/06/26 at 4:37 PM with NA #2. NA #2 confirmed she worked the night shift on 05/05/26 and previously had been Resident #100's assigned NA on multiple occasions. NA #2 stated she was aware Resident #100 wore dentures because she had seen them on the bed or nightstand. NA #2 stated she would do denture care but did not because, most times when she arrived Resident #100 had already eaten, was in bed and was very straight forward he did not want to take out his dentures. NA #2 revealed denture care meant they were soaked overnight.An observation and interviews were conducted on 05/06/26 at 3:24 PM with the Director of Nursing (DON) and Resident #100. Resident #100 stated no one had provided assistance with denture care and agreed to have his dentures cleaned at that time. Resident #100 removed his dentures and gave them to the DON. The DON observed Resident #100's upper and lower dentures had a buildup of debris and brown colored stains around the teeth and gums and took them to be cleaned.A follow-up interview was conducted on 05/06/26 at 3:53 PM with the DON. The DON revealed he reviewed the care plan and Kardex that indicated Resident #100 was supposed to receive oral care at least twice a day. The DON stated dentures should be brushed and soaked overnight and placed in the resident's mouth in morning.During an interview on 05/07/26 at 3:14 PM, the Administrator stated denture care was done daily either by Resident #100 or provided by the NA. The Administrator stated oral hygiene care, ideally should be done twice a day.

Based on record review and staff interviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) determination for a resident who was admitted to the facility with a serious mental health disorder for 1 of 2 residents reviewed for PASRR (Resident #11).Findings included:A PASRR Determination Notification letter dated 10/27/25 revealed Resident #11 had a Level I PASRR with no expiration date.Resident #11 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, generalized anxiety disorder, and vascular dementia with severe behavioral disturbance.A psychiatric progress note dated 10/29/25 revealed Resident #11 admitted to the facility from another facility and per the records received from the previous facility, she had a history of bipolar disorder for many years and recent behavioral and psychological symptoms of dementia (BPSD, refers to non-cognitive symptoms and behaviors such as agitation, aggression, anxiety, depression and hallucinations). The psychiatric provider noted Resident 11's had active diagnoses of bipolar disorder, bipolar depression and generalized anxiety disorder that were managed with duloxetine (medication used to treat depression and anxiety) 60 milligrams (mg) once a day, clonazepam (medication used to treat severe anxiety) 0.5 mg twice daily, quetiapine (antipsychotic) 50 mg every morning, quetiapine 150 mg at bedtime, and trazodone (medication used to treat depression) at bedtime.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #11's active psychiatric/mood disorder diagnoses included anxiety disorder and bipolar disorder. She received antipsychotic mediation on a routine basis only and a gradual dose reduction was documented by the physician as clinically contraindicated on 10/29/25.A North Carolina Medicaid Uniform Screening Tool (NC MUST, internet-based application utilized to communicate and manage PASRR requests) inquiry provided by the Administrator on 05/05/26 at 2:45 PM revealed Resident #11 had a Level I PASRR effective 04/03/23 with no expiration date. There were no PASRR requests submitted for an evaluation for a [NAME] II PASRR determination prior to 05/05/26.During interviews on 05/05/26 at 3:14 PM and 05/07/26 at 11:55 AM, the Social Worker (SW) revealed when residents admitted to the facility, she checked the NC MUST to see if the resident had a current PASRR but did not check to see if mental health diagnoses were included in the initial screening. The SW explained that previously, a PASRR evaluator had informed her that if a resident had a Level I PASRR then a request for an evaluation for a Level II PASRR determination did not need to be submitted unless the resident had a change in condition. The SW confirmed a request for a Level II PASRR evaluation was not submitted for Resident #11 based on the guidance she was given.During an interview on 03/10/26 at 2:37 PM, the Administrator stated the SW was responsible for submitting requests for Level II PASRR evaluations. She explained that based on previous guidance the SW received from the PASRR evaluator, a request for a Level II PASRR evaluation for Resident #11 was not completed. The Administrator stated she would expect for PASRR requests to be submitted per regulatory guidelines.

Based on interviews with residents and staff, the facility failed to ensure residents' right to receive mail delivered on Saturdays. This had the potential to affect 107 of 107 residents in the facility.Findings included:A Resident Council group interview was conducted on 05/06/26 at 11:00 AM with Residents #46 (Resident Council President), #33, #35, #42, and #83 in attendance. In addition, the Activity Director was present during the group interview at the residents request. Resident #35 reported if mail was delivered to the facility on Saturday, it was not delivered to the residents until Monday by the Activities Director. Resident #33 and Resident #83 both voiced agreement with Resident #35's statement and when asked, Resident #46 and Resident #42 did not disagree.During interviews on 05/06/26 at 11:00 AM and 11:44 AM, the Activity Director explained she was working as a Certified Occupational Therapist Assistant until 04/24/26 when she took over the position of the Activity Director. She stated she did not currently work weekends and was not sure how the process worked regarding mail being delivered to residents on the weekends.During an interview on 05/06/26 at 3:00 PM, the Receptionist reported she worked Mondays through Fridays during the hours of 8:00 AM to 4:00 PM and there was a weekend receptionist that worked Saturdays and Sundays, usually during the hours of 10:00 AM to 7:00 PM. The Receptionist stated the weekend Receptionist did not have a key to open the outside mailbox to check for any mail delivered on Saturday. The Receptionist explained she retrieved the mail from the outside mailbox on Monday morning and gave the mail to the Business Office Manager and the Activity Director delivered the mail to the residents.During an interview on 05/06/26 at 3:06 PM, the Business Office Manager confirmed that if she was not at work on the weekends, no one currently had access to open the outdoor mailbox to retrieve the mail. The Business Office Manager reported that she worked on Saturdays 90% of the time and she checked the mailbox, sorted the mail and gave the residents mail to activity staff to deliver or on occasion, she delivered the mail to the residents. She explained the previous Activity Director left employment approximately 6 to 7 weeks ago and since then there was no one at the facility to deliver the mail to residents if she was not working. The Business Office Manager stated the new Activity Director transitioned from the therapy department on 04/24/26 but she had not yet been trained on the process of sorting the mail to determine what needed to be delivered to the residents and what needed to be placed in the business office.During an interview on 05/07/26 at 3:45 PM, the Administrator stated the breakdown regarding mail not being delivered to residents on the weekend was due to turnover in the activity department. She explained there were approximately 3 weeks or so when mail wasn't delivered to residents on the weekends because they didn't have an Activity Director and only had an Activity Assistant. The Administrator stated it was important for residents to receive mail and acknowledged they should receive their mail when delivered, including weekends.

Based on observations, record review and resident, family and staff interviews, the facility failed to serve the lunch meal at the posted times on 03/05/25 and 03/06/25 in the main dining room during 2 of 3 meal observations. The findings included: Review of the facility's meal times schedule revealed lunch was to be served in the main dining room at 12:30 PM. a. Resident #54 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54 had severe cognitive impairment, required partial/moderate assistance with eating and received a mechanically altered diet. Resident #101 was admitted to the facility on [DATE]. The admission MDS assessment dated [DATE] indicated Resident #101 had severe cognitive impairment, required setup or cleanup assistance with eating and received a mechanically altered diet. An observation of the lunch meal service in the main dining room on 03/05/25 at 1:10 PM revealed residents were seated at various tables eating their lunch. Resident #54 was seated at a table in the back of the dining room by herself and had not received her meal tray. Resident #101 was seated at a table in the middle of the dining room and had not received her meal tray. There were three other residents sitting at the table with Resident #101 who all had received their meal tray and were eating their lunch. At 1:20 PM, both Resident #54 and Resident #101 received their lunch meal tray. During the lunch meal observation, an interview was conducted with the Responsible Party (RP) for another resident on 03/05/25 at 1:11 PM. The RP stated they came to the facility every day to sit with their family member during lunch. The RP expressed it was a regular occurrence that meals were often served late, which was why they made sure they were at the facility daily for at least one meal. During the lunch meal observation, an interview was conducted with the Speech Therapist on 03/05/25 at 1:13 PM. The Speech Therapist stated she was working with Resident #101 for therapy and was not sure why Resident #101 had not received her lunch meal tray. The Speech Therapist stated the Administrator was aware that both Resident #54 and Resident #101 had not received their meal trays. During an interview on 03/05/25 at 1:20 PM, the Administrator confirmed that meal trays were delivered late to the main dining but could not provide an explanation for the delay. The Administrator stated both Resident #54 and Resident #101 did not normally eat in the main dining room and their meal trays were delivered to the hall. She acknowledged that it was too late for both residents to just now receive their meals. A Resident Council group interview was conducted on 03/05/25 at 3:32 PM with Resident #4, Resident #11, Resident #35, Resident #42, Resident #51, Resident #62, and Resident #74 in attendance. The residents all voiced meals were served late on a daily basis regardless if they ate in their rooms or the main dining room. b. A continuous observation of the lunch meal service in the main dining room was conducted on 03/06/25 from 12:00 PM to 1:30 PM. At 12:00 PM, there were several residents already seated at various tables while staff continued to bring other residents into the dining room for lunch. Staff were observed assisting residents with donning clothing protectors and providing drinks to residents at the tables while they waited on lunch to be served. At 12:30 PM, meal carts had not arrived to the main dining room. At 12:40 PM, the meal cart arrived in the main dining room and there were five staff present who immediately started passing out meal trays to residents seated at the tables in the front of the main dining room. At 12:55 PM, the residents who were able to eat independently had all received their meal tray and were eating their lunch while the residents in the back of the main dining room, who needed staff assistance, had not been served their meal. At 1:00 PM, another meal cart arrived in the main dining room and staff started sitting down at the tables assisting dependent residents with their meal. At 1:25 PM the last two residents were provided their meal tray and staff proceeded to assist the residents with eating lunch. During the lunch meal observation on 03/06/25 at 1:21 PM, the Responsible Party (RP) for another resident, who was seated at the table with her family member, expressed now you understand why I make sure I am present for at least one meal. During an interview on 03/07/25 at 2:50 PM, the Dietary Manager (DM) revealed he was aware of the issue with meals being served late and there were several contributing factors. He explained one contributing factor was dietary had a limited amount of dinnerware to serve resident meals such as plates, plate covers and base, and silverware. He had ordered more dinnerware but the vendor had trouble getting certain items. The DM stated he requested facility staff collect and return meal trays by a certain time after each meal so that dietary staff could get the dinnerware clean and ready for the next meal service but that did not always happen. As a result, he stated there had been times they had to stop meal service just to wash dishes in order to finish serving meals. The DM stated he was provided a list of residents who ate in the main dining room and if a resident was not on that list, their meal tray was sent in the meal cart to the hall. He stated when a resident's meal tray was not delivered on the meal cart for the main dining room staff called the kitchen requesting they bring a meal tray to the dining room which took one of the three dietary staff off the meal line slowing production. He explained if a resident who normally ate in their room decided they wanted to eat in the main dining room, he relied on staff to let him know prior to the start of meal service so the resident's meal tray would be delivered to the correct location. During an interview on 03/07/25 at 4:34 PM, the Administrator revealed she was aware of the issue with meals being served late and confirmed residents had also brought their concerns regarding late meals to her attention. The Administrator stated when meal trays were not on the meal cart, facility staff would go down to the kitchen to get a resident's meal tray to help out but dietary staff were usually in the middle of tray line production and if they stopped to look for a certain meal ticket it would disrupt the process causing further delay. The Administrator acknowledged she knew there was a shortage of dinnerware for residents' meals and explained when meals were served late, she was not going to have staff rush residents to finish the meal so that dietary staff could get the dinnerware washed at a certain time. She stated when the lunch meal was served late, she expected dietary staff to push back the time dinner was served so that residents were not going throughout the night hungry. The Administrator stated she was not sure what the root cause was regarding late meals but felt it could be more of a process issue rather than a staffing issue.

Based on an observation of the lunch meal tray preparation, record review, and interviews with the Dietary Manager and staff, the facility failed to provide the correct portion size of beef hamburger steak for residents receiving a mechanically altered diet. This failure had the potential to affect 18 of 97 residents who received a lunch meal tray with a mechanically altered diet. Findings included: The facility's diet consistency census report dated 03/03/25 revealed 18 of 97 residents received a mechanically altered diet. The facility's planned menu for Wednesday (03/05/25) listed beef hamburger steak as the protein being served for lunch. The portion size listed on the menu indicated each plate received one beef hamburger steak. The beef hamburger steak packaging revealed each steak was a 4-ounce portion. A continuous observation of lunch trays being prepared for residents was conducted on 03/05/25 at 11:54 AM through 1:38 PM. The Dietary Manager served one (4 ounce) beef hamburger steak for residents that received a regular diet. The Dietary Manager and [NAME] used a ladle with a red colored handle (2 ounce) to portion each plate of beef hamburger steak for residents that received a mechanically altered diet. During an interview on 03/05/25 at 12:50 PM the [NAME] confirmed the red handle ladle was used to portion the beef hamburger steak for residents receiving a mechanically altered diet and confirmed the ladle was for plating a 2-ounce portion. The [NAME] revealed for portion sizes he used a guide to select the correct one based on the color of the handle and pointed to a guide posted on wall behind the steam table. The guide was a picture of kitchen scoop sizes in ounces and milliliters but did not include ladles or other utensils. During an interview on 03/05/25 at 1:30 PM the Dietary Manager confirmed the correct portion size for the beef hamburger steak being served to residents was 4 ounces. The Dietary Manager stated residents receiving a mechanically altered diet received half a portion because the incorrect ladle was used to portion the beef hamburger steak onto the plate. The Dietary Manager confirmed the incorrect ladle had a red handle and was a 2-ounce portion used by him and the [NAME] by mistake and was an oversight. During an interview on 03/07/25 at 6:14 PM the Administrator revealed she expected the residents who received a mechanically altered diet to be served the correct portion size. The Administrator revealed she expected the correct utensil to be used by dietary staff when plating food to ensure portion sizes were accurate.

Based on record review and staff interviews the facility failed to include documentation in the medical record of refusal or acceptance of the COVID-19 vaccination for 5 of 5 residents (Resident #20, Resident #44, Resident #37, Resident #80, and Resident #62) reviewed for immunizations and failed to assess the eligibility to receive the COVID-19 vaccine for 1 of 5 (Resident #44) residents reviewed for immunizations. Findings included: 1. (a). Resident #20 was admitted to the facility on [DATE]. Review of an unsigned Vaccine Declination Form dated 08/01/24 for COVID-19 revealed multiple attempts to contact Resident #20's Power of Attorney (POA) were unsuccessful. The significant change Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #20 was severely cognitively impaired. Review of Resident #20's electronic medical record revealed the Vaccine Declination Form dated 08/01/24 was not included in her medical record. (b). Resident #44 was admitted to the facility on [DATE]. Review of a Vaccine Consent Form dated 07/18/24 revealed Resident #44's Guardian had provided a verbal consent for Resident #44 to receive the COVID-19 vaccine, and he received the COVID-19 vaccine on 07/18/24. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was severely cognitively impaired. Review of Resident #44's electronic medical record revealed the Vaccine Consent Form dated 07/18/24 was not included in his medical record. (c). Resident #37 was admitted to the facility on [DATE]. Review of the Vaccine Declination Form dated 07/09/24 revealed Resident #37 declined the COVID-19 vaccine. The quarterly Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. Review of Resident #37's electronic medical record revealed the Vaccine Declination Form dated 07/09/24 was not included in his medical record. (d). Resident #80 was admitted to the facility on [DATE]. Review of a Vaccine Declination Form dated 07/10/24 revealed Resident #80's family member verbally declined the COVID-19 vaccine. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was severely cognitively impaired. Review of Resident #80's electronic medical record revealed the Vaccine Declination Form dated 07/10/24 was not included in her medical record. (e). Resident #62 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact. Review of Resident #62's electronic medical record revealed no documentation of acceptance or declination of the COVID-19 vaccine. An interview with the Director of Nursing (DON) on 03/06/25 at 11:23 AM revealed he tried to keep all resident consents or declination forms for vaccines in a binder in his office and he was not aware that they needed to be included in the resident's medical record. An interview with the Administrator on 03/07/25 at 5:16 PM revealed she expected vaccination consents or declination forms to be a part of the medical record. 2. Resident #44 was admitted to the facility on [DATE]. Review of a document titled Vaccine Consent Form dated 07/18/24 for Resident #44 read in part as follows: Please answer the following questions so we can assess the safety and the appropriateness of vaccination. Each of the fourteen questions had a box for yes or no and all of the questions were blank. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was severely cognitively impaired. The Vaccine Consent Form dated 07/18/24 revealed Resident #44 received a COVID-19 vaccine on 07/18/24. An interview with the Director of Nursing (DON) on 03/06/25 at 11:23 AM revealed the COVID-19 vaccine was administered through an outside vaccination company that came to the facility at least every six months but his staff were responsible for obtaining consent. He stated the staff member obtaining consent for the COVID-19 vaccine was responsible for determining if it was appropriate to offer the resident the vaccine or not and the questions for vaccine appropriateness should have been answered. An interview with the Administrator on 03/07/25 at 5:16 PM revealed she expected vaccine consents to contain all the required information and questions should not be left blank.

Based on record review and staff interviews the facility failed to include documentation in the medical record of refusal or acceptance of influenza and pneumonia vaccinations for 5 of 5 residents (Resident #20, Resident #44, Resident #37, Resident #80, and Resident #62) reviewed for immunizations and failed to assess the eligibility to receive the influenza and pneumonia vaccines for 2 of 5 (Resident #44 and Resident #37). Findings included: 1. (a). Resident #20 was admitted to the facility 04/06/23. Review of an unsigned Vaccine Declination Form dated 08/01/24 for influenza and pneumonia vaccines revealed multiple attempts to contact Resident #20's Power of Attorney (POA) were unsuccessful. The significant change Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #20 was severely cognitively impaired. The MDS reflected Resident #20 had not received the influenza or pneumonia vaccine. Review of Resident #20's electronic medical record revealed the Vaccine Declination Form dated 08/01/24 was not included in her medical record. (b). Resident #44 was admitted to the facility 05/05/23. Review of a Vaccine Consent Form dated 07/18/24 revealed Resident #44's Guardian had provided a verbal consent for Resident #44 to receive the pneumonia vaccine, and he received the pneumonia vaccine on 07/18/24. Review of a Vaccine Consent Form dated 10/04/24 revealed Resident #44's [NAME] had provided email consent dated 07/09/24 to receive the influenza vaccine, and he received the influenza vaccine on 10/04/24. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was severely cognitively impaired. The MDS reflected Resident #44 received the influenza vaccine 10/04/24 and was up to date with the pneumonia vaccine. Review of Resident #44's electronic medical record revealed the Vaccine Consent Form dated 07/18/24 and 10/04/24 were not included in his medical record. (c). Resident #37 was admitted to the facility 10/11/23. Review of the Vaccine Declination Form dated 07/09/24 revealed Resident #37 declined the influenza and pneumonia vaccines. Review of a Vaccine Consent Form dated 10/04/24 revealed Resident #37 consented to receive the influenza vaccine, and the vaccine was administered 10/04/24. The quarterly Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. The MDS reflected he received the influenza vaccine 10/04/24, was not up to date on the pneumonia vaccine, and had been offered and declined the pneumonia vaccine. Review of Resident #37's electronic medical record revealed the Vaccine Declination Form dated 07/09/24 and Vaccine Consent Form dated 10/04/24 were not included in his medical record. (d). Resident #80 was admitted to the facility 05/12/24. Review of a Vaccine Declination Form dated 07/10/24 revealed Resident #80's family member verbally declined the influenza vaccine. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was severely cognitively impaired. The MDS reflected resident #80 received the influenza vaccine on 09/08/24 and was not up to date on the pneumonia vaccine. Review of Resident #80's electronic medical record revealed the Vaccine Declination Form dated 07/10/24 was not included in her medical record. No consent or declination form for the pneumonia vaccine was present in Resident #80's medical record. (e). Resident #62 was admitted to the facility 04/05/23. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact. The MDS reflected Resident #62 was offered and declined the influenza and pneumonia vaccines. Review of Resident #62's electronic medical record revealed no documentation of acceptance or declination of the influenza and pneumonia vaccines. An interview with the Director of Nursing (DON) on 03/06/25 at 11:23 AM revealed he tried to keep all resident consents or declinations for vaccines in a binder in his office and he was not aware that they needed to be included in the resident's medical record. An interview with the Administrator on 03/07/25 at 5:16 PM revealed she expected vaccination consents or declinations to be a part of the medical record. 2. (a). Resident #44 was admitted to the facility 05/05/23. Review of a document titled Vaccine Consent Form dated 07/18/24 for Resident #44 read in part as follows: Please answer the following questions so we can assess the safety and the appropriateness of vaccination. Each of the fourteen questions had a box for yes or no and all of the questions were blank. The Vaccine Consent Form dated 07/18/24 revealed Resident #44 received the pneumonia vaccine on 07/18/24. Review of a document titled Vaccine Consent Form dated 10/08/24 for Resident #44 read in part as follows: Please answer the following questions so we can assess the safety and the appropriateness of vaccination. Each of the fourteen questions had a box for yes or no and all of the questions were blank. The Vaccine Consent Form dated 10/04/24 revealed Resident #44 received the influenza vaccine on 10/04/24. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was severely cognitively impaired. The MDS reflected Resident #44 received the influenza vaccine 10/04/24 and was up to date with the pneumonia vaccine. (b). Resident #37 was admitted to the facility 10/11/23. Review of a document titled Vaccine Consent Form dated 10/08/24 for Resident #37 read in part as follows: Please answer the following questions so we can assess the safety and the appropriateness of vaccination. Each of the fourteen questions had a box for yes or no and all of the questions were blank. The Vaccine Consent Form dated 10/04/24 revealed Resident #37 received the influenza vaccine on 10/04/24. The quarterly Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. The MDS reflected he received the influenza vaccine 10/04/24, was not up to date on the pneumonia vaccine, and had been offered and declined the pneumonia vaccine. An interview with the Director of Nursing (DON) on 03/06/25 at 11:23 AM revealed influenza and pneumonia vaccines were administered through an outside vaccination company that came to the facility at least every six months but his staff were responsible for obtaining consent. He stated the staff member obtaining consent for the influenza or pneumonia vaccine was responsible for determining if it was appropriate to offer the resident the vaccine or not and the questions for vaccine appropriateness should have been answered. An interview with the Administrator on 03/07/25 at 5:16 PM revealed she expected vaccine consents to contain all the required information and questions should not be left blank.

Based on record review, observations, and staff interviews the facility failed to remove food items stored and available for use that had signs of spoilage or were past the expiration date from the walk-in refrigerator and dry goods storage area located in the kitchen. The facility also failed to date an opened container of nectar thick milk stored in the nutrition refrigerator used for residents on the memory care unit for 1 of 2 nutrition refrigerators. This deficient practice had the potential to affect food and beverages served to residents. Findings included: The initial tour of the kitchen with the Dietary Manager on [DATE] at 7:55 AM revealed the following: 1a. A container of enchilada sauce with an expiration date ,d+[DATE] stored in the walk-in refrigerator and available for use. b. A container of sliced lemons with a white, slimy discoloration with a use by date [DATE] stored in the walk-in refrigerator and available for use. c. A container of sliced bananas mixed with pineapple tidbits with the slices of banana that had turned brown to black in color. The use by date written on the container was [DATE] and stored in the walk-in refrigerator available for use. d. A 32-ounce container of vanilla flavored nutritional drink supplement with a use by date [DATE] stored in the dry goods storage area of the kitchen and available for use. e. Forty-eight 4 ounce containers of thickened lemon flavor water of honey thick consistency with a use by date [DATE] stored in the dry goods storage area of the kitchen and available for use. f. Nine 32 fluid ounce containers of vanilla protein drink supplement with an expiration date [DATE] stored in the dry goods storage area of the kitchen and available for use. During an interview on [DATE] at the Dietary Manager revealed for open food containers dietary staff were expected to the label with an open and use by date and the item was kept available for use in the walk-in refrigerator for seven days then discarded. The Dietary Manager stated he checked food items stored in the walk-in refrigerator daily to ensure foods were labeled and discarded if there were signs of spoilage or it was out of date. He revealed today ([DATE]) he was busy and had not had time to check the walk-in refrigerator for out of date or spoiled food. The Dietary Manager revealed he checked the dates on food items in dry goods storage area when putting away newly delivered items. He revealed the expired items in the dry goods storage area were stored on the shelf designated for emergency food and he had not checked the expiration dates on those. An interview was conducted with the Administrator on [DATE] at 6:14 PM. The Administrator revealed she expected food items were appropriately discarded. The Administrator revealed she expected food items were discarded based on expiration or use by dates and not left available for use. 2. An observation of the nutrition refrigerator designated for residents located on the memory care unit was conducted on [DATE] at 12:41 PM in the presence of Nurse #1. Stored and available for use was an open 32-ounce container of nectar-thick milk with an expiration date of [DATE]. The label on the container read discard 4 days after opening. There was no date on the container to identify when it was opened. During an interview on [DATE] at 12:41 PM Nurse #1 revealed nutritional supplements were provided to residents by the nursing staff and she did not know when the container of nectar-thick milk was first opened or how long it was in use. Nurse #1 revealed she was unsure how long a container of nectar-thick milk could be kept in use after opened but thought it was good for seven days. Nurse #1 revealed it was the responsibility of the person who opened the container to write the date it was opened and confirmed the label read to discard 4 days after opened. Nurse #1 discarded the container of milk. An interview was conducted with the Administrator on [DATE] at 6:14 PM. The Administrator revealed she expected food items were appropriately discarded. The Administrator revealed she expected food items served to residents were discarded based on expiration or use by dates and not left available for use.

Based on record review, resident and staff interviews, the facility failed to communicate resolution to concerns voiced for 1 of 2 Resident Council meetings reviewed (January 2025). Findings included: A review of the Resident Council Meeting policy revised 01/01/25 stated the facility would act upon concerns and recommendations of the Resident Council, make attempts to accommodate recommendations to the extent practicable and communicate its decisions to the Resident Council. The Resident Council meeting minutes dated 01/31/25 noted under new business that residents communicated to the Dietary Manager, who was in attendance at the meeting, their preferences for specific beverages with an outcome noted as resolved-still monitoring. It was also noted under new business that residents voiced laundry concerns regarding clothing being placed in the wrong closets. The action to the concern indicated a grievance form regarding missing items would be completed and the outcome was noted as resolved-still monitoring. A grievance form dated 01/31/25 noted attendees of the Resident Council meeting voiced concerns about laundry staff putting clothing in the wrong resident closets. There was no staff member assigned to investigate the concern and no summary of the investigation. The plan to resolve the grievance indicated the concern would be reviewed with the Environmental Services Director and noted the concerns was ongoing. It was further noted the investigation results and resolution was provided to the Resident Council. There were no other details listed on the grievance form. The Resident Council meeting minutes dated 02/26/25 revealed the last meeting's minutes was read and approved. There was no notation under old or new business that the facility's efforts (response, action and/or rationale) to address the concerns voiced during the 01/31/25 meeting was communicated to the Resident Council. A Resident Council group interview was conducted on 03/05/25 at 3:32 PM with Resident #4, Resident #11, Resident #35, Resident #42, Resident #51, Resident #62, and Resident #74 in attendance. The residents stated when they voiced concerns during meetings, they rarely received communication from facility staff regarding what was done to address the concerns. The residents stated they did not feel the ongoing concerns they voiced related to clothing not being returned from laundry and dietary, specifically meals being served late, had been resolved. They stated if facility administration did attempt to address their concerns, it took a long time and the situation might get better for a little while but improvement didn't last long. The residents all stated they felt when they voiced concerns either in the Resident Council meetings or directly to the Administrator, Director of Nursing or Social Worker (SW), it didn't do any good. During an interview on 03/07/25 at 12:15 PM, the Activities Director (AD) revealed she just started conducting Resident Council meetings in January 2025 and most of the groups concerns revolved around dietary or laundry. She verified that residents had voiced concerns with late meals. She explained she followed up with residents regarding resolution to individual concerns but did not follow-up with the Resident Council regarding resolution to group concerns. She stated she was still learning the process and would do much better about that in the future. During an interview on 03/07/25 at 3:44 PM, the SW revealed the staff member who facilitated the Resident Council meeting was the one responsible for communicating the resolution of group concern(s) to the members of the Resident Council. During an interview on 03/07/25 at 4:34 PM, the Administrator revealed she was aware of the issue with meals being served late and confirmed residents had brought their concerns regarding late meals to her attention. She stated she was not sure what the root cause was regarding late meals but felt it could be more of a process issue rather than a staffing issue. The Administrator expressed she was not aware that residents felt they did not receive communication regarding resolution to their concerns or that they felt voicing their concerns would not do any good. The Administrator stated resolution to concerns voiced during the Resident Council meetings should be discussed with and communicated to the Resident Council attendees at the next meeting.

Based on observations, record review, resident and staff interviews the facility failed to honor a resident's preference for twice weekly showers for 1 of 3 residents reviewed for choices (Resident #104). Findings included: Resident #104 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy and heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #104's cognition was moderately impaired, she had limited range of motion affecting one side of the upper extremity, and bathe/shower was not applicable and not attempted. A review of the shower assignment revealed Resident #104's showers were scheduled on Tuesday and Friday. There was no documented shower sheets to indicate a bed bath or shower was provided on 02/25/25 (Tuesday) or 02/28/25 (Friday). A shower sheet dated 03/04/25 revealed Resident #104 had received one shower since admission on 02/24/25. During an interview and observation on 03/03/25 at 2:36 PM Resident #104 revealed she had not received a shower since being admitted to the facility. Resident #104's hair and face appeared clean, and she had no body odors. The care plan initiated on 03/04/25 revealed Resident #104 required assistance from staff for activities of daily living related to weakness with the goal to be clean and well-groomed daily through the next review. Interventions included provide assistance with activities of daily living. During an interview on 03/07/25 at 8:37 AM the Unit Manager (UM) revealed bathing was documented by Nurse Aide (NA) staff included using a paper shower sheet that was kept in a binder at the nurse station. The UM revealed the shower sheets were kept in the binder for one month then placed in medical record storage. The UM confirmed Resident #104 showers were scheduled on Tuesday and Friday and the first one should have been given on 02/25/25. The UM was unable to provide a shower sheet for 02/25/25 and 02/28/25. The UM revealed she filled out the shower assignment using room numbers to identify which residents NA staff were to provide a shower/bathe. After reviewing the assignment, the UM revealed Resident #104's room number was not added, and the assigned NA would not have known to provide the shower and was an oversight on her part. During an interview on 03/07/25 at 9:24 AM in presence of the UM, Resident #104 stated she had received only one shower (3/4/25) since her admission and wanted two showers a week and it was her preference not to receive a bed bath in place of a shower. The UM reassured Resident #104 her bathing preference for a shower twice a week would be honored. An interview was conducted with the Administrator on 03/07/25 at 6:10 PM. The Administrator revealed she expected resident bathing preferences for two showers a week were honored.

Based on observations, record review and staff interviews, the facility failed to provide a dignified dining experience for a dependent resident seated at a table in the main dining room waiting to be served and assisted with his lunch while watching other residents in the main dining room receive and eat their lunch for 1 of 2 residents reviewed for dignity (Resident #49). The reasonable person concept was applied to this deficiency as an individual might feel forgotten or experience frustration at not being able to eat while watching others receive and eat their meals. Findings included: Resident #49 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the left non-dominant side and vascular dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had severe cognitive impairment. He had impairment on one side of both the upper and lower extremities and required substantial/maximal staff assistance with eating. Review of the scheduled meal time posted at the facility revealed lunch was to be served in the main dining room at 12:30 PM. A continuous observation of the lunch meal was conducted on 03/06/25 from 12:00 PM to 1:30 PM. At 12:00 PM, Resident #49 was observed sitting in his wheelchair at a table in the back of the main dining room. Resident #49 was alert and looking around, watching the activity in the dining room. When asked if he was hungry, Resident #49 replied, yeah lawd (term often used as an expression to heighten an emotion). At 12:30 PM, meal carts had not arrived to the main dining room. At 12:40 PM, the meal cart arrived in the main dining room and there were five staff present who immediately started passing out meal trays to residents seated at the tables in the front of the main dining room. At 12:55 PM, the residents who were able to eat independently had all received their meal tray and were eating their lunch while the residents in the back of the main dining room, who needed staff assistance including Resident #49, had not been served their meal. At 1:00 PM, another meal cart arrived in the main dining room and staff started sitting down at other tables assisting dependent residents with their meal. Resident #49 looked over at the staff assisting residents with their meals with a look of confusion on his face and made a groaning sound. When asked if he was ok, Resident #49 stated no and when asked if he was hungry, he replied yeah lawd. At 1:25 PM, staff brought Resident #49's meal tray to the table and began assisting Resident #49 with his meal. Resident #49 eagerly accepted sips of fluid and bites of food when offered by staff. Resident #49 waited approximately one hour from the scheduled mealtime to be served and assisted with his lunch. During an interview on 03/07/25 at 4:34 PM, the Administrator expressed it was a dignity issue when residents sat in the main dining room an hour or longer waiting to be served their meal or receive assistance with a meal. She explained staff assisted residents to the dining room a little earlier than the scheduled meal time because once the meal trays arrived on the hall, staff couldn't stop passing meal trays out to the residents eating in their rooms in order to bring other residents to the main dining room. The Administrator revealed she was aware of the issue with meals being served late and stated while she was not sure where or how the breakdown occurred she felt it could be more of a process issue rather than a staffing issue.

Based on record review and staff and resident interviews the facility failed to implement their grievance policy for 1 of 1 resident (Resident #8) reviewed for grievances. Findings included: Review of the facility's grievance policy revised 01/01/25 read in part as follows: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. [Prompt Efforts to Resolve] include facility acknowledgement of a complaint grievance and actively working toward resolution of that complaint/grievance. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; and issuing written grievance decisions to the resident. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. The Grievance Official will take steps to resolve the grievance and record information about the grievance and those actions on the grievance form. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. If the resident or complainant do not wish to have a written copy of the decision, verbal discussion is acceptable. The written decision will include at a minimum: (a). The date the grievance was received (b). The steps taken to investigate the grievance (c). A summary of the pertinent findings or conclusions regarding the resident's concern (f). A statement as to whether the grievance was confirmed or not confirmed (g). Any corrective action taken or to be taken by the facility as a result of the grievance (h). The date the written decision was issued. Resident #8 was admitted to the facility 11/24/23 with diagnoses including non-Alzheimer's dementia. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #8 was cognitively intact and was always incontinent of bowel and bladder. Review of the facility's grievance logs from December 2023 through March 2025 revealed Resident #8 had filed 2 grievances. A grievance filed by Resident #8 on 01/08/24 regarding various care concerns. The nursing department investigated the grievance and findings of the investigation were blank. The form indicated the plan to resolve the grievance included staff counseling and medication review. An in-service dated 01/08/24 revealed nursing staff were educated on Respectful Talk to Residents and the grievance was considered resolved. The results of the investigation were verbally communicated to Resident #8 on 01/09/24. The grievance form did not contain any additional information regarding the care concerns and was not signed by Resident #8. A grievance was filed by Resident #8 on 02/10/25 regarding timely response to incontinence care. The Director of Nursing (DON) investigated and determined Resident #8 received incontinence care, but had to wait until care staff were done with another resident. The plan to resolve the grievance was to encourage staff to notify Resident #8 they will be right there or as soon as possible when she is waiting. Resident #8 verbalized understanding that staff were to notify and respond to call lights in timely manner. The result of the investigation was verbally communicated to Resident #8 and the grievance was considered resolved 02/10/25. The grievance did not contain any additional information regarding Resident #8's concern and was not signed by Resident #8. In an interview with the Social Worker (SW) on 03/05/25 at 9:31 AM he confirmed he was the Grievance Officer. When he was asked what various care concerns meant on the grievance filed by Resident #8 on 01/08/24 he stated her concerns were usually the same and were concerns regarding not receiving water, call light response time, or the length of time it took to receive incontinence care. The SW stated when Resident #8 filed a grievance he verbally discussed the resolution with her, and she seemed to be satisfied. He confirmed he did not provide written resolutions to grievances. An interview with Resident #8 on 03/05/25 at 4:22 PM revealed she had never been provided with a resolution to any grievance she filed. She stated she would like to receive a resolution to her grievances in writing so she would know what had been done to address the grievances, but she didn't know that was an option. An interview with the Administrator on 03/07/25 at 5:16 PM revealed grievance forms could probably contain a little more information about what the grievance was regarding and what had been done to resolve the grievance.

Based on record review and staff interviews the facility failed to complete a thorough investigation of an allegation of staff-to-resident abuse for 1 of 9 residents reviewed for abuse (Resident #8). Findings included: The facility's Abuse, Neglect, and Exploitation policy revised 03/02/23 read in part as follows: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: 1. Identifying staff responsible for the investigation 2. Investigating different types of alleged violations 3. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations 4. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause 5. Providing complete and thorough documentation of the investigation. Review of the medical record revealed Resident #8 was admitted to the facility 11/24/23. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and had a diagnosis of non-Alzheimer's dementia. A summary of the initial investigation report completed by the Director of Nursing (DON) indicated the incident date was 05/14/24 and the facility became aware of the incident on 05/15/24 10:15 AM. The fax date and time revealed the report was submitted at 12:18 PM on 05/15/24. A summary of the investigation was as follows: Resident #8 reported on the night of 05/14/24 as she was being put to bed, Nurse Aide (NA) #1 pushed her head onto the bed. A facility investigation was initiated, NA #1 was suspended pending the investigation, and the Physician, Responsible Party (RP), Adult Protective Services (APS), and Transylvania Police were notified of the incident. Resident abuse questionnaires were initiated with alert and oriented residents and body audits for residents with impaired cognition were initiated. Staff abuse education was being completed. The investigation was ongoing. A summary of NA #1's written statement dated 05/15/24 is as follows: First shift reported they assisted Resident #8 to bed the evening of 05/14/24 but she had since gotten up in her wheelchair. The statement indicated Medication Aide (MA) #1 informed her Resident #8 was asking about her mother, so NA #1 went to the resident's room to check on her. The statement further stated as NA #1 walked into Resident #8's room she was trying to get in bed, but she was going down to the floor, so she grabbed the back of Resident #8's pants and pulled her up and onto the bed. An undated document titled Root Cause is as follows: The Interdisciplinary Team (IDT) determined the incident occurred because the resident did not wait for assistance to transfer. The resident did get moved quickly onto the bed, but her face was not pushed into/onto the bed. The resident was re-assured and reminded to use her call bell for assistance. An unnamed typed document dated 05/20/25 revealed the Director of Nursing (DON) had NA #1 do a re-enactment of how she transferred Resident #8 to bed the night of 05/14/25 and determined NA #1 prevented Resident #8 from falling. A summary of the facility 5-day report completed by the Administrator and faxed on 05/20/24 at 5:01 PM is as follows: Resident #8 reported as she was being assisted to bed on the night of 05/14/24, NA#1 pushed her head down onto the bed. Resident abuse questionnaires and body audits revealed no concerns of abuse. A written statement was obtained from NA #1 on 05/15/24 and did not address whether Resident #8's head was pushed into the bed or not. The facility determined Resident #8 was trying to self-transfer from the wheelchair to the bed and was falling. The investigation further determined NA #1 grabbed Resident #8 and pulled her up and onto the bed. The allegation of abuse was not substantiated. The investigation did not include a statement from Resident #8. An interview with the Director of Nursing (DON) on 03/06/25 at 2:52 PM revealed he could not recall how he became aware of the allegation of abuse from Resident #8 and was unable to provide an answer for why the investigation did not contain a statement from Resident #8. He confirmed there were no other interviews included in the investigation. An interview with the Administrator on 03/07/25 at 5:15 PM revealed she could not recall how she became aware of the allegation of abuse from Resident #8 and was unable to provide an answer for why the investigation did not contain a statement from Resident #8. She stated she did not have concerns with the way the abuse investigation was conducted. The Administrator confirmed she was not aware of any other interviews obtained during the course of the investigation.

Based on record review, observations and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of restraints (Resident #71), dental (Resident #20), and falls (Resident #4) for 3 of 26 resident assessments reviewed for accuracy. Findings included: 1. Resident #71 was admitted to the facility 06/12/24. Review of Resident #71's quarterly Minimum Data Assessment (MDS) dated [DATE] indicated Resident #71 had bed rails that were used daily as a restraint. Observations of Resident #71's bed on 03/05/25 at 8:49 AM and 03/07/25 at 9:17 AM revealed no bed rails were observed on his bed. An interview with the MDS Coordinator on 03/07/25 at 3:52 PM revealed Resident #71's quarterly MDS assessment was coded by an employee that did not work in the building. He stated it was difficult to accurately code MDS assessments if you were not present in the building. The MDS Coordinator stated that the MDS should not have reflected that bed rails were used as a restraint, and it was a coding error. An interview with the Director of Nursing (DON) on 03/07/25 at 4:11 PM revealed he expected MDS assessments to be coded correctly and no residents in the facility used a restraint. An interview with the Administrator on 03/07/25 at 5:16 PM revealed she expected MDS assessments to be coded correctly and be an accurate reflection of the resident. 2. Resident #20 was admitted to the facility 04/06/23. Review of a dentist's note dated 01/08/25 revealed Resident #20 had multiple teeth that were broken to the gum line and had hopeless dentition (teeth that are severely compromised due to gum disease or other problems). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] indicated she did not have any dental problems. Review of Resident #20's dental care plan last updated 03/05/25 revealed she had poor dentition/broken and carious teeth (teeth with cavities). Interventions included providing her diet as ordered and monitoring and reporting any signs or symptoms of oral problems. An observation of Resident #20's teeth on 03/05/25 at 8:29 AM revealed multiple broken teeth. An interview with the MDS Coordinator on 03/07/25 at 3:47 PM revealed Resident #20's teeth were not in good shape, and they had been that way for a while. He stated the significant change MDS assessment should have reflected Resident #20 had obvious or likely cavities. The MDS Coordinator stated another staff member coded the section for Oral/Dental Status, but he was responsible for ensuring it was correct, and it was an oversight. An interview with the Director of Nursing (DON) on 03/07/25 at 4:11 PM revealed he expected MDS assessments to be coded correctly. An interview with the Administrator on 03/07/25 at 5:16 PM revealed she expected MDS assessments to be coded correctly and be an accurate reflection of the resident. 37538 3. Resident #4 was admitted to the facility on [DATE] with diagnoses including poly-osteoarthritis (arthritis that involves at least five joints). A review of the nurse's progress note dated 1/17/25 at 3:54 PM revealed when assisted to the bathroom Resident #4 was unable to complete the transfer and was lowered to the floor using a gait belt and two person assistance. A review of the discharge MDS assessment dated [DATE] indicated Resident #4 had not had any falls since the prior assessment. During an interview on 3/6/25 at 2:16 PM the MDS Coordinator confirmed he completed the discharge MDS assessment on 1/17/25 for Resident #4 and did not code the fall. He revealed the discharge MDS assessment dated [DATE] should reflect Resident #4 had a fall with no injury. During an interview on 03/07/25 at 4:12 PM the Director of Nursing (DON) revealed the discharge MDS assessment dated [DATE] should reflect Resident #4 had fall. An interview was conducted on 03/07/25 at 5:17 PM with the Administrator. The Administrator revealed she expected MDS coding to be accurate and reflect Resident #4 had a fall.

Based on observations, record review, resident, and staff interviews the facility failed to provide assistance with nail care and shaving for 1 of 5 dependent residents reviewed for activities of daily living (Resident #99). Findings included: 1. Resident #99 was admitted to the facility on [DATE] with diagnoses including a right femur (upper leg bone) fracture, presence of artificial hip joint, and epilepsy (a brain condition causing recurring seizures with varying symptoms). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #99's cognition was moderately impaired with no rejection of care behaviors during the lookback period. Resident #99 had impaired range of motion affecting one side of the lower extremity and required setup/clean up assistance for personal hygiene and substantial to maximal assistance for shower/bathing. The care plan revised on 2/12/25 revealed Resident #99 had a deficit in the ability to perform activities of daily living related to a fracture of the right femur, epilepsy, and pain. Interventions included provide extensive assistance using one person assist for shower/bathing and personal hygiene. A review of the shower assignment revealed Resident #99 was scheduled to receive a shower every Tuesday and Friday. The Shower sheets documented Resident #99 had received two showers since admission on 2/17, and 2/24 and a bed bath on 2/7, 2/11, 2/20, and 3/4. There was no shower sheet completed for 2/14 and 2/28 to indicate bathing was provided. During an observation and interview on 03/03/25 at 2:32 PM Resident #99 fingernails were approximately one-half inch past the tip of the finger, and she had multiple patchy areas of overgrown gray chin hairs. When asked Resident #99 revealed her fingernails were long and she wanted them cut and she was not aware of the chin hair but if she had a pair of tweezers would pull them out. Resident #99 revealed she had not requested her fingernails be trimmed or to shave her chin hair and was not offered assistance by staff. During an interview on 03/07/25 at 8:58 AM Nurse Aide (NA) #2 revealed fingernails were trimmed and chin hairs shaved during bath days. An interview and observation was conducted on 03/07/25 at 9:21 AM with Resident #99 in the presence of the Unit Manager (UM). The UM observed Resident #99's long fingernails and multiple patchy areas of overgrown gray chin hairs and revealed if chin hairs needed to be shaved, and fingernails trimmed it was done during a bed bath or shower and as needed. Resident #99 shared with the UM a staff member recently gave her a pair of nail clippers, but she was unable to cut her own fingernails because they were too hard. Resident #99 shared she did not like long chin hairs and normally plucked them. The UM reassured Resident #99 her fingernails would be trimmed and chin hair shaved. An interview was conducted with the Administrator on 03/07/25 at 6:10 PM. The Administrator stated she would expect Resident #99 to be offered assistance to shave long chin hairs and clip long fingernails and was typically done by the NA during a bed bath or shower.

Based on record review, Medical Director and staff interviews, the facility failed to provide written documentation which stated the reason the facility could not meet the residents' needs for 2 of 4 residents reviewed for transfer and discharge (Residents #87 and #184). The findings included: 1. Resident #87 was admitted to the facility on [DATE] with multiple diagnoses that included dementia without behavioral disturbance and adjustment disorder with anxiety. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #87 had severe impairment in cognition. He wandered 4 to 6 days and displayed no behaviors such as physical or verbal aggression and no hallucinations or delusions during the MDS assessment period. A physician's order dated 07/31/23 read, transfer to ER (emergency room ) for evaluation. A Social Worker (SW) progress note dated 07/31/23 at 10:03 AM read in part, SW was informed that Resident #87 hit another resident. SW completed immediate discharge notice due to being a danger to other residents in the facility. SW proceeded to file Involuntary Commitment (IVC) with the Magistrate and returned to the facility. Review of Resident #87's medical record revealed no documentation of a physician's statement describing the specific needs and behaviors that could not be managed or met at the facility, facility efforts to meet those needs and specific services the receiving facility would provide to meet the needs of Resident #87. During interviews on 11/15/23 at 3:28 PM and 11/17/23 at 12:40 PM, the Administrator confirmed Resident #87 was discharged to the hospital on 07/31/23 and explained the facility was not equipped to handle residents with psych-related behaviors. The Administrator revealed she was not that familiar with the regulation and was not aware of a written physician statement in Resident #87's medical record summarizing the specific needs that could not be met, facility efforts to meet those needs or specific services provided by the receiving facility that would meet his needs. During a telephone interview on 11/17/23 at 3:24 PM, the Medical Director confirmed Resident #87 was discharged to the hospital on 07/31/23 due to increased behaviors. The Medical Director explained Resident #87 displayed unpredictable, aggressive behaviors that would have likely continued despite psychiatric medication adjustments. The Medical Director stated Resident #87 resided on the Memory Support Unit at the facility and would become upset when others wandered into his room/space which was what usually happened on a dementia unit. The Medical Director stated he felt Resident #87 needed a less stimulating environment. The Medical Director revealed he was unaware of the regulation that required documentation by the resident's physician which indicated the specific needs of Resident #87 the facility could not meet, facility efforts to meet those needs or specific services the receiving facility would provide to meet his needs and confirmed he had not documented a statement in Resident #87's medical record. 2. Resident #184 was admitted to the facility on [DATE] with multiple diagnoses that included dementia with behavioral disturbance and bipolar disorder. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #184 had moderate impairment in cognition. She wandered and displayed verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others 1 to 3 days during the MDS assessment period. The quarterly MDS assessment dated [DATE] revealed Resident #184 had moderate impairment in cognition. She wandered and displayed other behavioral symptoms not directed toward others 1 to 3 days during the MDS assessment period. A physician's order dated 06/13/23 read, send to ER (emergency room ) for psychiatric behavior management. A Social Worker (SW) progress note dated 06/13/23 at 11:07 AM read in part, SW was informed that Resident #184 was hitting other residents and staff unprovoked today. It was recommended by administration to initiate Involuntary Commitment (IVC) to send her to the ER due to these behaviors. SW went to the Magistrate and initiated IVC. Review of Resident #184's medical record revealed she was not readmitted to the facility upon her discharge from the hospital. Further review revealed no documentation of a physician's statement describing the specific needs and behaviors that could not be managed or met at the facility, facility efforts to meet those needs and specific services the receiving facility would provide to meet the needs of Resident #184. During interviews on 11/15/23 at 3:28 PM and 11/17/23 at 12:40 PM, the Administrator confirmed Resident #184 was discharged to the hospital on 06/13/23. The Administrator revealed she had not yet started at the facility when Resident #184 was discharged to the hospital but was told there was a lot of discussion about what kind of facility/treatment would be best for Resident #184 upon her discharge from the hospital. She explained the hospital felt her behaviors were more psych-related rather than due to dementia and the facility was not equipped to handle residents with psych-related behaviors. The Administrator revealed she was not that familiar with the regulation and was not aware of a written physician statement in Resident #184's medical record summarizing the specific needs that could not be met, facility efforts to meet those needs or specific services provided by the receiving facility that would meet her needs. During a telephone interview on 11/17/23 at 3:24 PM, the Medical Director confirmed Resident #184 was discharged to the hospital on 06/13/23 due to increased behaviors. The Medical Director explained Resident #184's cognition was not that bad and her behaviors were primarily psych-related. He recalled she would just hit someone and remember doing it but was not able to explain why. The Medical Director revealed he was unaware of the regulation that required documentation by the resident's physician which indicated the specific needs of Resident #184 the facility could not meet, facility efforts to meet those needs or specific services the receiving facility would provide to meet her needs and confirmed he had not documented a statement in Resident #184's medical record.

Based on record review, Responsible Party, Hospital Case Manager, Medical Director and staff interviews, the facility failed to allow residents to return to the facility after being sent to the hospital for a psychiatric evaluation using the residents' behaviors prior to discharge as a basis for their decision for 2 of 4 residents reviewed for transfer and discharge (Residents #87 and #184). The findings included: 1. Resident #87 was admitted to the facility on [DATE] with multiple diagnoses that included dementia without behavioral disturbance, psychotic disturbance and adjustment disorder with anxiety. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #87 had severe impairment in cognition. He wandered 4 to 6 days and displayed no behaviors such as physical or verbal aggression and no hallucinations or delusions during the MDS assessment period. A behavioral care plan initiated on 07/26/23 revealed Resident #87 had the potential to be physically aggressive related to dementia. Interventions included one-to-one monitoring by staff and document/report as needed any signs or symptoms of him posing a danger to self and others. A Social Worker (SW) progress note dated 07/31/23 at 10:03 AM read in part, SW was informed that Resident #87 hit another resident. SW completed immediate discharge notice due to being a danger to other residents in the facility. SW proceeded to file Involuntary Commitment (IVC) paperwork with the Magistrate. Review of a Nursing Home Notice of Transfer/Discharge document revealed on page 1 the date of the notice was listed as 08/31/23; however, on page 2 the date of the notice was listed as 07/31/23. The reason for discharge was marked as the safety of individuals in this facility is endangered due to the clinical or behavioral status of the resident and the location of transfer/discharge was noted as the hospital emergency room (ER). A physician's order dated 07/31/23 read, transfer to ER for evaluation. The discharge MDS assessment dated [DATE] was coded as return not anticipated. Review of the hospital records for Resident #87 revealed the following: A case management note dated 07/31/23 read in part, received call from the Director of Nursing (DON) at the skilled nursing facility who reports he spoke with their SW and all the appropriate paperwork has been completed and gone through the Ombudsman, including the right to appeal notice, and Resident #87 was unable to return to the facility as he has been discharged . An ER report note dated 08/01/23 read in part, Resident #87 presents from nursing home for aggressive behavior. They are not taking him back. A case management note dated 08/02/23 read in part, ER Medical Doctor agrees to release IVC and refer Resident #87 to care management for placement assistance. Resident #87 is psychiatrically cleared. Several referrals sent out to secure memory care units. An ER report dated 08/02/23 read in part, Resident #87 is waiting a safe discharge plan. Medically clear prior to this evaluation. An ER report dated 08/04/23 read in part, Resident #87 continues to board in our emergency department pending community placement in a nursing facility. His IVC has been lifted and he is hemodynamically (referring to stable blood pressure and heart rate) stable. An ER report dated 08/05/23 revealed in part, Resident #87 has been with us for approximately one week awaiting community placement after being sent from the skilled nursing facility under IVC. During a telephone interview on 11/15/23 at 12:42 PM, Resident #87's Responsible Party (RP) revealed she was notified by the facility SW on 07/31/23 that Resident #87 was being sent to the hospital due to behaviors and he would not be allowed to return to the facility. She stated she was shocked to hear Resident #87 had displayed behaviors while at the facility as she had not been informed previously. The RP could not recall the exact date but stated when Resident #87 was ready for discharge, the hospital found him placement at another skilled nursing facility. The RP stated the whole ordeal was not a good experience and even if the facility had agreed to accept Resident #87 back, she would not have wanted him to return to the facility. During interviews on 11/15/23 at 2:16 PM and 11/17/23 at 10:50 AM, the SW revealed Resident #87 was issued an immediate discharge on 07/31/23 when he was sent back to the hospital via IVC due to his aggressive behaviors. The SW stated it was his understanding the facility did not have to accept a resident back when a discharge notice was issued to the resident upon their discharge to the hospital as the hospital would find appropriate placement for the resident. The SW confirmed he notified Resident #87's RP on 07/31/23 of his discharge and that he would not be allowed to return to the facility due to his behaviors. He stated he felt he would have told the RP about Resident #87's behaviors during his stay at the facility but did not document anything in Resident #87's medical record. During a telephone interview on 11/16/23 at 12:15 PM, the former Admissions Director revealed when Resident #87 was initially admitted to the facility, they were made aware of his previous behaviors but since he had been stable while hospitalized , they felt they could manage him and he was admitted to the facility. The former Admissions Director recalled when Resident #87 was sent out to the hospital in July 2023, she was told by administration that he would not be allowed to return to the facility upon his discharge from the hospital. During an interview on 11/17/23 at 12:07 PM, the DON revealed when a resident was ready to be discharged from the hospital back to the facility, the Interdisciplinary Team (IDT) met to review the hospital records to determine if readmission was appropriate. The DON explained when a resident was sent to the hospital under IVC and they had behaviors that was or could be a danger to others down the road, which he explained was the case with Resident #87, the IDT and administration made the decision not to allow the resident to return to the facility and the hospital was good to find the resident alternate placement. During interviews on 11/15/23 at 3:28 PM and 11/17/23 at 12:40 PM, the Administrator confirmed Resident #87 was discharged to the hospital on 07/31/23 and stated the facility was not equipped to handle residents with psych-related behaviors. The Administrator explained Resident #87 was ambulatory and exit-seeking and unfortunately, all the activity on the Memory Support Unit (MSU) seemed to agitate and irritate him. She stated one minute Resident #87 would be ok and the next minute he wanted to be left alone in his room. If someone happened to wander into his room, which happened a lot on MSU, he would get upset. The Administrator recalled the IDT talking about Resident #87 and if this facility was really the best place for him and they felt like he would do much better in a smaller facility with less stimulation. The Administrator confirmed a Notice of Transfer/Discharge was issued to Resident #87 when he was sent out to the hospital on 07/31/23 and stated it was her understanding from the SW that Resident #87's RP planned on taking him home when he was discharged from the hospital. During a follow-up telephone interview on 11/17/23 at 3:37 PM, Resident #87's RP stated she never told the SW that she would take Resident #87 home when he discharged from the hospital. The RP explained she worked full-time and it would not be safe for Resident #87 to remain home alone while she was at work. During a telephone interview on 11/17/23 at 3:24 PM, the Medical Director confirmed Resident #87 was discharged to the hospital on 07/31/23 due to increased behaviors. The Medical Director explained Resident #87 displayed unpredictable, aggressive behaviors that would have likely continued despite psychiatric medication adjustments. He stated Resident #87 resided on the MSU at the facility and would become upset when others wandered into his room/space which was what usually happened on a dementia unit. The Medical Director stated he felt Resident #87 needed a less stimulating environment than what could be provided at the facility. 2. Resident #184 was admitted to the facility on [DATE] with multiple diagnoses that included dementia with behavioral disturbance and bipolar disorder. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #184 had moderate impairment in cognition. She wandered and displayed verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others 1 to 3 days during the MDS assessment period. The behavioral care plan initiated on 06/01/23 and last revised 06/05/23 revealed Resident #184 had a history of violent behaviors, sitting on the floor and feigning unresponsiveness. Interventions included to intervene as necessary to protect the rights and safety of others, divert attention and remain in line of sight of sitter 24/7. The quarterly MDS assessment dated [DATE] revealed Resident #184 had moderate impairment in cognition. She wandered and displayed other behavioral symptoms not directed toward others 1 to 3 days during the MDS assessment period. A physician's order dated 06/13/23 read, send to ER (emergency room ) for psychiatric behavior management. A Social Worker (SW) progress note dated 06/13/23 at 11:07 AM read in part, SW was informed that Resident #184 was hitting other residents and staff unprovoked today. It was recommended by administration to initiate Involuntary Commitment (IVC) to send her to the ER due to these behaviors. SW went to the Magistrate and initiated IVC. The discharge MDS dated [DATE] for Resident #184 was coded as return anticipated and noted the discharge location was acute hospital. Review of email correspondence provided by the SW revealed the following: On 07/20/23 at 3:12 PM the SW sent an email to the former Administrator, former Admissions Director and Director of Nursing that was subsequently forwarded by the former Administrator to the Regional Nurse Consultant and Regional Director of Clinical Operations on 07/20/23 at 3:14 PM. The email correspondence read in part, Case Manager #1 is asking if we are considering Resident #184 to return to our facility or not. He said he would understand if it is a hard no and they would seek placement elsewhere. However, if we are considering her return, he would send a medication administration record and other notes. I don't believe they have done much to change her medications. I need to let Case Manager #1 know something before the end of the day. On 07/20/23 at 4:01 PM the SW sent an email to the former Administrator, former Admissions Director and Regional Nurse Consultant regarding Resident #184. The email correspondence read in part, SW just spoken with Case Manager #1 who stated they had to call a code due to Resident #184 being a flight risk. He is saying she really needs a behavioral health unit versus dementia unit. The ER doctor is now hesitant to release the IVC and referring back to psych at the moment. During a telephone interview on 11/13/23 at 2:31 PM, Resident #184's Guardian revealed when Resident #184 was sent out to the hospital on 06/13/23, she had wanted Resident #184 to return to the facility. The Guardian recalled the facility went back and forth with the hospital on whether or not Resident #184 would be allowed to return; however, when she was ready for discharge, the facility refused to accept her back and the hospital found placement for her at another skilled nursing facility. The Guardian was unable to recall the date Resident #184 was discharged from the hospital. During a telephone interview on 11/13/23 at 10:43 AM, Case Manager #2 stated it had been a while since Resident #184 was at the hospital and she could not recall the exact date of her discharge. Case Manager #2 revealed when she contacted the facility to inquire about Resident #184's return, she was informed by facility staff they would not accept her back and as a result, the hospital had to locate alternate placement. During an interview on 11/15/23 at 2:16 PM, the SW revealed Resident #184 was sent out to the hospital 06/13/23 via IVC due to her aggressive behaviors and was not sure what happened or why she didn't return to the facility. The SW explained there had been multiple conversations with other administrative staff as well as Case Manager #1 about Resident #184 and whether or not she would be appropriate to return to the facility upon her discharge from the hospital but he never told the hospital that the facility would not accept her back. The SW indicated the former Admissions Director would have been the one the hospital contacted when Resident #184 was ready for discharge. A joint interview was conducted with the SW, Regional Nurse Consultant, and Regional Director of Clinical Operations (RDCO) on 11/15/23 at 2:59 PM. The RDCO stated they had followed Resident #184 while she was at the hospital and there had been a lot of conversations with hospital Case Manger #1. She recalled Case Manager #1 stating he felt Resident #184 needed permanent placement in a behavioral treatment/psych unit when she discharged . She explained the facility had a dementia unit that was geared more toward elopement specific behaviors, not geri-psych, and they felt they wouldn't be able to give Resident #184 the behavioral care treatment she needed. The RDCO stated the Interdisciplinary Team (IDT) had multiple conversations about what to do but they never made a definite decision not to accept Resident #184 back. During a telephone interview on 11/16/23 at 12:15 PM, the former Admissions Director revealed when Resident #184 was initially admitted to the facility, they were made aware of her previous behaviors but since she had gone several days without any incidents while at the hospital, they felt they could manage her and she was admitted to the facility. The former Admissions Director recalled when Resident #184 was sent out to the hospital in July 2023 via IVC, other members of administration felt the facility wasn't equipped to handle her behaviors and it was pretty much implied she would not be allowed to return. She couldn't recall the exact dates but stated the hospital Case Managers had reached out to her on more than one occasion to see if the facility would accept Resident #184 back. She recalled having discussions with Case Manager #1 who was on the fence as to whether Resident #184 would be suitable to return to the facility and him stating as long as Resident #184 remained on the medications she was discharged with, she would be fine at the facility but if the medications were discontinued then she would be more appropriate for a behavioral health unit. She stated her last discussion was with Case Manager #2 who indicated Resident #184 was stable, her medications had been tweaked and she was ready for discharge. She told Case Manager #2 the facility would not accept Resident #184 back and explained it was out of her hands as it was a Corporate decision. She recalled Case Manager #2 stating she understood the position the facility was in and they would find placement elsewhere for Resident #184. Telephone attempts for interview with Case Manager #1 on 11/16/23 at 2:54 PM and 5:34 PM were unsuccessful. During an interview on 11/17/23 at 12:07 PM, the DON revealed when a resident was ready to be discharged from the hospital back to the facility, the IDT met to review the hospital records to determine if readmission was appropriate. The DON explained when a resident was sent to the hospital under IVC and they had behaviors that was or could be a danger to others down the road, the IDT and administration made the decision not to allow the resident to return to the facility and the hospital was good to find the resident alternate placement. The DON stated Resident #184's behaviors were more psych-related than dementia-related and when she displayed behaviors, such as hitting others, she never had any remorse. During interviews on 11/15/23 at 3:28 PM and 11/17/23 at 12:40 PM, the Administrator revealed she had not yet started at the facility when Resident #184 was discharged to the hospital on 06/13/23 but was told there was a lot of discussion about what kind of facility/treatment would be best for Resident #184 upon her discharge from the hospital. She explained the hospital felt her behaviors were more psych-related rather than due to dementia and the facility was not equipped to handle residents with psych-related behaviors. During a telephone interview on 11/17/23 at 3:24 PM, the Medical Director confirmed Resident #184 was discharged to the hospital on 06/13/23 due to increased behaviors. He recalled she would just hit someone and remember doing it but was not able to explain why. The Medical Director stated he did not feel Resident #184 was appropriate to remain at the facility as her cognition was not that bad and her behaviors were primarily psych-related.

Based on record review and interviews with staff and the Medical Director (MD), the facility failed to check capillary blood glucose prior to administering insulin lispro (a rapid acting medication used to treat high blood sugar) for 1 of 2 resident reviewed for insulin administration (Resident #88). Findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, type 2 diabetes mellitus, and vascular dementia. Resident #88 was discharged back to the community on 02/18/23. Review of the admission Minimum Data Set assessment dated [DATE] indicated Resident #88's cognition was moderately impaired and insulin injections were received during the lookback period. The care plan focus area for diabetes initiated on 01/30/23 included interventions to administer medication as ordered and monitor and document for side effects and effectiveness; obtain fasting serum blood sugar (capillary blood glucose levels) as ordered by the doctor; monitor and document and report as needed any signs or symptoms of hypoglycemia or hyperglycemia. Review of the physician orders for insulin lispro were to inject 6 units subcutaneously with meals and inject 4 units subcutaneously in the evening for diabetes. Insulin lispro per sliding scale before meals for a capillary blood glucose reading of 201-250 inject 2 units; 251-300 inject 3 units; 301-350 inject 5 units; 351-400 inject 7 units and if greater than 400 notify the MD for orders. Insulin lispro per sliding scale at bedtime for a capillary blood glucose reading of 201-250 inject 1 unit; 251-300 inject 2 units; 301-350 inject 3 units; 351-400 inject 5 units and if greater than 400 notify the MD for new orders. The orders were started on 01/30/23. Review of the Medication Administration Records (MAR) for Resident #88 revealed on 01/30/23 the physician's orders for insulin lispro were transcribed and included the documented capillary blood glucose checks with sliding scale at mealtimes and bedtime. The documented blood glucose results done on 01/30/23 at 4:20 PM was 161 and 01/30/23 at 9:00 PM was 292 and 01/31/23 at 6:17 AM was 230 and at 1:30 PM was 335. Review of the physician's progress note revealed on 01/31/23 the MD saw Resident #88 and planned to discontinue both the mealtime and bedtime sliding scales for insulin lispro that included capillary blood glucose checks and increase the mealtime dose to 8 units. Review of the physician order dated 01/31/23 for insulin lispro inject 8 units subcutaneously before meals for diabetes. The physician orders for sliding scale insulin at mealtimes and bedtime were discontinued on 01/31/23. Review of MAR revealed the new physician order dated 01/31/23 was transcribed to inject 8 units of lispro insulin subcutaneously before meals scheduled to be administered at 6:30 AM, 11:30 AM, and 4:30 PM. There were no documented blood glucose checks on the MAR prior to the administration insulin lispro from 02/01/23 through 02/18/23 and Resident #88 received 53 injections. Review of nurse progress notes written on 02/01/23, 02/07/23, and 02/18/23 indicated Resident #88 was not in distress. During a phone interview on 11/17/23 at 2:00 PM Nurse #9 confirmed her initials on the MAR for Resident #88 for 02/08/23, 02/09/23, 02/13/23, 02/14,23, 02/15/23, and 02/16/23. She revealed if the physician order included checking capillary blood glucose, she would have done it otherwise she used her nursing judgement of when to check a resident's capillary blood glucose. During a phone interview on 11/17/23 at 3:14 PM the MD revealed he assumed the capillary blood glucose checks were automatically added to insulin orders. The MD stated he discontinued the mealtime and bedtime sliding scales on 01/31/23 but wanted the capillary blood glucose checks to remain in place prior to the administration of insulin lispro. He explained when capillary blood glucose checks were not done, and insulin administered there was a risk of hypoglycemia if Resident #88's blood sugar was low prior to administering insulin lispro. An interview was conducted on 11/17/23 at 3:46 PM with the Director of Nursing (DON). The DON revealed he was not the acting DON when Resident #88 resided at the facility and had not reviewed the physician orders for insulin lispro. The DON explained the process for new orders was the MD puts the orders in the system and the nurse or himself confirms the order before it becomes active. The DON stated the MD would have to provide an order to check Resident #88's capillary blood glucose when administering insulin lispro and should be clarified by the nurse if not included. The DON revealed if the blood sugar was low prior to administering insulin it put Resident #88 at risk for hypoglycemia. During an interview on 11/17/23 at 4:08 PM the Administrator revealed she would expect MD orders were followed and if there was not an order to check the capillary blood glucose prior to the administration of insulin the nurse would clarify with the MD to ensure the checks were included.

Based on observations, staff interviews and record reviews, the facility failed to remove expired medications in accordance with manufacturer's expiration dates for 1 of 3 medication storage rooms and 1 of 6 medications carts observed during medication storage checks (South Wing medication storage room and Memory care unit medication cart). The findings included: 1. A medication storage audit was conducted on 11/15/23 at 11:08 AM for the South Wing medication storage room in the presence of Nurse #2. One bottle containing approximately 130 milliliters (ml) of used Omeprazole (medication used to treat heartburn) 2 milligrams (mg)/ml suspension that expired on 11/03/23 was found in the locked refrigerator within the locked metal box and was ready to be used. At the same time, 4 unopened bottles of Lorazepam (medication used to treat anxiety) 2 mg/ml injection liquid that expired on 05/31/23 were found in the same metal box and were ready to be used as well. During an interview conducted on 11/15/23 at 11:11 AM, Nurse #2 stated that she was instructed to check each medication for expiration before administration. One of the nurses working on Sunday evening was designated to audit the medication storage room and all the medication carts in South Wing once weekly. She added that the refrigerator was checked last Sunday evening and stated that the incident could be an oversight. An interview was conducted with the Unit Manager on 11/15/23 at 11:26 AM. She stated that she had just audited this medication storage room with Nurse #2 last Saturday and acknowledged that it was an oversight. It was her expectation for all the medication storage rooms and medication carts to remain free of expired medications. 2. A medication storage check of the only medication cart in the Memory care unit was conducted on 11/16/23 at 11:15 AM in the presence of Nurse #3. There was one used blister card containing 16 tablets of Metoprolol (medication used to treat high blood pressure) 25 mg that expired on 10/31/23 was found in the medication cart and ready to be used. An interview was conducted with Nurse #3 on 11/16/23 at 11:53 AM. She stated this was her first time working in this hall in the past 3 months. She did not know when this medication cart was last audited by the nursing staff. She acknowledged that the expired Metoprolol needed to be returned to the pharmacy. During an interview conducted on 11/16/23 at 2:11 PM, the Director of Nursing stated that all expired medications, including controlled medications that required refrigeration, should be pulled and labelled as Return to Pharmacy and stored in the locked refrigerator. It was his expectation for the facility to remain free of expired medication all the time. An interview was conducted with the Administrator on 11/16/23 at 2:36 PM. She stated that the facility had a system in place to check for expired medications on a regular basis and she attributed the above incidents as the oversight of the nursing staff. It was her expectation for the facility to remain free of expired medications all the time.

Based on record review, staff and physician interviews, the facility failed to prevent a significant medication error by not accurately transcribing and administering medication orders from the hospital discharge summary prescribed to treat a bacterial infection for 1 of 3 residents reviewed for medication errors (Resident #6). As a result, Resident #6 was not administered 24 doses of [MEDICATION(S)] (antibiotic) and 24 doses of [MEDICATION(S)] (antibiotic) and subsequently readmitted to the hospital for suspected severe [CONDITION(S)] (life-threatening complication of an infection) secondary to incompletely treated bacteremia (presence of bacteria in the bloodstream). Findings included: The hospital records for Resident #6 dated 12/31/20 to 01/13/21 noted in part, Resident #6 presented to the Emergency Department (ED) the morning of 12/31/20 for reported increased weakness, recurrent falls, and left arm pain. On arrival to the ED, he was afebrile with stable vital signs. Labs showed stable renal functions, urinalysis without evidence of infection, chest x-ray showed possible faint infiltrate at the lung bases, nonspecific. Resident #6 was admitted and placed on Intravenous (IV; process of administering medications/fluids through a tube inserted into a vein) antibiotics. On 01/04/21 Infectious Disease (ID) consult was done with recommendation to continue monitoring blood cultures. Throughout the hospitalization , he had multiple sets of positive blood cultures through 01/06/21 and finally negative on 01/07/21 and 01/08/21. ID recommended 6 weeks of [MEDICATION(S)] and [MEDICATION(S)] through 02/18/21. Peripherally Inserted Central Catheter (PICC; used to draw blood and give treatments) line was placed and he was deemed stable for discharge to the skilled nursing facility for long-term IV antibiotics. The hospital discharge summary dated 01/13/21 for Resident #6 included the following orders: [MEDICATION(S)] 2 grams (gm) via IV every 4 hours for 37 days and [MEDICATION(S)] 2 gm every 12 hours for 37 days through 02/18/21. Resident #6 admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse progress note dated 01/13/21 written by Nurse #1 read in part, Resident #6 arrived from the hospital at approximately 1:30 PM. PICC is in right arm. Medications verified by the Medical Doctor (MD). The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #6 with intact cognition and noted he received antibiotics 6 of 7 days during the MDS assessment period. Review of Resident #6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Coli; infection caused by bacteria) and bacteremia until 01/21/21. The order for [MEDICATION(S)] was initialed on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] was not administered from 01/22/21 through his discharge to the hospital on 01/26/21, resulting in a total of 24 missed doses. There was no order for [MEDICATION(S)] from the time of his admission on 01/13/21 through his discharge on 01/26/21, resulting in a total of 24 missed doses. The hospital records dated 01/26/21 to 02/03/21 noted in part, Resident #6 was recently discharged from this facility on 01/13/21 following a hospital stay for recurrent enterococcus faecalis bacteremia. Blood cultures cleared and the patient was discharged with a recommendation for [MEDICATION(S)] 2 gm every 4 hours and [MEDICATION(S)] 2 gm every 12 hours through 02/18/21. In reviewing available records in the system, it appears the patient never received [MEDICATION(S)] at discharge, and according to notes his [MEDICATION(S)] was discontinued on 01/21/21. PICC line remains in place. The infectious disease service became aware of this on 01/25/21 and recommended blood cultures times 2, resume [MEDICATION(S)] and [MEDICATION(S)] unless repeat blood cultures positive. The following day, the resident was sent to the Emergency Department (ED) with a fever. ED work-up was notable for lactic acid above 4, white blood cell count 7,000 but with left shift and bandemia (blood infection). Patient was febrile to 102.3 degrees Fahrenheit on arrival, [CONDITION(S)] (rapid heartbeat) in the 120s, blood pressure generally above 120 systolic. Is referred for inpatient admission for suspected severe [CONDITION(S)] secondary to incompletely treated bacteremia. I suspect the rapid return of positive blood cultures likely indicates recurrent enterococcal bacteremia, or more accurately incompletely treated enterococcal bacteremia. During a telephone interview on 09/10/21 at 10:10 AM, the Infectious Disease (ID) physician explained the type of infection Resident #6 had was very difficult to treat and usually his blood cultures did not come back as positive until after his antibiotics were finished. She stated she was alarmed when notified that Resident #6 had not received the antibiotic [MEDICATION(S)] in addition to [MEDICATION(S)] which were both on the hospital discharge summary and should have been administered as ordered. As a result, she added his bacteremia relapsed and directly related to him becoming septic and hypotensive (abnormally low blood pressure). The ID physician further stated Resident #6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 09/09/21 at 10:32 AM, Nurse #1 confirmed she completed Resident #6's admission to the facility on [DATE]. She was unable to recall who she spoke with to verify his admitting orders but stated it was either the MD or Nurse Practitioner (NP). Nurse #1 was unable to recall if the antibiotic order was changed when verified with the MD/NP or explain how the order for [MEDICATION(S)] was missed. Nurse #1 did state that the Director of Nursing (DON) became involved at one point when the error was discovered but could not remember the exact date or further specifics. During a telephone interview on 09/09/21 at 11:13 AM, the previous MD for the facility could not recall if he had talked with Nurse #1 to verify Resident #6's admitting medication orders. He did state that while he may have questioned the dosage of the [MEDICATION(S)], he would not have changed or discontinued the order until speaking with the ID physician. The MD stated Resident #6 should have received both the [MEDICATION(S)] and [MEDICATION(S)] as ordered by the ID physician. The MD added on 01/26/21 Resident #6 was hypotensive and sent out to the hospital. The MD stated it was a significant medication error that Resident #6 did not receive both antibiotics as ordered and could have led to his hospital diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON and Administrator at the time this incident occurred were no longer employed at the facility and unavailable for an interview. During interviews on 09/09/21 at 11:40 AM and 09/13/21 at 12:52 PM, the Regional Clinical Operations Consultant (RCOC) stated she could not understand how the medication order for Resident #6 was missed until she reviewed his medical records and discovered the initial hospital discharge summary sent from the hospital, that was used to create his list of medications upon his admission to the facility, did not contain the order for [MEDICATION(S)]. She added two days later they received a duplicate discharge summary that did contain the [MEDICATION(S)] order; however, the hospital did not inform them that anything had been added or changed, and the summary was given to the MD to sign and then uploaded into Resident #6's electronic medical record. Regarding the antibiotic medication being discontinued on 01/21/21 instead of 02/18/21 as ordered, she stated staff likely reviewed the narrative of the hospital course next to the medication list on the initial hospital discharge summary that contained a statement indicating the medication would be completed 01/21/20 and just didn't notice the statement was referring to a prior year. The RCOC explained when Resident #6's condition declined and prior to his rehospitalization on [DATE], the previous DON identified the transcription errors related to Resident #6's antibiotic orders in addition to the order for [MEDICATION(S)] that was not entered into the system or administered and Infectious Disease was notified on 01/25/21. She revealed Resident #6's medication error occurred prior to the facility being placed out of compliance due to a separate incident involving a medication error and the IV antibiotic error identified for Resident #6 was reviewed during the QAPI meeting held on 03/23/21. The facility provided the following corrective action plan with a completion date of 03/05/21: * Facility failed to administer Resident #6's IV medications as ordered per hospital discharge orders. Infectious Disease at Hospital was notified on 1/25/2021 by Director of Nursing of Resident #6 not receiving IV antibiotics at admission. The infectious disease service became aware of this on 01/25/21 and recommended blood cultures times 2, resume [MEDICATION(S)] and [MEDICATION(S)] unless repeat blood cultures positive. * A review of the discharge instructions for residents going to outside medical appointments or to the emergency room in February was conducted to ensure that any new medications were entered into the Electronic Medical Record (EMR) correctly. Review completed by the Medical Records Clerk (MRC) by 3-2-21. Any errors identified were corrected with the Physician and Responsible party being notified by the Director of Nursing (DON). * Measures put into place to prevent this same alleged deficient practice from recurring include: 1) All licensed nurses will be inserviced on the significance of this citation and how discharge instructions are to be handled. The DON is providing the inservice education. All nurses will be inserviced by 3-5-21. New nurses will be educated about this process during orientation as will agency nurses. 2) Discharge instructions from outside appointments/ER are to be reviewed by the Charge Nurse as well as the DON upon receipt. 3) New orders are to be entered into the EMR by the Charge Nurse immediately. 4) DON will receive a copy of the discharge instructions and these will be reviewed daily (M-F) in the morning meeting. In the meeting any new orders will be checked in the EMR for accuracy (DON/MDS nurse). 5) A monitor listing residents with outside appointments/ER visits will be started which reflects any new orders starting 3-1-21. This monitor will be used in the morning meetings to verify that no new orders were missed. This monitor will be maintained and completed by the DON/MDS nurses. * The results of the monitor will be presented by the DON in the monthly Quality Assurance Performance Improvement (QAPI) meeting starting in March. The QAPI team may make suggestions to adjust this plan/monitor in order to achieve compliance. The results of this monitor will be reviewed for a period of at least 3 months by the QAPI team. * Completion date 3-5-21 The facility's corrective action plan was validated by the following: *On 03/30/21, the facility's plan of correction was validated upon review of the sign-in sheets for in-service education provided to nursing staff on how to enter and review new orders. Review of the monitoring audits revealed they were completed as specified in the plan of correction with no concerns identified. The facility was placed back into compliance effective 03/05/21. *On 09/20/21, The Director of Nursing described the process implemented to ensure the accuracy of all orders which consisted of reviewing all new orders during the clinical morning meetings, comparing the orders with the hospital discharge summary if related to a new admission, and double checking the order in the computer system to ensure the order was transcribed correctly. Interviews conducted with licensed nursing staff revealed they received re-education on the importance of accurately entering and reviewing new medication orders and were able to describe the process. Record review of sampled residents recently admitted and/or with new orders revealed no concerns.

Based on record review and staff interviews, the facility failed to have a dependent resident assessed by a licensed medical professional when the resident complained of pain and swelling was noted to her leg that was subsequently determined to be a fracture which caused a delay of treatment for 1 of 3 residents reviewed for accidents (Resident #5). Findings included: Resident #5 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's medical record revealed the following physician orders: · 11/19/20 read in part, Observation: pain - observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. · 11/19/20 read in part, [MEDICATION(S)] (pain medication) 50 mg three times a day for leg pain. · 11/24/20 Tylenol (pain medication) 325 milligrams (mg) - give 2 tablets by mouth two times a day for pain. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #5 with severe impairment in cognition for daily decision making. The MDS noted Resident #5 required extensive staff assistance with bed mobility, total staff assistance with transfers and had impairment on both lower extremities. Review of Resident #5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] · 05/30/21 at 6:30 AM, pain level was documented as a level 0. · 05/30/21 at 2:30 PM, pain level was documented as a level 0. · 05/31/21 at 6:30 AM, pain level was documented as a level 0. · 05/31/21 at 2:30 PM, pain level was documented as a level 5. · 05/31/21 at 10:30 PM, pain level was documented as a level 5. A nurse progress note for Resident #5 dated 05/31/21 written by Nurse #4 read in part, Resident complained of Right Lower Extremity (RLE) pain. During assessment resident's RLE had mild swelling and tender to touch. RLE elevated using a pillow and cold compress applied to site. One hour post scheduled pain medication pain lessened. Nurse Practitioner notified via written report to evaluate. The radiology x-ray results dated 06/02/21 revealed in part, acute proximal (nearer to the center) tibia (larger of the two bones in the lower leg) fracture. A nurse progress note for Resident #5 dated 06/03/21 written by Nurse #5 stated x-ray results were received and indicated a proximal tibia fracture to the right leg. Nurse #5 documented a physician was contacted and gave orders for Resident #5 to be transferred to the emergency room for treatment. Nurse #5 noted Resident #5 left the facility with emergency medical services at 6:00 AM. Review of the medical record revealed Resident #5 returned to the facility later that same day with a splint on her right leg. The Medical Doctor (MD) progress note for Resident #5 dated 06/03/21 read in part, acute visit for evaluation of right leg fracture at the request of nursing staff. Resident #5 was noted to have swelling in her right leg yesterday. STAT (urgent) x-ray obtained and demonstrated an acute proximal tibia (long bone on inside of lower leg) fracture with malignment (displacement). I spoke in length with the nursing team including the Director of Nursing (DON). Resident #5 has not had any witnessed falls or recent injuries. I saw Resident #5 in her room, she denies any falls or injury, however, she is a very poor historian. She does have a history of [CONDITION(S)] and previous fractures. Assessment: Right tibial fracture. She appears to have sustained a spontaneous fracture. Spontaneous fractures are seen in elderly, debilitated patients. She has multiple risk factors for spontaneous fractures including her advanced age, diabetes, [CONDITION(S)], Vitamin D deficiency and history of previous fractures. I have no suspicion for abuse. Pain Management: still with some pain. Will increase [MEDICATION(S)] to 50 mg every 6 hours scheduled with Tylenol 650 mg. every 6 hours as scheduled. Continue to monitor. During an interview on 09/13/21 at 3:34 PM, Nurse Aide (NA) #2 confirmed she was assigned to provide care to Resident #5 during the hours of 6:30 AM to 2:30 PM on 05/31/21. NA #2 recalled being told during shift report Resident #5's leg was swollen and they had applied ice. She stated during the shift, Resident #5 complained of some pain but nothing abnormal for her. NA #2 stated Resident #5's leg was swollen but she did not grimace or voice any complaints of pain when care was provided during the shift. During an interview on 09/13/21 at 10:03 AM, NA #3 confirmed she was assigned to provide care to Resident #5 during the hours of 10:30 PM to 6:30 AM on 05/31/21 and 06/01/21. On 05/31/21 during the shift, she stated she had notified the nurse that Resident #5's leg was bruised and was told by the agency nurse she was aware and there was nothing she could do about it except leave a note for the MD. On 06/01/21, NA #3 stated she told another agency nurse Resident #5's leg was bruised and was told the same thing as the previous evening. NA #3 could not recall the names of the agency nurses she had notified. NA #3 recalled Resident #5 never really complained of any pain during her shift and her leg wasn't that swollen, not like you would expect with a fracture, just bruised. During an interview on 09/13/21 at 11:31 AM, Nurse #2 confirmed she was assigned to provide care to Resident #5 on 05/30/21 during the hours of 6:30 AM to 6:30 PM. Nurse #2 could not recall the exact time but stated she was in Resident #5's room, fluffing her pillows and assisting with repositioning her in bed, when she complained about her leg being sore. Nurse #2 added when she assessed Resident #5's legs, she didn't remember her having any swelling in either leg and explained both legs looked the same with no discoloration or other signs of a fracture. Nurse #2 stated she administered Resident #5's scheduled pain medication which was effective and since Resident #5 did not display signs of severe pain, she felt it was just the normal aches and pains. During an interview on 09/09/21 at 1:40 PM, Nurse # Nurse #4 confirmed she was assigned to provide care to Resident #5 on 05/30/21 during the hours of 6:30 PM to 6:30 AM. Nurse #4 stated during early morning rounds on 05/31/21, Resident #5 complained of pain in her right lower extremity and upon assessment, she noticed it was swollen but had no discoloration or signs of obvious fracture. Nurse #4 stated when Resident #5 received her scheduled pain medication and ice was applied, her pain lessened. Nurse #4 added she did not contact the on-call physician but did give report during shift change and left a communication note for the MD or Nurse Practitioner to evaluate. The Nurses assigned to provide care to Resident #5 during both shifts on 06/01/21 and during the hours of 6:30 AM to 6:30 PM on 06/02/21 were no longer employed by the facility and unavailable for an interview. During an interview on 09/13/21 at 11:47 AM, Nurse #5 confirmed she was assigned to provide care to Resident #5 on 06/02/21 during the hours of 6:30 PM to 6:30 AM. Nurse #5 could not recall the exact time but stated during the shift, Resident #5 was grimacing and she couldn't recall what Resident #5's response was but when she looked at her leg, she noticed it was bruised. Nurse #5 did not remember being told anything had happened to Resident #5's leg during shift report and nothing was written in the previous nurses' notes; however, she did receive the x-ray results confirming a fracture. Nurse #5 added she notified the on-call MD who gave orders to send Resident #5 to the hospital for evaluation and treatment. Telephone attempts on 09/10/21 at 1:46 PM and 09/13/21 at 12:26 PM to speak with the facility's former MD who evaluated Resident #5 on 06/03/21 were unsuccessful. Attempts to interview the radiologist who interpreted Resident #5's x-ray completed on 06/02/21 were not successful. The Director of Nursing (DON) and Administrator at the time this incident occurred were no longer employed at the facility and unavailable for an interview. During an interview on 09/13/21 at 12:40 PM, the current DON explained she was not employed with the facility when Resident #5's fracture was identified and was not sure what their process was at the time related to notifying the physician with changes in condition. The DON stated in her opinion, they should have notified the on-call physician when the swelling was first identified. During interviews on 09/09/21/21 at 5:00 PM and 09/20/21 at 2:30 PM, the Regional Clinical Operations Consultant (RCOC) explained Resident #5 was noted to have mild swelling to her knee on 05/31/21 and upon exam an x-ray was ordered by the Nurse Practitioner (NP) on 06/02/21 which confirmed a fracture and she was sent to the Emergency Department for evaluation and treatment. The RCOC explained since Resident #5 had no known falls or injuries and Resident #5's scheduled pain medications were effective she felt it was appropriate for the nurse to leave a written communication note for the NP or MD.

Based on observations, record review, physician interview, staff interviews, and review of the facility's COVID-19 Policy/Plan for Facilities, COVID Response Plan, facility memorandum for staff regarding the screening process and reporting of symptoms, and Emergency Plan for Pandemic Policy, the facility: 1) failed to implement their infection control policies and procedures on work criteria for staff reporting symptoms consistent with COVID-19 and failed to ensure Nurse #1 followed the facility's infection control policies and procedures regarding the screening process and work criteria by not completing the screening questionnaire in its entirety and working her scheduled shifts with symptoms consistent with COVID-19; 2) failed to ensure facility staff donned Personal Protective Equipment (PPE) per the Centers for Disease Control (CDC) guidelines for residents under Enhanced Droplet/Contact Precautions (EDCP) by Nurse #2 not donning a face shield or goggles when providing [MEDICAL CONDITION] care and administering a nebulizer treatment to 1 of 1 resident (Resident #1) with a confirmed [DIAGNOSES REDACTED].#1 donned a face shield when providing care to 1 of 1 resident (Resident #1) on EDCP and performed hand hygiene after contact with objects within a resident's room and common area for 2 of 2 rooms located on the facility's COVID positive unit. These failures occurred during a COVID-19 pandemic. As of 09/15/20, a total of 52 residents had tested positive for COVID-19. Immediate Jeopardy began on 08/10/20 when the facility allowed Nurse #1 to work her scheduled shifts on the non-COVID unit after reporting symptoms of an intermittent fever of 100 degrees, cough and sore throat. Immediate Jeopardy was removed on 09/17/20 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring symptoms put into place are effective. The findings included: 1. A facility memorandum dated 03/18/20 to all facility staff read in part, per guidance from the Centers for Disease Control (CDC), we are implementing new measures daily including: actively screening all health care personnel for respiratory symptoms including actively checking temperatures for a fever at the beginning of each shift. Anyone with these symptoms will not be permitted to enter the facility at any time. Sick employees need to stay at home. If you have any symptoms, stay at home and notify your supervisor. Those symptoms include: cough, fever, sore throat, and/or shortness of breath. The facility policy titled, COVID-19 Policy/Plan for Facilities last updated on 05/06/20, read in part, Staff Considerations: remind staff that they should not report to work with a sore throat, fever, cough or shortness of breath, until they have been cleared by their physician. Other symptoms being reported by infected persons include loss of taste and smell, dizziness, overwhelming feeling of exhaustion. Symptoms may come on suddenly. Not all infected persons will experience symptoms. Symptoms may be present with or without fever. Staff who are reporting symptoms will be asked to a) confirm the infection is not COVID-19 or b) remain out of work until they have been without a fever for at least three days (72 hours) without the use of fever reducing agents and without, or significantly improving, other symptoms for at least 72 hours. Request that staff report any of the above symptoms or if a person they have been in close contact has symptoms or has been diagnosed with [REDACTED]. The facility's COVID Response Plan, updated May 2020, read in part, Staff and any personnel entering the center are educated that they should not report to the facility if they have a temperature and/or lower respiratory symptoms and that they should report these symptoms immediately to their supervisor. During the entrance conference on 09/15/20 at 8:55 AM, the Administrator confirmed baseline testing for COVID-19 was conducted on 08/10/20 for all residents and facility staff. The Administrator stated when the COVID test results were received on 08/13/20, there were three confirmed positive results: Nurse #1, Nurse Aide (NA) #2 and Resident #2. She added both Nurse #1 and NA #2 worked together on the same resident hall and Nurse #1 would have been assigned to provide care to Resident #2. The COVID-19 Employee Sign In/Out log screening log for 08/10/20 noted the following: · Nurse #1's signature. · No time in was documented. · Temperature upon entry was recorded as 97 degrees. · Screening question #1 (Do you have any symptoms of sore throat, fever, cough, shortness of breath, malaise (fatigue), or Gastrointestinal (GI) symptoms) was answered as allergies. · Screening question #2 (Have you had any type of sickness or generally not feeling well in the last 72 hours) was left blank and not answered. · Screening question #3 (Have been in any location or around anyone that has had a confirmed case of COVID-19 in the last 14 days. If yes, please see charge nurse) was left blank and not answered. · No time out was documented. · Screening question #4 (Did you at any time during your shift feel sick or have any respiratory symptoms. If yes, please see the charge nurse) was left blank and not answered. · Temperature upon exit was recorded as 97.6 degrees. The COVID-19 Employee Sign In/Out screening log for 08/11/20 noted the following: · Nurse #1's signature. · No time in was documented. · Temperature upon entry was recorded as 97.5 degrees. · Screening question #1 was answered as cough due to allergies. · Screening questions #2, #3 and #4 were left blank and not answered. · Temperature upon exit was recorded as 99 degrees. The facility's COVID-19 infection and testing spreadsheet, updated 09/15/20, revealed a line item for Nurse #1 that revealed a lab specimen was collected for COVID-19 testing and sent to an outside laboratory for processing on 08/10/20. It was noted Nurse #1 had COVID-like symptoms of a low-grade temperature, some cough and some shortness of breath with an onset date of 08/11/20. Further review revealed the test results were received on 08/13/20 and confirmed Nurse #1 was positive for COVID-19. During a telephone interview on 09/15/20 at 10:56 AM, Nurse #1 revealed on 08/09/20 she called and spoke with the Director of Nursing (DON) to report an onset of cough, sore throat and low-grade temperature. She stated she explained to the DON that her symptoms were intermittent but she felt fine and just wanted to make sure it would be ok for her to report to work on 08/10/20. Nurse #1 added the DON told her it would be ok to report to work as scheduled. Nurse #1 confirmed she was tested for COVID-19 on 08/10/20 along with other facility staff and worked her scheduled shifts on both 08/10/20 and 08/11/20 on the non-COVID unit of the facility. She explained she was scheduled to return to work on 08/13/20 but called in sick because her symptoms had progressed and she felt worse. She reported being notified by the facility on 08/13/20 that her test results were positive for COVID-19. Nurse #1 stated she was surprised to learn she tested positive for COVID-19 and had thought her symptoms were allergy or cold related. During a follow-up telephone interview on 09/16/20 at 10:49 AM, Nurse #1 explained when her allergy symptoms flared she rarely got a cough but typically had a runny nose, slight headache, sore throat, and low-grade temperature. Nurse #1 confirmed she received training on the facility's screening process which included reporting the onset of respiratory or COVID related symptoms and stated that was why she contacted the DON by telephone on 08/09/20 to report her symptoms. During the telephone conversation on 08/09/20, she recalled informing the DON she had a low-grade temperature of 100 degrees. She added she explained to the DON her symptoms were mild and intermittent. Nurse #1 confirmed the DON did not tell her she had to report to work if she did not feel well but did ask her if she felt well enough to come in on 08/10/20 for COVID testing. She stated she told the DON she felt fine and would be at work as scheduled on 08/10/20. Nurse #1 confirmed she completed the screening process prior to the start of each shift, which included taking her temperature and answering the screening questions. She was unable to recall if she had self-screened or another staff member had completed the screening for her on 08/10/20 and 08/11/20 nor was she able to explain why all the screening questions were not answered. She restated they were instructed to report the onset of symptoms to the nurse but since she had spoken to the DON on 08/09/20, she did not report her symptoms to anyone on 08/10/20. Nurse #1 added she never spoke with the Administrator on 08/10/20 or 08/11/20 about her symptoms. During a telephone interview on 09/21/20 at 11:21 AM, the Infection Control Nurse (ICN) confirmed she provided staff education on the facility's screening process which included what signs and symptoms should be reported to the nurse supervisor. The ICN explained staff were instructed to record their temperature when reporting to work and leaving for the day, answer all the screening questions and if their temperature was 99.6 degrees or higher and/or they answered any screening question with yes, they were to report to the nurse supervisor. The ICN added staff were instructed not to work with any signs or symptoms consistent with COVID-19 and immediately report if they developed any symptoms including fever, sore throat, cough and/or shortness of breath. During an interview on 09/15/20 at 11:20 AM, the DON recalled on 08/09/20 Nurse #1 reported to her that she had a cough and allergies but could not remember if Nurse #1 mentioned she also had a low-grade temperature. The DON stated she asked Nurse #1 if she felt well enough to come into the facility on [DATE] to be tested but emphasized she didn't have to work if she didn't feel well. She recalled Nurse #1 stating it was only allergies and would report to work as scheduled. The DON confirmed residents were also tested at the same time as Nurse #1 on 08/10/20 and several residents Nurse #1 worked with later tested positive. The DON stated she should have instructed Nurse #1 to remain at home but trusted Nurse #1's nursing judgment and didn't think to question her symptoms when she stated she felt fine. During interviews on 09/15/20 at 12:43 PM and 3:00 PM, the Administrator confirmed facility staff were instructed not to work with any signs and symptoms consistent with COVID-19 until the return to work criteria was met as outlined in the facility's COVID-19 infection control policy/plan and stated she was the one responsible for reviewing the staff screening logs daily. She explained she did review the screening logs to make sure the screening questions were answered; however, her primary focus was ensuring staff had not reported and/or worked with an increased temperature. She added if there were any respiratory symptoms reported, she talked with the individual about their symptoms but would not necessarily send them home if their symptoms were mild and temperature normal. She recalled noticing Nurse #1 had reported allergy related symptoms on 08/10/20 and when she asked her about it, Nurse #1 stated she got allergies all the time and felt fine. The Administrator explained she didn't think to question her further because her temperature was normal and her reported symptoms did not cause alarm that something else might be wrong or could be COVID related. 2. A review of the facility's Infection Control Policy and Procedure named, COVID Response Plan, updated August 2020, read in part: required Personal Protective Equipment (PPE) on the quarantine units: N-95 mask, gown, face shield, and gloves worn in resident rooms. A review of the facility's Policy and Procedure named, Emergency Plan for Pandemic Policy revised 06/01/2020, noted under the section Hand Hygiene and read in part: healthcare personnel should perform hand hygiene before and after all patient contact and before putting on and after removing PPE, including gloves. The section named Eye Protection read in part: put on eye protection (goggles or face shield that cover the front and sides of the face) upon entry to a patient's room or care area. Personal eye glasses are not considered adequate eye protection. The section named, Gloves read in part: put on clean, non-sterile gloves upon entry into a patient's room or care area. Remove and discard gloves when leaving the patient room and immediately perform hand hygiene. A review of the Center for Disease Control and Prevention (CDC) website page named, Interim Infection Prevention and Control Recommendations During the Coronavirus Disease 2019 Pandemic, noted under the section named, Implement Universal Use of Personal Protective Equipment and read in part: healthcare personnel working in facilities with moderate or substantial community transmission were more likely to encounter patients with [DIAGNOSES REDACTED]-CoV-2 (Coronavirus) infection and should follow standard and transmission based precautions if required based on the suspected diagnosis. Healthcare personnel should also wear eye protection in addition to their face mask to ensure the eyes, nose, and mouth were all protected from exposure to respiratory secretions during patient care encounters. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/24/2020 Resident #1 was diagnosed with [REDACTED]. A review of the physician orders [REDACTED]. 1. Provide [MEDICAL CONDITION] care every shift and as needed, 2. Administer 3 milliliters of [MEDICATION NAME]-[MEDICATION NAME] (a combination of liquid medications used to treat [MEDICAL CONDITION]) solution via [MEDICAL CONDITION] four times a day for wheezing and shortness of breath. An observation on 09/09/2020 at 9:10 AM revealed enhanced droplet-contact precautions signage placed on the plastic barrier of the entrance to the COVID positive unit listed instructions which included: to stop and perform hand hygiene and to wear gloves and eye protection before entering the room. A continuous observation was made of the COVID positive unit on 09/09/2020 from 8:55 PM through 9:02 PM. Nurse #2 was observed in the room of Resident #1 and had begun to provide [MEDICAL CONDITION] care. Resident #1 was observed to cough while Nurse #2 swabbed the opening of the [MEDICAL CONDITION] site with a cotton tipped device. At 9:02 PM Nurse #2 administered a nebulizing treatment of [REDACTED].#1 Nurse #2 did not wear a face shield or goggles. During an interview on 09/09/2020 at 9:05 PM Nurse #2 identified Resident #1 as being placed on enhanced droplet-contact precautions. Nurse #2 acknowledged she was not wearing a face shield or goggles prior to entering the room and providing [MEDICAL CONDITION] care and a nebulizer treatment to Resident #1. Nurse #2 was aware enhanced droplet-contact precautions included eye protection when entering the room and knew she should have worn either a face shield or goggles. Nurse #2 explained the reason she had not was because the goggles would fog up and she had forgotten the face shield. Nurse #2 indicated she tested and resulted positive for COVID-19 and worked only on the COVID positive unit and remained asymptomatic. An interview conducted with the facility's Medical Director on 09/11/2020 at 3:18 PM revealed when Nurses provided [MEDICAL CONDITION] care or a nebulizer treatment a face shield or goggles should be worn for protection. The Medical Director indicated enhanced droplet-contact precautions had been implemented by the facility to provide protection during the COVID-19 Pandemic. During an interview on 09/22/2020 at 10:49 AM the Administrator revealed residents positive for COVID-19 received care under enhanced droplet-contact precaution guidelines which provided instructions for eye protection when entering the room. The Administrator asked Nurse #2 about not wearing the face shield or goggles who explained she was not at risk of being exposed or exposing residents on the COVID positive unit. The Administrator expected Nurse #2 to follow proper PPE instructions in place on the COVID positive unit and to wear a face shield or goggles before entering a resident's room. An interview conducted on 09/22/2020 at 11:23 AM with the Director of Nursing (DON) revealed the enhanced droplet-contact precautions were initiated for the COVID-19 Pandemic to protect the residents and facility staff. The DON expected Nurse #2 to follow precautions that had been implemented for the care of residents and wear eye protection, either a face shield or goggles, when entering the room. 3. A continuous observation of the COVID positive unit made on 09/09/2020 from 9:33 PM through 9:48 PM revealed enhanced droplet-contact precaution signage was posted in a highly visible area on the plastic barrier entry to the unit. At 9:33 PM Nurse Aide (NA) #1 entered the room occupied by Resident #1 wearing gloves but was not seen to perform hand hygiene prior to entering the room. NA #1 did not don eye protection before she entered the room. With gloved hands NA #1 touched the bed linens to reposition Resident #1, then placed one of the pillows from the same bed between the resident's legs. While wearing the same gloves NA #1 pushed the button on the wall switch to turn off the call light and repositioned a rolling table within reach of Resident #1. NA #1 then removed her gloves and exited Resident #1's room without performing hand hygiene. There was a sink located in the room with soap and water and paper towels available for use. At 9:48 PM NA #1 walked down the hallway and entered room [ROOM NUMBER] occupied by a resident without performing hand hygiene or donning gloves and turned off the light switch then left the room. NA #1 proceeded to walk down the hallway and enter a common area of the COVID positive unit and without performing hand hygiene touched the volume button on the television to lower the sound. NA #1 then walked to the nurse station where she washed her hands. During an interview on 09/11/2020 at 9:50 PM NA #1 indicated all the residents on the COVID-19 positive unit were under enhanced droplet-contact precautions. NA #1 explained she kept hand sanitizer on her cart which she usually took with her but had not. NA #1 was aware enhanced droplet-contact precautions included to perform hand hygiene and wear gloves and she should have followed those steps before entering a resident's room. NA # 1 said she did remove her gloves before she touched the light switch and television volume control but had not performed hand hygiene but should have. An interview conducted with the facility's Medical Director on 09/11/2020 at 3:52 PM revealed enhanced droplet-contact precautions had been implemented by the facility to provide protection during the COVID-19 Pandemic. NA #1 should follow precautions and wear eye protection and perform hand hygiene after contact with a resident placed on enhanced droplet-contact precautions and before she touched inanimate objects and considered not doing so a break in infection prevention. A second interview on 09/11/2020 at 5:07 PM revealed NA #1 did not like wearing a face shield because it would fog up which made it difficult to see. NA #1 did not like to wear goggles because she wore glasses and indicated those protected her eyes. During an interview on 09/21/2020 at 10:49 AM the Administrator revealed residents positive for COVID-19 received care under enhanced droplet-contact precaution guidelines which provided instructions for hand hygiene and eye protection when entering the room. The Administrator explained NA #1 should have worn eye protection and assumed NA #1 thought her eye glasses provided protection. The Administrator indicated NA #1 was headed to the nurse station to wash her hands and became side tracked when she turned off the light switch and volume on the television and thought since she had not touched another resident that was okay. During an interview on 09/22/2020 at 11:23 AM the Director of Nursing revealed the enhanced droplet-contact precautions were initiated for the COVID-19 Pandemic to protect the residents and facility staff. The DON expected NA #1 to follow precautions that had been implemented for the care of residents. Those precautions included to wear eye protection either a face shield or goggles when entering the room and perform hand hygiene after patient care and when inanimate objects, such as a call light or light switch were touched. The Administrator and DON were notified of Immediate Jeopardy on 09/16/20 at 3:25 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Allegation of Immediate Jeopardy Removal F880 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance All residents are at risk from the failure to adhere with correct and adequate infection control processes as guided by the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid (CMS). CMS guidance states that all employees must be screened prior to beginning work. Facility had in place a screening process for employees to follow prior to beginning their shift for 8/10/20 and 8/11/2020 Nurse # 1 failed to complete her screening tools as she has been instructed. Facility also failed to review screening logs to ensure they were being completed. The Director of Nursing (DON) failed to follow facility policy for not allowing employees with reported signs and symptoms to work. Nurse Number # 2 failed to wear a face shield or goggles as per facility policy when working on the COVID unit while providing care because she felt that since she and the resident were both positive there was no risk of spreading COVID to the resident. Specify the Action the Facility will take to alter the process or system failure to Prevent a Serious Outcome from occurring or reoccurring and when the Action will be complete. The Accordius Corporate COVID-19 management policy has been and will continue to be updated by the Accordius Corporate management team to remain current with Centers for Disease Control (CDC) guidance and Centers for Medicare and Medicaid (CMS) requirements as the information around managing the pandemic evolves. As new guidance comes out the Accordius Management team will educate the facility on new guidance and polices for COVID-19. This includes the use of a screening tool, PCR testing and [MEDICATION NAME] testing in accordance with CDC's recommendations for testing, screening and donning and doffing PPE per CDC recommendations. On 9/16/20, the Regional Director of Operations for Accordius in-serviced the Administrator, Director of Nursing and Infection Control Preventionist on the facility policy and procedure for screening employees both before and after their work shift. The Director of Nursing, Administrator and Infection Control Preventionist have also been instructed on how to handle staff reports of signs and symptoms prior to scheduled shifts to also include not reporting to work until medically cleared as per facility policy. This included but was not limited to the symptoms to look for and the temperature threshold regarding the employee responses on the log. Administrator or Director of Nursing will review all screening logs daily Monday- Friday to ensure all information is filled in correctly and fully. Charge Nurse will check logs on night shift. Charge nurse will review logs for completion on Saturday and Sunday and will notify Director of Nursing or Administrator of any issues. This in-service also addressed Personal Protective Equipment (PPE) that is to be worn in the facility and the steps to don and doff the PPE per CDC recommendations. Regional Director of Operations verified complete understanding of re-education upon completion with Director of Nursing, Administrator and Infection Control Preventionist to ensure proper delivery to all staff. Following this in-service on 9/16/20, by the Regional Director of Operations the Administrator, Director of Nursing and Infection Control Preventionist, immediately began in-servicing/re-educating all facility staff that were currently at the facility. As of 9/17/2020 all staff have been in-serviced by the Administrator and or the Director of Nursing or Infection Control Preventionist on Personal Protective Equipment (PPE) that is to be worn in the facility and the steps to don and doff the PPE per CDC recommendations. All staff are required to wear a provided N95 mask, gown and goggles or face shield at all times while in the covid-19 area of the facility. All staff were also educated on sign in log and screening questions and completion of the screening questions and re-educated on facility policy for not reporting to work when and if they have experienced any signs and symptoms. Staff are to call the facility Administrator or Director of Nursing if they are showing or experiencing any signs and symptoms prior to reporting to work. All agency staff have been included in the re-education. Facility will also educate all new hires prior to starting work. The remainder of staff will be in-serviced on this plan by telephone and review the plan in person when they arrive for their next assigned shift by the Administrator, Director of Nursing and/or Infection Control Preventionist. No person will be permitted to work on the floor until completing the in-service regarding this plan. As of 9/17/2020 all facility staff have been re-educated on facility policy and procedure for screening prior to beginning work by the Director of Nursing, Administrator and/or Infection Control Preventionist. Facility will assign receptionists to the screening area to monitor sign in log to ensure all screening questions are answered without any issues during Day shift 6:30 am - 5 pm seven days per week. Charge Nurse's will screen night shift employees upon entry from 5:00 pm - 6:30am seven days a week . Prior to working screening area receptionists and Charge Nurses have been in-serviced on 9/17/2020 by the Administrator, Director of Nursing on process for completing screening tool per facility policy to ensure all screening questions are answered and there are no employees to start their shift if yes is answered to any screening questions or any temperature higher than 99.6 degrees Fahrenheit. Employees who answer yes to any of the screening tools will have to report to the Director of Nursing or Administrator prior to being allowed to start their shift. If Administrator or Director of Nursing is not in the building employee will have to call the Director of Nursing or Administrator before they can start their shift. Any employee with a temperature greater than 99.6 degrees Fahrenheit or showing any signs or symptoms related to COVID-19 will be sent home as per facility policy. Employee will only be allowed back to work after being cleared by a physician. The Facility alleges the removal of the immediate jeopardy on 9/17/20. On 09/23/2020 the facility's credible allegation for Immediate Jeopardy removal was validated by the following: Review of in-service training records of staff from all departments including agency staff, Administrator, Director of Nursing and Infection Control Nurse. The topic of training received was named, Proper PPE and how it relates to COVID-19 and signing and temperature recording in and out and reporting illness or symptoms. Employee screening logs were reviewed for accuracy which revealed temperatures were recorded and screening questions were answered. Interviews with facility and agency staff revealed they received training and were able to describe the facility's processes for screening, proper use of PPE and hand hygiene procedures. Observations on the quarantine COVID unit revealed staff wore the correct PPE for enhanced droplet-contact precautions, including eye protection, and performed hand hygiene after gloves were removed. The facility's date of Immediate Jeopardy removal of 09/17/20 was validated.

Based on observations, record reviews, and staff interviews the facility failed to implement intervention of mechanical lift transfer which resulted in 1 of 3 sampled residents (Resident#1), sustaining a laceration which required sutures. Findings included: A record review of quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was admitted to the facility on [DATE] and was cognitively impaired. Resident #1 was diagnosed with [REDACTED]. Resident #1 required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. A record review of Resident #1's care plan most recently updated on 02/04/15, revealed an identified problem with transfers. Resident #1 required use of mechanical sit to stand lift for transfers. An intervention for Resident #1 included providing a mechanical lift for transfers. Nurse's situation, background, assessment, and recommendation (SBAR) note dated 03/09/15, indicated Resident #1 received laceration to right foot 3rd toe, full thickness laceration required stitches, transferred to hospital. Resident #1 was on blood thinner. A record review of physician's orders [REDACTED]. A record review of emergency room discharge note dated 03/09/15 revealed Resident #1 had a [DIAGNOSES REDACTED]. An interview with unit manager was conducted on 05/06/15 at 2:50 PM. Unit manager stated Resident #1's care plan indicated Resident #1 required mechanical sit to stand lift for transfers and could not be transferred using 2 person physical assist without using mechanical lift as per care plan. Unit manager stated Nurse Aide #1 and Nurse Aide #2 no longer worked at the facility and were not available for interview. An incident and accident form was completed that indicated Nurse Aide #1 and Nurse Aide # 2 were involved with the accident that occurred with Resident #1. An interview with the Director of Nursing (DON) was conducted on 05/06/15 at 4:08 PM. DON stated Nurse Aide #1 and Nurse Aide #2 performed a 2 person physical transfer of Resident #1 without using mechanical sit to stand lift as per Resident #1's care plan. DON stated Resident #1 was noted to have injury to right foot 3rd toe. DON revealed toe injury was noticed when Resident #1 was sitting in the shower chair post transfer without using mechanical sit to stand lift. DON revealed Resident #1 went to the emergency roiagnom on [DATE] and received stitches and returned to the facility on [DATE]. DON stated statements obtained from Nurse Aide #1 and Nurse Aide #2 revealed they did not use the mechanical lift to transfer Resident #1. Nurse Aide #1 and Nurse Aide #2 statements indicated they used 2 person physical assist to transfer Resident #1. DON stated Nurse Aide #1 and Nurse Aide #2 were counseled and educated on the use of mechanical lifts and to follow resident care plan. Nurse Aide #1 and Nurse Aide #2 were informed by DON that any further infractions would result in discharge. A telephone interview was conducted with Nurse #1 on 05/07/15 at 10:20 AM. Nurse #1 stated she remembered Resident #1 was sitting in a shower chair at doorway of her room with feet dangling and blood was on the floor under her feet. Nurse #1 stated she thought Resident #1 had a loose toe nail and wrapped foot in plastic bag so Resident #1 could finish her shower. Nurse #1 stated after dinner when Resident #1 was lying in bed, she reassessed Resident #1's foot and discovered Resident #1 had a full thickness laceration of foot which began to bleed and required stitches. Nurse #1 stated Resident #1 was transferred via ambulance to the hospital. Nurse #1 stated at the beginning of the shift on 3/09/15, she provided Nurse Aide #1 and Nurse Aide #2 with a nurse aide care guide (plan of care) for Resident #1. Nurse #1 stated it was the responsibility of Nurse Aide #1 and Nurse Aide #2 to read and follow the plan of care for Resident #1. A record review of Nurse Aide #1's nurse aide attention to daily living (ADL) detailed report sheet documentation for 03/09/15 revealed Nurse Aide #1 documented Resident #1 required extensive assistance for transfers and was transferred using one person physical assist. An interview was conducted with the DON on 05/07/15 at 12:15 PM. DON stated Nurse Aide #1 and Nurse Aide #2 did not attend safe transfer in-service provided on 03/06/15. DON stated her expectations were for Nurse Aide #1 and Nurse Aide #2 to follow the interventions on the care plan guide provided to them at the beginning of the shift that indicated Resident #1 required mechanical sit to stand lift for transfers. DON stated her expectations were that Nurse Aide #1 and Nurse Aide #2 would not have transferred Resident #1 using 2 person physical assist. An interview was conducted with the Administrator on 05/07/15 at 1:05 PM. The Administrator stated her expectations were that staff would follow care guides to know what care was needed to be provided for residents. Administrator stated her expectations were that nurses on the unit would monitor that nurse aides implemented interventions on the nurse aide care guide for the resident.