Every finding on record at Shoreland Health Care and Retirement Center Inc

Based on observation, record review, and staff and Responsible Party interviews, the facility failed to arrange necessary dental services to replace a lower denture for a resident with a diagnosis of dysphagia (difficulty swallowing) after the denture was reported missing. This occurred for 1 of 1 resident reviewed for dental services (Resident #75). Findings included: Resident #75 was admitted to the facility on [DATE] with diagnoses including dysphagia and dementia. A physician's order dated 4/15/25 revealed Resident #75 was prescribed a modified texture diet of soft bite size food with mildly thick liquids. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #75 had severe cognitive impairment and moderately impaired vision. She required set up or clean up assistance with eating and with oral hygiene. Resident #75 received a mechanical and therapeutic diet and had no dental issues at the time of assessment. A grievance report dated 10/21/25 completed by the Social Worker revealed Resident #75's Responsible Party stated she was missing her bottom denture. The family brought in an extra pair of dentures and the family was filling out paperwork so that Resident #75 could get dental care in house. The resolution of the grievance was that in-house dental would come at the beginning of the year as this was the earliest time to get started on replacing dentures. The grievance form was signed by the Social Worker on 10/31/25. During an interview on 02/24/26 at 11:19 AM the Social Worker stated a grievance was filed on 10/21/25 by Resident #75's Responsible Party regarding the missing lower denture. She stated she gave Resident #75's Responsible Party the paperwork to complete for in-house dental services and did not get the paperwork back until 11/13/25. The Social Worker indicated she called on 11/13/25 to schedule an appointment with the in-house dental services for denture replacement after receiving the paperwork back and the earliest available appointment was scheduled for 3/16/25. The Social Worker indicated she did not attempt to call after that time to get a dental appointment scheduled sooner or call an outside dentist to get faster service due to Resident #75's diagnoses of dysphagia. During an interview on 2/24/26 at 2:00 PM Resident # 75's Responsible Party (RP) stated that Resident #75 was missing the lower denture since October 2025. The RP stated they brought in a lower denture from home for temporary use soon after her denture was lost in the facility. The RP stated the temporary lower denture brought in did not fit well and caused Resident #75 pain, and she did not like to wear it. The RP stated Resident #75 was able to voice when she was in pain. The RP stated they returned the paperwork for in-house dental within a couple of weeks of the grievance being filed but had no idea it would take six months to get an appointment. She stated she was told by someone at the facility that the appointment would be around the first of the year. She stated Resident #75 had difficulty chewing and swallowing and the facility had ordered a pureed diet earlier this year. The RP stated they signed a waiver to allow her to have soft bite size foods instead of pureed to maintain some quality of life. A care plan revised 12/18/25 revealed Resident #75 had oral and dental health problems with a risk for further decline and decline in nutritional intake related to wearing dentures. Interventions included to coordinate arrangements for dental care as needed. During an observation on 02/24/26 at 12:45 PM Resident #75 was observed in her room sitting in a wheelchair eating lunch independently. Resident #75 was oriented to self as evidenced by responding to her name. She was observed with a divided plate with spaghetti and green beans. She was not wearing the lower denture that was brought in by the RP. The observation further revealed Resident #75 was slow to chew her food, and had food smeared on the towel draped on her chest. During an interview on 02/24/26 at 1:00 PM Nurse Aide #2 stated she was Resident #75's assigned Nurse Aide today from 7:00 AM until 3:00 PM. She stated Resident #75 was able to feed herself, but she would go in the room during meals and offer assistance as needed. Nurse Aide #2 indicated she had not observed Resident #75 having difficulty chewing or swallowing her food. During an interview on 02/24/26 at 1:00 PM Nurse Aide #1 stated Resident #75 had a lower denture in her room that was brought in by the family (unable to specify a date) after the lower denture was reported missing, but Resident #75 did not like to wear it because it caused her pain. Nurse Aide #1 explained that Resident #75 was able to let you know if she had pain by grimacing or saying no when asked about wearing the dentures. Nurse Aide #1 indicated she had not observed Resident #75 having difficulty chewing or swallowing but stated it would be much easier for Resident #75 to chew her food if she had the bottom denture. During an interview on 02/24/26 at 1:19 PM the Speech Therapist stated Resident #75 was prescribed a soft bite size foods diet earlier this year following a FEES study (Fiberoptic Endoscopic Evaluation of Swallowing - a test used to evaluate how well someone can swallow) that was done in January 2025, which showed that Resident #75 was at high risk of choking. The Speech Therapist recommended a pureed diet, but the family wanted her to have soft foods and did not want her on a pureed diet. She stated a waiver was signed to allow soft foods. The Speech Therapist indicated Resident #75 was not currently on Speech Therapy services. During an interview on 02/25/26 at 2:45 PM the Occupational Therapist stated she was currently working with Resident #75. The Occupational Therapist stated she did not realize Resident #75 was waiting for so long for the lower denture, and it was important that she had a full set of dentures due to her risk of choking. The Occupational Therapist stated she would reevaluate Resident #75 to determine the need for increased assistance with eating since the resident continued to not have the lower denture. During an interview on 2/26/26 at 2:00 PM the Director of Nursing (DON) indicated she was aware of Resident #75's missing lower denture but stated she was not aware Resident #75 was not scheduled for new lower dentures until 3/16/26. She stated the RP brought in a lower denture to use while waiting for the appointment to replace the lost denture, but she was not aware that the lower denture caused the resident pain. The DON stated Resident #75 should have been scheduled with an outside dentist if the in-house dentist appointment was going to be six months out. She indicated the Social Worker called an outside dentist yesterday and Resident #75 went for her first fitting today and would be reevaluated by the Occupational Therapist to assess her need for increased assistance with eating while waiting on the lower denture to be replaced. The DON indicated there had been no reported episodes of Resident #75 choking on her food and her weight remained stable. The DON stated the Social Worker should have made attempts to get an appointment scheduled sooner than six months out for a resident with dysphagia, dementia and high risk of choking.

Based on record review, observations, and staff interviews, the facility failed to implement their infection control policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to a resident with an indwelling urinary catheter (Resident #7) and a resident with a feeding tube (Resident #46). This occurred with 2 of 3 staff members who were observed for infection control practices (Nurse #2 and Nurse #3).Findings included: The Infection Control Policy dated 6/1/25 revealed Enhanced Barrier Precautions referred to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of multi-drug resistant organisms (MDROs) to hands and clothing. High contact resident care activities that required enhanced barrier precautions included indwelling medical device care such as urinary catheters and feeding tubes. a.) During an observation on 2/23/26 at 11:30 AM Resident #7 was observed lying in bed. An Enhanced Barrier Precaution sign was observed by the door outside of Resident #7's room. A PPE (personal protective equipment) supply cart was in the hallway outside of the residents room with supplies including gloves and gowns. Nurse #2 was observed at Resident #7's bedside changing the urinary catheter bag. Nurse #2 was wearing gloves but did not don (put on) a gown prior to providing direct care to Resident #7. During an interview on 2/23/26 at 11:30 AM Nurse #2 stated she did not realize that Resident #7 was on enhanced barrier precautions, and she did not see the sign on the outside of Resident #7's room. Nurse #2 stated she did not know why Resident #7 was on enhanced barrier precautions. Nurse #2 stated she had received infection control training including training on enhanced barrier precautions and when to wear PPE. Nurse #2 stated she should have worn a gown along with gloves when changing the urinary catheter bag. b.) During an observation on 2/23/26 at 11:45 AM Resident #46 was observed lying in bed. An Enhanced Barrier Precaution sign was observed by the door outside of Resident #46's room. A PPE supply cart was in the hallway outside of the residents room with supplies including gloves and gowns. Nurse #3 was observed at Resident #46's bedside administering medications and water flushes through the feeding tube then replaced the blankets over Resident #46. Nurse #3 was wearing gloves but did not don a gown prior to providing direct care to Resident #46. During an interview on 2/23/26 at 11:50 AM Nurse #3 stated she did not see the sign on the outside of Resident #46's room, and she did not know why Resident #46 was on enhanced barrier precautions. Nurse #3 stated she had received infection control training including training on enhanced barrier precautions and when to wear PPE. Nurse #3 stated she should have read the sign and put on a gown along with the gloves when giving medications through a feeding tube. During an interview on 2/26/26 at 10:30 AM the Infection Control Preventionist Nurse stated staff had been trained on enhanced barrier precautions. She stated they provided in-service education on infection control including enhanced barrier precautions throughout the year, and she conducted random audits to ensure staff were adhering to PPE guidelines. She stated Nurse #2 and Nurse #3 should have donned a gown along with gloves when providing urinary catheter care and when administering medications through a feeding tube. She stated continued education would be provided to staff. During an interview on 2/26/26 at 2:00 PM the Director of Nursing (DON) stated staff received infection control training including training on enhanced barrier precautions annually. The DON indicated staff should be following the infection control guidelines and wearing PPE when providing direct care to residents on enhanced barrier precautions.

Based on record review and resident, staff, and Medical Director interviews, the facility failed to ensure a resident attended an oncology appointment for cancer-related care as scheduled. This deficient practice affected 1 of 1 resident reviewed for care to maintain wellbeing (Resident #62). Findings included: Resident #62 was admitted to the facility [DATE] with diagnoses including prostate cancer. A care plan dated [DATE] revealed Resident #62 had an activities of daily living self-care deficit related to disease process including malignant prostate cancer. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #62 was cognitively intact. He had no rejection of care, and he required staff assistance with activities of daily living. Record review revealed an after-visit summary from the cancer center dated [DATE] at 3:00 PM for Resident #62 to return to the cancer center on [DATE] at 1:15 PM for labs and 1:30 PM for an oncology appointment and Lupron injection (used to treat prostate cancer by lowering testosterone levels). During an interview on [DATE] at 12:32 PM Resident #62 stated he had prostate cancer and had to go to the cancer center every six months for Lupron injections. Resident #62 stated he had been receiving Lupron injections every six months for over five years. He stated he had an appointment scheduled by the cancer center on [DATE] for the Lupron injection but Transportation Aide #2 told him that day that she had a mandatory meeting and could not transport him to the cancer center and they would have to reschedule the appointment. He stated the appointment was rescheduled and he went a month later at the end of [DATE]. Resident #62 expressed concern about the delay in cancer treatment and stated he was not happy about having to miss an appointment and thought that other arrangements could have been made to get him there. Resident 62's medical record from [DATE] through [DATE] revealed no documentation in the medical record, or progress notes, regarding Resident #62's appointment on [DATE] at the cancer center. A follow up visit note from the cancer center dated [DATE] revealed Resident #62 was evaluated for prostate cancer and Lupron therapy. Resident #62 was high risk prostate cancer and was there for follow up and treatment. The treatment plan was for Leuprolide (Lupron) 45 milligram injections every six months with last injection on [DATE], noting that he was slightly overdue for his next dose. Resident #62 denied weight loss, fatigue, or changes in appetite. Resident #62's physical exam was unremarkable. The plan of treatment noted was to continue Lupron therapy every six months until [DATE], then shorten the interval to every four months to keep a closer eye on him and his tumor markers. Recheck labs in three months and follow up with oncologist in six months. There were no new labs listed on the [DATE] follow-up note. The next appointments were scheduled for labs on [DATE] and oncology and labs on [DATE]. During a phone interview on [DATE] at 3:00 PM Transportation Aide #2 stated that she and Transportation Aide #1 shared the responsibility for transporting residents to appointments. She stated if she could not take residents to their appointments, she would notify Transportation Aide #1 or reschedule the appointment. Transportation Aide #2 stated she did not take Resident #62 to his appointment at the cancer center on [DATE] because she had a CPR (cardiopulmonary resuscitation) class scheduled that day, but she did transport other residents after CPR class. Transportation Aide #2 stated that she notified Transportation Aide #1 that she was unable to transport Resident #62 to his appointment on [DATE]. She stated she did get Resident #62 to his appointment on [DATE] at the cancer center. Transportation Aide #2 stated they did not usually notify the nurses or Director of Nursing (DON) when appointments were rescheduled. She indicated that she and Transportation Aide #1 could reschedule appointments when they needed to in order to accommodate the residents' appointments. During a phone interview on [DATE] at 4:00 PM Transportation Aide #1 stated Transportation Aide #2 did let her know that she could not take Resident #62 to his appointment at the cancer center on [DATE]. Transportation Aide #1 stated she could not take Resident #62 to his appointment on [DATE] either because her transportation schedule could not accommodate getting Resident #62 to the cancer center, so she called and rescheduled the appointment, and the new appointment was scheduled for [DATE]. Transportation Aide #1 stated she did not notify the DON that she had to reschedule Resident #62's appointment. She stated since [DATE] they had a new process to where she emailed the clinical team including the DON every Friday to notify them of upcoming appointments for the following week. During a phone interview on [DATE] at 3:40 PM the Medical Director stated Resident #62 was followed by oncology for prostate cancer treatment. She stated there was no difference in getting the injection at seven months versus getting the injection at six months. The Medical Director stated the cancer center report on [DATE] read that Resident #62 was slightly overdue for the treatment. She stated if there had been a concern regarding a delay in treatment then oncology would have rescheduled the appointment sooner than four weeks. She stated she did not order testosterone or PSA levels (PSA - prostate specific antigen- a blood test used to monitor and guide treatment for prostate cancer) for Resident #62 and that was done at oncology, and she was not aware of what those levels were at this time. The Medical Director stated oncology didn't order a PSA to be drawn for three months following the [DATE] appointment indicating to her there was no acute concern, and Resident #62 has had no change in condition. She stated she did not need to be notified that his appointment had to be rescheduled.During an interview on [DATE] at 2:00 PM the Director of Nursing (DON) stated she was not made aware that Resident #62 had his cancer treatment appointment rescheduled with a four-week delay. She stated corporate changes became effective in [DATE] and now she and the clinical team get an email every Friday from the Transportation Aides that show what appointments were upcoming the following week for their residents. The DON stated she specifically reviewed the upcoming appointments when she received the email on Fridays. The DON stated the Transportation Aides should have notified her that they could not take Resident #62 to his appointment for cancer treatment on [DATE] and she would have made arrangements with an outside medical transport to get him to the appointment that day.

Based on observations, record reviews, and staff, Nurse Practitioner and Physician interviews, the facility failed to maintain a medication error rate below 5%. Three (3) medication errors were observed out of 25 opportunities, resulting in a medication error rate of 8 %. This occurred for 2 of 5 residents reviewed during a medication pass observation (Residents #29 and #82). Findings included:A review of the facility's mealtime schedule showed that breakfast meal tray carts were delivered to the 200 Hall (the hall where Resident #29 and #82 resided) at 7:30 AM and 7:40 AM. 1. Resident #29 was admitted on [DATE] with diagnosis which included diabetes, diabetic retinopathy, and long-term use of insulin. A review of a physician order dated 2/16/26 in Resident #29's electronic health record read to administer Humalog insulin solution (100 units/milliliter) 10 units subcutaneously before meals for diabetes; hold for blood sugar less than 100. Resident #29 also had a separate order dated 2/16/26 for sliding-scale Humalog insulin solution (100 units/milliliter) to be administered subcutaneously before meals and at bedtime based on the following blood sugar readings: 70-150: 0 units 151-199: 1 unit 200-249: 2 units 250-299: 4 units 300-349: 6 units 350-399: 8 units 400-999: 10 unitsA review of Resident #29's quarterly Minimum Data Set assessment dated [DATE] indicated that the resident was cognitively intact, had a diagnosis of diabetes and received insulin daily.During a medication pass observation on 2/25/26 at 9:15 AM Nurse #1 obtained Resident #29's blood sugar with a result of 295. Nurse #1 administered a total of 14 units Humalog insulin to Resident #29, the 4 units of sliding scale insulin according to the blood sugar result and the scheduled dose that was ordered to be administered before the breakfast meal. Resident #29's breakfast tray was not observed in the room. An interview was conducted with Nurse #1 on 2/25/26 at 10:40 AM. Nurse #1 stated she worked at the facility through a temporary agency and had only worked there a few times. Nurse #1 stated that she was assigned to complete the blood sugar checks and administer insulin for all Residents on the 200 and 300 halls. Nurse # 1 indicated that she was not familiar with the residents or who required blood sugar checks or insulin, so she was late administering the insulin to the residents and did not administer the medication according to the physician order. An interview was conducted with Resident #29 on 2/25/26 at 3:15 PM. Resident #29 indicated that Nurse #1 administered her insulin after she finished her meal in the morning on 2/25/26. An interview with the Nurse Practitioner on 2/25/26 at 11:20 AM revealed that she expected that insulin be given as ordered prior to the meal. The Nurse Practitioner stated that it was important that insulin was administered accurately and this included the time. An interview was conducted with the Director of Nursing (DON) on 2/25/26 at 1:15 PM. The DON stated that the nurses should follow the physician orders and administer the insulin before the meals.An interview was conducted with the Physician on 2/25/26 at 3:48 PM. The Physician indicated that Humalog insulin was to be given prior to the meal and administering it after the meal was incorrect. The Physician stated that the resident could potentially have a hypoglycemic (low blood sugar) event when the medication was administered after the meal. 2). Resident #82 was admitted on [DATE] with diagnosis which included diabetes, chronic kidney disease and long-term use of hypoglycemic drugs. A physician order dated 9/19/25 in Resident #82's electronic health record indicated to administer sliding-scale Humalog insulin solution (100 units/milliliter) subcutaneously before meals and at bedtime based on the following blood sugar readings: 60-200 : 0 units 201-250 : 2 units 251-300: 4 units 301-350: 6 units 351-400: 8 units401-999: 10 units and call the physician immediately.A review of Resident #82's quarterly Minimum Data Set assessment dated [DATE] indicated the resident was cognitively intact, had a diagnosis of diabetes and received insulin daily.During a medication pass observation on 2/25/26 at 9:25 AM Nurse #1 obtained Resident #82's blood sugar with a result of 256. Nurse #1 administered 4 units Humalog insulin to Resident #82. Resident #82's breakfast tray was not observed in the room. An interview was conducted with Nurse #1 on 2/25/26 at 10:45 AM. Nurse #1 stated that she was assigned from 7:00 AM to 3:00 PM on 2/25/26 to complete all blood sugar checks and administer insulin for the Residents on the 200 and 300 halls. She reported that she was not familiar with which residents required blood glucose monitoring or insulin administration, which resulted in delays in administering insulin and failure to administer the medication according to the physician's orders.An interview was conducted with Resident #82 on 2/25/26 at 3:10 PM. Resident #82 stated that his blood sugars were up and down, and that the nurses usually obtained his blood sugar before meals, but he typically received his insulin after he finished eating. Resident #82 reported that on 2/25/26 he ate his breakfast, and Nurse #1 administered his insulin after he finished his meal, and this was later than the usual time.An interview with the Nurse Practitioner on 2/25/26 at 11:20 AM revealed that she expected that insulin be administered as ordered prior to the meal. The Nurse Practitioner stated that it was important that insulin was administered accurately and this included the time. An interview was conducted with the Physician on 2/25/26 at 3:48 PM. The Physician stated that Humalog insulin was to be administered prior to meals and administering it after the meal was incorrect and could result in an adverse effect.An interview was conducted with the Director of Nursing (DON) on 2/25/26 at 1:15 PM. The DON stated that nurses were expected to follow the physician's orders and administer insulin before meals. She explained that timing was one of the rights of medication administration, and she expected staff to adhere to this requirement.

Based on record review, staff interviews and observations, the facility failed to provide supervision to prevent a moderately cognitively impaired resident (Resident #9) from being outside alone without nursing staff's knowledge when the Nursing Assistant Instructor entered the code on the wander guard system without ensuring there were no residents with wander guard alarms that had passed the threshold and exited the facility. This deficient practice was identified for 1 of 4 residents reviewed for supervision to prevent accidents. Findings included: Resident #9 was admitted on [DATE] with diagnosis which included dementia with behavioral disturbance, epilepsy and history of falls. Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident had moderate cognitive impairment, wandering was not exhibited, and he used a wheelchair for mobility. Review of Resident #9's electronic health record revealed a health status note written by Nurse #1 dated 11/1/24 at 7:10 PM. The note revealed Resident #9 was found having exited the building, wandered into the parking lot and then positioned himself into an unlocked vehicle and claimed it was his own. The note indicated Resident #9 was assisted out of the vehicle and helped back into the building. A wander guard was placed on his right lower extremity. Review of an elopement incident report dated 11/1/24 at 7:10 PM prepared by the Director of Nursing (DON) revealed Resident #9 was found having exited the building and was sitting in an unlocked private vehicle. Resident #9 claimed the vehicle was his. Resident #9 was assisted out of the vehicle and brought back into the facility uninjured. The physician and responsible party were notified. Resident #9 stated he did not recall what had occurred. The incident report indicated predisposing factors were impaired memory. Medical record review indicated Resident #9 was able to propel himself independently in the wheelchair. The root cause was determined to be Resident #9's impaired cognition. The intervention implemented to prevent further elopement was to place a wander guard on the resident. An interview was conducted with Nurse #1 on 12/17/24 at 11:55 AM. Nurse #1 indicated he was assigned to Resident #9 on 11/1/24 from 7:00 PM to 7:00 AM. Nurse #1 indicated he was getting report from the 7:00 AM to 7:00 PM nurse when a family member called the facility and reported a resident was outside. Nurse #1 stated she and another nurse, he could not recall which nurse, went outside and Resident #9 was found outside the facility sitting in an unlocked car parked on the first row of cars outside the building. Resident #9 was in the back passenger seat of the car. No injuries were observed, and the resident was assisted back into the building. Prior to this incident the nurse indicated Resident #9 had not attempted to exit the building that he was aware of. Nurse #1 stated a wander guard device was applied to Resident #9. Nurse #1 stated the wander guard was checked to see ensure it was functioning properly. An interview was conducted with Nurse #2 on 12/17/24 at 2:40 PM. Nurse #2 stated she was working on 11/1/24 from 7:00 AM to 7:00 PM. Nurse #2 stated on 11/1/24, a family member called the facility and informed her that a resident was outside the building. Nurse #2 stated she and Nurse #1 who was coming on for 7:00 PM to 7:00 AM shift went outside and brought the resident back into the facility. After the incident that occurred on 11/1/24, Nurse #2 stated a wander guard was placed on Resident #9 and it was checked that it was working properly. After the incident on 11/1/24, Resident #9 continued to exhibit exit seeking behavior by going to the front door repeatedly and sounding the alarm. A review of Resident #9's electronic health record revealed a nursing progress note dated 11/2/24 at 3:11 PM written by Nurse #2 indicated resident had confusion and was trying to go out the front door numerous times but the wander guard was alarming. Staff redirected the resident several times to his room. A review of Resident #9's electronic health record revealed a health status note dated 11/3/2024 at 2:50 PM written by Nurse #2 which indicated a staff member assisted resident back into the facility from outside of the facility. The resident had a wander guard bracelet on, and the note indicated the wander guard alarm did not sound. Resident #9's wander guard bracelet was checked following the incident and was working. Resident #9 stated that he was going home. Resident #9 made no further attempts to go out of the building since the incident. Review of an incident report completed by Nurse #2 dated 11/3/24 at 2:50 PM revealed a staff member stated she was returning from her break when she observed Resident #9 outside the facility unsupervised and she brought him back in. The incident report indicated the wander guard alarm did not sound and Resident #9 stated to the Nursing Assistant (NA) that he was going home. Immediate action was taken. The wander guard was checked and was working. Resident #9 was brought to his room and was asked why he exited the building and resident stated he was going home. Resident #9 was assessed, and no injuries were noted. The root cause was the Nursing Assistant (NA) Instructor silenced the wander guard alarm without checking the surroundings for residents that were identified as high risk for wandering or elopement. One on one (1:1) was initiated for the resident and education was initiated for all staff and the NA Instructor and students on the elopement process/policy. An interview was conducted with NA #1 on 12/17/24 at 2:09 PM. NA #1 stated Resident #9 talked about wanting to go home before the elopement incident on 11/1/24 but he was not actively exit seeking. NA #1 indicated she knew Resident #9 eloped on 11/1/24, had a wander guard placed on him after the incident and was able to propel his wheelchair independently. NA #1 stated as she was returning from her break, she observed Resident #9 sitting in his wheelchair on the sidewalk to the left of the building a short distance from the driveway at the entrance to the facility. NA #1 stated Resident #9 was not near the road. NA #1 stated she brought Resident #9 back into the building when she saw him outside as she was returning from her break. NA #1 stated she knew Resident #9 was not supposed to be outside unsupervised. NA #1 stated the front door had a wander guard alarm sensor that sounds when a resident with a wander guard approaches the door. An interview was conducted via phone with the Nursing Assistant (NA) Instructor on 12/17/24 at 2:17 PM. The NA Instructor stated she was bringing students to the facility for clinical instruction for several months but stated she did not know about all the policies. The NA Instructor stated she instructed the NA students to stop and act when they heard an alarm sounding in the facility. The NA Instructor stated she recalled the incident on 11/3/24 in which the wander guard alarm was sounding near the front door and she entered the code on the key pad to silence and reset the alarm. The NA Instructor stated she was explaining to the NA students about how to silence and reset the alarm. She indicated she did not look around to ensure there was not a resident near or exiting the facility. The NA Instructor stated she could have done more to prevent a resident from eloping and that she should have gotten a facility employee to check for a resident that was high risk for elopement that might have been in the area. The NA Instructor stated she had been given the code to reset the keypad for the wander guard system, but she could not recall by whom. The NA Instructor stated she should not have silenced and reset the alarm. An interview with the Administrator on 12/17/24 at 3:05 PM revealed the facility had video surveillance that she and the DON reviewed following the elopement on 11/3/24 but the video footage storage did not go back that far. The Administrator stated she and the Director of Nursing (DON) reviewed the video surveillance immediately after the elopement incident occurred and determined that the NA Instructor had silenced the wander guard alarm thus staff were not aware that Resident #9 exited the building unsupervised. An interview and observation conducted with the Maintenance Director on 12/17/24 at 3:20 PM indicated there are three wander guard sensors in the building that sound the alarm and have keypads in place. The Maintenance Director used a transmitter device to demonstrate the sounding of the first wander guard sensor that was positioned at the threshold of the lobby at the front of the building. The alarm sounded when the transmitter device was in close proximity to the sensor and was silenced when a code was entered into the key pad. The Maintenance Director demonstrated the activation of the wander guard sensor positioned just before the sliding exterior exit door. The alarm sounded and was silenced when the code was entered on the key pad. The Maintenance Director demonstrated the activation of the wander guard sensor located at the back door using the transmitter device. The alarm sounded and was silenced when the code was entered on the key pad. The Maintenance Director stated he was called on 11/3/24 to come out and check the wander guard sensor alarms following the incident. He indicated that the doors were working properly. The Maintenance Director stated normally, when the wander guard sensor in the lobby just before the sliding door is activated, the sliding exterior door will not open. The Maintenance Director stated if people were standing in front of the sliding door, the door remains open and does not lock. An interview and reenactment of Resident #9's elopement incident that occurred on 11/3/24 was conducted on 12/17/24 at 3:45 PM with the Director of Nursing (DON). The DON provided the reenactment of what occurred with Resident #9 during the incident on 11/3/24 based on her review of the video footage. The DON demonstrated that Resident #9 propelled his wheelchair up the hallway and into the lobby. As he passed the first wander guard sensor that is at the threshold to the lobby, the alarm sounded. The Nursing Assistant Instructor was close to the keypad at the threshold to the lobby. The NA Instructor went to the keypad and entered the code silencing the wander guard alarm. Resident #9 continued to propel his wheelchair to the front sliding exterior door which was open due to a group of NA students standing in front of the door thus causing the door to remain open and not lock down when Resident #9's wander guard was sensed. The DON indicated that if someone is standing in front of the sliding door it remains open and will cause the wander guard sensor to not sound the alarm. The DON stated the video footage revealed that Resident propelled his wheelchair out the sliding exterior door. The video footage indicated 9 minutes later at 2:02 PM, Resident #9 was assisted back into the facility by a nursing assistant that was walking up towards the facility returning from her break. The DON stated the NA walked up and observed Resident #9 outside and realized he should not be outside unsupervised and assisted him back inside. An interview was conducted with the Physician Assistant (PA) on 12/19/24 at 11:30 AM. The PA stated Resident #9 had moderate dementia, impaired communication and seizure disorder. The PA stated Resident #9 should not be outside unattended. The PA indicated Resident #9 had potential for medical issues related to seizure disorder and required supervision from staff when going outside. The facility provided the following Corrective Action Plan with a completion date of 11/15/24: 1. On 11/3/24 at 1:53 PM Resident #9 approached the first wander guard alarm sensor. Resident #9 continued to the front exit door where another wander guard sensor was located. The Nursing Assistant (NA) Instructor from the local community college was seen entering the code into the keypad for the wander guard alarm without checking for a resident with a wander guard bracelet that wandered too close to the sensor or eloped the facility. Root cause analysis indicated the NA Instructor did not check the area for a resident with a wander guard alarm that triggered the alarm, and this action allowed the resident to pass through the door. NA students were standing outside the front sliding door in a way that kept the door from closing and the resident was able to propel himself outside. 2. A head-to-toe assessment of Resident #9 was completed to ensure the resident sustained no injuries after he was returned from outside the facility. On 11/3/24 following Resident #9's elopement incident, the staff nurses identified residents that were potentially impacted by this by completing a head count of all current residents and ensuring wander guards were present and functioning properly for all residents at risk for wandering. On 11/4/24, the Director of Nursing (DON) identified the residents that were potentially impacted by ensuring all residents had an accurate elopement risk assessment. 7 of 77 residents required updated risk assessments. In addition, the DON completed interviews with staff to identify residents with exit seeking behaviors or wandering not previously identified. No other residents were identified. On 11/4/24, the Maintenance Director conducted a 100 percent audit on all doors to ensure the doors were functioning and closing properly. There were no identified concerns with the doors or the wander guard system. 3. On 11/4/24, the reeducation on the Elopement Process policy was completed with the NA Instructor, NA students and all full, part-time and as needed staff. The training included all facility and agency staff. The training included: the difference between wandering, elopement, near miss and missing resident, how to identify residents at risk for elopement, what are exit seeking behaviors, what to do for residents that are high risk for elopement, what to do if the wander guard system alarm sounds and what to do if a resident is missing. The DON will monitor Elopement Prevention and Elopement System Review and Door Functioning weekly for 2 weeks and then monthly for 3 months or until resolved for signs of exit seeking behavior as well as risk scores and proper functioning of the wander guard system. Reports will be presented weekly at the Quality Assurance committee by the Administrator or DON to ensure corrective action was initiated as appropriate. 4. The results of the elopement and door functioning audits will be discussed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting for 3 months to sustain substantial compliance. 5. Allegation of Compliance Date: 11/15/24. The Corrective Action plan was validated on 12/19/24 by the following: Review of Resident #9's care plan revealed the care plan was updated and included a care plan dated 11/4/24 which indicated resident was at risk for elopement related to exit seeking behaviors and episodes of confusion. Interventions dated 11/4/24 included check wander guard transmitter for placement, education initiated for all staff, the NA instructor and students on the elopement process, encourage family to visit as much as possible, especially during episodes of exit seeking behavior, notify the DON of exit seeking behaviors, notify nurse immediately if resident spends long periods of time close to the door/exits, notify nurse immediately if resident verbalizes desire to leave, and re-direct away from exits as needed. An interview with NA #1 on 12/17/24 at 2:09 PM revealed she received in-service training regarding the wander guard system and the elopement policy following the incident on 11/3/24. An interview with the NA Instructor on 12/17/24 PM at 2:17 PM revealed that following the incident on 11/3/24 she and the nursing assistant students received an in-service education regarding the wander guard system and elopement. The NA Instructor stated she was informed of the facility elopement policy. An interview with the Maintenance Director on 12/17/24 at 3:20 PM revealed on 11/4/24 all wander guard sensor alarms on the doors were functioning properly. The Maintenance Director further stated he checked the door alarm sensors weekly. Logs were reviewed which indicated the doors were checked weekly starting on 11/4/24 with no issues noted. Further interviews with nursing staff revealed the facility had provided education and training on the elopement process policy, exit seeking behaviors and the wander guard system alarm. Staff interviewed all verbalized they received reeducation prior to starting their next shift. Review of the monitoring tools that began on 11/4/24 revealed that audits were completed weekly as outlined in the corrective action plan with no concerns identified. The completion date of 11/15/24 for the corrective action plan was validated.

Based on observations, manufacturer's recommendations review, and staff interviews, the facility failed to 1) securely store medication on an unattended medication cart for 1 of 2 (200 hall) medication carts observed for medication pass and 2) failed to dispose of 2 expired inhalers on the 300-hall medication cart for 1 of 2 medication carts reviewed for medication storage. Findings included: 1) A continuous observation on 10/18/23 from 9:05 AM to 9:10 AM revealed a white paper medication cup with a white capsule on top of the 200-hall medication cart unattended in an area where residents and staff could access. The medication cart was not within direct observation of a nurse. Housekeeper #1 and Nursing Assistant (NA) #1 passed the unattended medication cart in the hallway several times at the time the medication was observed on top of the medication cart. There were cognitively impaired residents as well as visitors in the vicinity of the medication cart. At 9:10 AM Nurse #1 came out of a resident room down the hallway and returned to the unattended 200 hall medication cart. Nurse #1 stated she was assigned to the 200-hall medication cart. Nurse #1 observed the medication in the white paper medicine cup, stated it was medication for a resident and she must not have seen it when she went to give the other medications. The medication was identified as gabapentin, a medication used to treat seizures and nerve pain. During an interview on 10/18/23 at 9:01 AM Nurse #1 revealed the medication should not have been left unattended on top of the medication cart and she must not have seen it when she administered medications to one of the residents. An interview was conducted on 10/19/23 at 5:10 PM with the Corporate Nurse Consultant, in the presence of the Administrator. The Corporate Nurse Consultant further stated Nurse #1 made a mistake and should not have left medication unattended on top of the medication cart. 2). An observation of the 300-hall medication cart and interview with Nurse #2, the nurse assigned, on 10/18/23 at 10:53 AM revealed the following: a. The manufacturer's recommendations indicated the Stiolto Aero Respimat inhaler expired 90 days after assembly of the device (cartridge into the dispensing unit). An observation of Resident #19's Stiolto Aero Respimat inhaler had a pharmacy label which indicated the medication was delivered on 7/3/23 and had an expiration date of 10/1/23. An interview on 10/18/23 at 10:53 AM with Nurse #2 revealed the label on Resident #19's inhaler indicated the medication was expired and it should have been discarded. Nurse #2 stated she had administered the Stiolto inhaler to Resident #19 that morning and did not recall checking the expiration day prior to administration. b. The manufacturer's recommendations indicated the Trelegy Ellipta inhaler expired 6 weeks after it was opened. Resident #16's Trelegy Ellipta 100 microgram inhaler had a label on the inhaler which indicated the date opened was 8/21/23 and to discard the medication 6 weeks after it was opened. The printed label from the pharmacy, on the bag indicated an expiration date of 10/2/23. An interview on 10/18/23 at 10:55 AM with Nurse #2 revealed the labels on Resident #19 and Resident #16's inhalers indicated the medications were expired and should have been discarded. Nurse #2 stated all nurses were expected to check the expiration dates when administering medications. Nurse #2 explained she thought the medication carts were checked by someone regularly, but she was not sure who did this or when. Nurse #2 further indicated she had administered the inhalers to Resident #19 and Resident #16 that morning and had not noticed that the medications were expired. An interview on 10/19/23 at 5:00 PM with the Director of Nursing (DON) revealed expired medications should be discarded and medications should be securely stored on the medication carts. An interview was conducted on 10/19/23 at 5:10 PM with the Administrator and the Corporate Nurse Consultant. The Administrator revealed the facility was working to ensure there were no expired medications on the medication cart. The Corporate Nurse Consultant stated it was a human error that the facility did not discard the expired medications from the medication cart, and it was a problem that required constant staff reminders and auditing.

Based on record review, observations and staff interviews the facility's Quality Assessment and Assurance (QAA) program failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint investigation survey completed on 6/24/22 and the recertification survey completed on 3/12/21. This was for three repeat deficiencies originally cited in the areas of comprehensive assessments (F636), quarterly assessments (F638) and labeling and storing of medication (F761) recited on the current recertification and complaint investigation survey of 10/19/23. The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QA program. Findings included: This tag is cross-referenced to: F636: Based on record review and staff interviews the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory timeframes as specified in the Resident Assessment Instrument (RAI) manual for 3 of 20 residents reviewed for MDS assessments (Resident #47, Resident #46, Resident #4). During the recertification and complaint investigation survey of 6/24/22, the facility failed to 1) complete Minimum Data Set (MDS) admission assessments within the required timeframe for 2 of 9 residents 2) failed to complete a discharge with return anticipated assessment within the required timeframe for 1 of 9 residents and 3) failed to complete a 14-day MDS assessment within the required timeframe for 1 of 9 residents reviewed for Resident Assessments. Interview with the Administrator on 10/19/23 at 5:10 PM revealed the QAA program for MDS assessments did not work due to it not being continued long enough. The Administrator further revealed there were changes in the facility that have caused the measures implemented to not be sustained. The Administrator indicated closer monitoring and evaluation of the interventions implemented was necessary to sustain the QAA program. F638: Based on record review and staff interview, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the regulatory timeframe as specified in the Resident Assessment Instrument (RAI) manual for 7 of 20 residents reviewed for MDS assessments (Resident #21, Resident #11, Resident #27, Resident #1, Resident #32, Resident #25, Resident #31). During the recertification and complaint investigation survey completed on 6/24/22, the facility failed to complete quarterly MDS assessments within 14-calendar days of the Assessment Reference Date (ARD, the last day of the look-back period) for 5 of 9 residents reviewed for resident assessments. Interview with the Administrator on 10/19/23 at 5:10 PM revealed the QAA program for MDS assessments did not work due to changes in the facility that caused the measures implemented to not be sustained. The Administrator further revealed that the facility needed to improve systems that were implemented and investigate why the previous program did not work. F761 Based on observations and staff interviews, the facility failed to 1) securely store medication on an unattended medication cart for 1 of 2 (200 hall) medication carts observed for medication pass and 2) failed to dispose of 2 expired inhalers on the 300-hall medication cart for 1 of 2 medication carts reviewed for medication storage. During the recertification survey of 3/12/21, the facility failed to keep unattended treatment medications (creams and ointments) secured in a locked treatment cart for 1 of 1 treatment carts observed. During the recertification and complaint investigation survey of 6/24/22, the facility 1) failed to remove expired medications from 2 of 3 medication carts (100 hall and 200 hall medication carts), 2) failed to record an opened date for a narcotic located in the locked box in 1 of 1 medication refrigerators and 3) failed to secure medications stored on top of 1 of 3 unattended medication carts. (Medication storage cart 300 Hall) Interview with the Administrator on 10/19/23 at 5:10 PM revealed the QAA program should have investigated the deficient practice related to labeling and storage of medication more closely and the interventions implemented should have been revised as needed to be successful at maintaining the program. The Administrator further stated ongoing monitoring and education was required to ensure that expired or unsecured medications were not observed on the medication carts.

Based on record review and staff interview, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the regulatory timeframe as specified in the Resident Assessment Instrument (RAI) manual for 7 of 20 residents reviewed for MDS assessments (Resident #21, Resident #11, Resident #27, Resident #1, Resident #32, Resident #25, Resident #31). Findings included: a. Resident #21 was admitted to the facility on [DATE] with diagnoses which included in part chronic kidney disease, failure to thrive and dementia. Review of Resident #21's 7/18/23 quarterly Minimum Data Set assessment revealed the assessment was completed on 8/2/23. b. Resident #11 was admitted to the facility on [DATE] with diagnoses which included diabetes. Review of Resident #11's 9/8/23 quarterly MDS revealed the assessment was completed on 9/24/23. c. Resident #27 was admitted to the facility on [DATE] end stage renal disease and dialysis. Review of Resident #27's 9/26/23 quarterly MDS revealed the assessment was completed on 10/11/23. d. Resident #1 was admitted to the facility on [DATE] with diagnoses which included dementia and contractures. Review of Resident #1's 8/20/23 quarterly MDS revealed the assessment was completed on 9/7/23. e. Resident #32 was admitted to the facility on [DATE] with diagnosis which included in part arthritis, diabetes and heart failure. Review of Resident # 32's 8/19/23 quarterly MDS revealed the assessment was completed on 9/7/23. f. Resident #25 was admitted to the facility on [DATE] with diagnosis which included hip fracture. Review of Resident #25's 8/22/23 quarterly MDS revealed the assessment was completed on 9/8/23. g. Resident #31 was admitted to the facility on [DATE] with diagnosis which included in part lumbar disc degeneration, chronic pain and dementia. Review of Resident #31's 9/14/23 quarterly MDS revealed the assessment was completed on 9/29/23. Interview with the MDS Nurse on 10/19/23 at 10:30 AM revealed she was aware the assessments were late, and they were not completed during the 14-day allotted time from the Assessment Reference Date (ARD). The MDS Nurse said there were corporate nurses that assisted remotely with the completion of assessments. The MDS Nurse stated she was pulled to the floor to work an assignment if needed; was on call every third week of the month for the entire week and if needed she worked the floor or did other tasks as needed; and stated there was a high volume of admissions and discharges. Interview with the Administrator and the Corporate Nurse Consultant on 10/19/23 at 5:10 PM revealed she was aware of the situation with the MDS assessments not completed within the regulatory timeframe. The Administrator stated the corporate nurses assisted the MDS Nurse with completion of the assessments, but they had other duties also. The Administrator further revealed the MDS Nurse was required to work the floor as a staff nurse and was required to be on call for the nursing department. The Administrator stated the facility was implementing new procedures to check the timeliness of assessments and hoped to see improvement.

Based on record review and staff interviews the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory timeframes as specified in the Resident Assessment Instrument (RAI) manual for 3 of 20 residents reviewed for MDS assessments (Resident #47, Resident #46, Resident #4). Findings included: a. Resident #47 was admitted to the facility on [DATE] with diagnoses which included in part diabetes and chronic kidney disease. Review of Resident #47's 9/28/23 annual assessment revealed a completion date of 10/13/23. b. Resident #46 was admitted to the facility on [DATE] with diagnoses which included in part diabetes and dementia. Review of Resident #46's 9/14/23 Significant Change Minimum Data Set (MDS) assessment revealed a completion date of 9/29/23. c. Resident #4 was admitted to the facility on [DATE] with diagnoses which included in part diabetes and Alzheimer's dementia. Review of Resident #4's 9/15/23 Significant Change MDS assessment revealed a completion date of 10/2/23. Interview on 10/18/23 at 4:50 PM with the MDS Nurse revealed there were different people completing MDS assessments including some who worked remotely. The MDS Nurse stated she was aware of the timing of the MDS assessments and that MDS assessments were to be completed per the Resident Assessment Instrument (RAI) manual. The MDS Nurse stated she did not know why some of the assessments were completed late. A follow up interview with the MDS Nurse on 10/19/23 at 10:30 AM revealed she was aware the assessments were not completed during the 14-day allotted time from the Assessment Reference Date (ARD) date established. The MDS Nurse stated corporate nurses were helping her complete assessments remotely. The MDS Nurse indicated she was assigned to work as a staff nurse when needed and was on call every third week of the month for the entire week. During the week on call she worked the floor or completed other tasks if needed. The MDS Nurse further stated she had a high volume of admissions and discharges, and this made it difficult to complete the assessments within the required timeframes. The MDS Nurse stated there were other nurses that worked remotely to assist with completing assessments. Interview with the Administrator and the Corporate Nurse Consultant on 10/19/23 at 5:10 PM revealed they were aware of the situation with the MDS assessments not completed within the regulatory timeframe and the corporate nurses assisted the MDS Nurse with completion of the assessments. The Administrator stated the facility was implementing new procedures to check the timeliness of assessments and hoped to see improvement.

Based on observation, staff interviews, and record review the facility failed to accurately code Minimum Data Set (MDS) assessments to reflect ostomy status and use of assistive devices for ambulation, (Resident #47); and failed to accurately assess a resident's cognition and participation in the assessment and goal setting, (Resident #38), for 2 of 23 residents reviewed for MDS assessments. 1. a. Resident #47 was admitted to the facility on [DATE] with diagnoses that included, in part: Type 2 Diabetes Mellitus, Stage 3 chronic kidney disease, right knee pain, frequent bowel and bladder incontinence, and a history of falls. An observation of Resident #47 was made on 10/16/23 at 2:30 PM. She was sitting in her wheelchair self-propelling in the hallway. An additional observation was made on 10/18/23 in the afternoon when Resident #47 attended the Resident Council meeting using a wheelchair. Review of an annual MDS assessment completed on 09/28/23 documented Resident #47 did not use any assistive devices for ambulation. An interview with the MDS Nurse on 10/19/23 at 10:30 AM revealed Resident #47 had used a wheelchair for ambulation during the assessment period in September 2023. She noted the assessment had been completed by a corporate MDS nurse remotely. She reported it had been clearly documented in the electronic record that Resident #47 used a wheelchair for ambulation during the assessment period. She concluded she did not know why the corporate MDS Nurse did not document Resident #47 used a wheelchair for ambulation and that she had modified the assessment to accurately document how Resident #47 ambulated. b. The bowel and bladder section of the quarterly MDS assessment dated [DATE] for Resident #47 documented she had an ostomy. Review of all progress notes in June 2023 revealed Resident #47 did not have an ostomy. An interview with the MDS Nurse on 10/19/23 at 10:30 AM revealed Resident #47 never had an ostomy. She reported the assessment had been completed by a corporate MDS Nurse remotely. She stated when she reviewed the data, she discovered the task section in the computer system that is completed by Nurse Aides was completed incorrectly documenting that the resident had an ostomy. This information auto populated into the assessment dated [DATE]. She concluded the nurse who completed the assessment should have reviewed the information that auto populated and changed the assessment to reflect Resident #47 did not have an ostomy. She stated she modified the assessment to accurately document Resident #47 did not have an ostomy. An interview was conducted with the Administrator on 10/19/23 at 4:30 PM. The Administrator stated she expected MDS assessments to be accurate. 35173 2) Resident #38 was admitted to the facility on [DATE]. Diagnoses included, in part, dementia with anxiety. The MDS quarterly assessment dated [DATE] revealed section C for cognition was coded as not assessed and section Q for participation in assessment and goal setting was coded as not assessed. An interview was conducted with the Social Worker (SW) on 10/19/23 at 10:45 AM. The SW revealed she was usually responsible for completing section C and section Q of the MDS assessments, but she was out of facility at the time the assessment was due. She stated the Activities Director would have been responsible for completing the assessment for any MDS portions the SW was responsible for if she was unavailable. An interview with the Activities Director on 10/19/23 at 2:00 PM revealed on the quarterly assessment dated [DATE], she was responsible for completing Resident #38's assessment in section C and Q. The Activities Director stated she could not remember why she did not complete the assessment and added it was an oversite. An interview was conducted with the Administrator on 10/19/23 at 4:55 PM. The Administrator stated her expectation of the staff was to complete the MDS assessments accurately and in their entirety to reflect the current care of the residents.

Based on record review and a staff interviews, the facility failed to provide oversight and leadership to ensure effective systems were implemented for staff to provide the necessary care and services by following the policy and procedure to call a code blue for a resident in [CONDITION(S)], to initiate Cardiopulmonary Resuscitation (CPR), to verify employed staff were current with their CPR certifications and failed to verify nurses who were present in the facility had a current CPR certification for 1 of 1 residents (Resident #205) reviewed for CPR. Findings included: This tag is cross referenced to F678 Based on record review, staff interview and Nurse Practioner interview, the facility failed to perform cardiopulmonary resuscitation (CPR) while waiting for Emergency Medical Services (EMS) to arrive for 1 of 1 resident reviewed for CPR (Resident #205) who was observed by Nurse #7 to have no pulse and determined to have a full code status. Resident #205 was provided CPR by EMS and transported via EMS to the hospital where she was intubated and admitted to the intensive care unit. A Cardiopulmonary Resuscitation (CPR) policy written [DATE] and revised in [DATE] stated, in part, it was the policy of this nursing facility to act affirmatively to preserve the life of all residents. It is the policy of this facility to initiate Basic Life Support CPR as defined by the American Heart Association or the American Red Cross. This will be done by trained staff that have completed either of the above-mentioned courses and have a current certification. The policy stated the purpose of CPR was to ventilate and establish circulation on a resident with absence of respirations and pulse once resident was assessed: 1) if a resident was noted with a significant change of condition, the staff member should immediately alert the nurse for the resident and a code blue called over the intercom, 2) all nurses and staff should respond to the room and the crash cart taken to the room, 3) the staff nurse responsible for resident begins an assessment of the resident, applies the (Automated external defibrillator (AED), and implements CPR if the resident was a full code status. Another staff member should be verifying the code status by reviewing the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Nurse #7 via phone on [DATE] at 2:12 PM revealed she never called a code blue to alert staff to respond to Resident #205. Nurse #7 stated it seemed like only minutes went by before EMS appeared and she walked them down to the resident ' s room after letting them in. She stated when they entered Resident #205 ' s room, Medication Aide (MA) #2 was in the room with the resident, but she was not performing CPR and EMS determined the resident had no pulse and started CPR. During the interview with Nurse #7, she stated in looking back, I should have started CPR on the resident. Nurse #7 could not recall when her CPR certification expired, and she was aware she was working without a current certification. She stated she worked at the facility again on ,d+[DATE]-night shift into [DATE] before getting recertified for CPR on [DATE]. Nurse #7 stated the facility never asked her for a copy of her certification so they would not have it on file. An interview with the Administrator on [DATE] at 8:55 AM revealed Nurse #7 was following the protocol when she went to the nurses ' station to confirm the resident ' s code status and called EMS. The Administrator stated only nurses were required to be CPR certified. The Administrator stated the facility should be verifying credentials and CPR certifications for the nurses. The process that should have been in place would have been to verify the CPR certification for all nurses with a copy of the CPR card in the employees ' file before orientation. The Administrator stated this was the process, but it fell through the cracks. The Administrator stated she was not aware that Nurse #7 ' s CPR certification had expired. An interview with the Director of Nursing (DON) on [DATE] at 9:30 AM revealed that only nurses were required to be CPR certified, but nurse aids and medication aides were encouraged to become CPR certified. The DON stated she had no knowledge Nurse #7 was not CPR certified while she was working here and added that being the only nurse in the building on night shift she would expect her to be CPR certified. The DON stated prior to the event on [DATE] with Resident #205, the DON did not have a tracking system in place to verify CPR certifications or to monitor when CPR certifications were going to expire. The corrective action for noncompliance completed [DATE] was as follows: F835: · For the resident affected by the deficient practice. All residents are at risk to be affected by the deficient practice. On [DATE] a 100% audit was completed by the Director of Nursing of 100% current licensed nursing staff and current agency nurses to ensure all with current/valid Cardiopulmonary resuscitation (CPR) certifications. It was identified that 2 of the 6 licensed staff did not have current CPR certifications. The 100% audit, conducted by the Director of Nursing, included all contract/agency licensed nursing staff who were working in the facility on [DATE]. Root Cause Analysis On [DATE] a root cause analysis was conducted by the Administrator, Director of Nursing, and Clinical Services Consultant and determined that there was not a system in place to track staff CPR certifications related to a new Director of Nursing was installed [DATE] and did not receive education on tracking cardiopulmonary certifications. · Identification of potentially affected residents and corrective actions taken. All current residents experiencing a change in condition are at risk to be affected. On [DATE] the Clinical Services Consultant audited 100% current licensed nursing staff and current agency nurses to ensure all with current/valid CPR certifications. It was identified that 2 of the 6 licensed staff did not have current CPR certifications. Any licensed nurse found without active CPR certification was scheduled for a CPR class [DATE]th or [DATE]th, 2022. Completed: [DATE] By Whom: Regional Staff Development Coordinator · Systemic Changes Review of facility system to track CPR certifications reviewed by Director of Nursing on [DATE]. No current system was in place. On [DATE] the Licensed Administrator and Director of Nursing were educated by the Corporate Clinical Services Consultant regarding the CPR policy, initiating timely CPR, and ensuring all licensed nursing staff who work have current/valid CPR Certifications. The education included required monitoring of CPR Systems to ensure compliance. The licensed Administrator and the Director of Nursing Services voiced understanding. The education was delivered in person, via policy provided, review of policy, and review of required system implementation for tracking and ensuring compliance with policy. Time was allowed for feedback and question/answering session. Completed: [DATE] By Whom: Corporate Clinical Services Consultant This training was incorporated into the general orientation program and will be discussed during all general orientation programs that is completed for identified staff. The identified staff who have not received this education by [DATE] will not be allowed to work until the education has been received. On [DATE], a system for tracking CPR certifications for licensed nurses was initiated by the Director of Nursing. Director of Nursing and/or Staff Development Coordinator (or designee) will log each licensed nurse who has active CPR certification, and date of expiration into the electronic scheduling system. The electronic scheduling system will not allow the staff member to be scheduled for a working shift if the CPR certification was expired. Agency Nurses will be tracked by this same electronic system when agency nurses are utilized. The Quality Assurance Committee members are as follows: Medical Director Administrator Director of Nursing Admissions Marketing Dietary Manager Maintenance Director Social Services Activities Director Business Office Manager Minimum Data Set Nurse The Clinical Services Consultant will monitor the facility compliance with entering CPR certifications into the electronic scheduling system upon hire, ensuring newly hired licensed nurses are provided the current CPR policy specifically referencing who is required to be certified when on duty. The monitoring will be quarterly ongoing with no end date at this time. The results of the monitoring will be provided to the facility quality assurance committee each quarter for review and any recommendations/feedback, or adjustments made based on results. Completed: [DATE] By Whom: Clinical Services Consultant Completed: [DATE] As part of the validation process on ,d+[DATE] through [DATE], the plan of correction was reviewed and included interviews with the Licensed Administrator and the Director of Nursing regarding in services they received related to the deficient practice. The Licensed Administrator and the Director of Nursing stated they had been in serviced by the Clinical Services Consultant regarding the CPR policy, initiating timely CPR, and ensuring all licensed nursing staff who work have current/valid CPR Certifications. A review of the current system for tracking CPR certifications for licensed nurses was conducted and validated. The facility policy and procedures for implementing a code blue and CPR was provided and reviewed to address the deficient practice. The facility alleges full compliance with this plan of correction effective [DATE].

Based on record review, staff interviews and Nurse Practioner interview, the facility failed to perform cardiopulmonary resuscitation (CPR) while waiting for Emergency Medical Services (EMS) to arrive for 1 of 1 resident reviewed for CPR (Resident #205) who was observed by Nurse #7 to have no pulse and determined to have a full code status. Resident #205 was provided CPR by EMS and transported via EMS to the hospital where she was intubated and admitted to the intensive care unit. Findings included: A Cardiopulmonary Resuscitation (CPR) policy written [DATE] and revised in [DATE] stated, in part, it was the policy of this nursing facility to act affirmatively to preserve the life of all residents. It is the policy of this facility to initiate Basic Life Support CPR as defined by the American Heart Association or the American Red Cross. This will be done by trained staff that have completed either of the above-mentioned courses and have a current certification. The policy stated the purpose of CPR was to ventilate and establish circulation on a resident with absence of respirations and pulse once resident was assessed: 1) if a resident was noted with a significant change of condition, the staff member should immediately alert the nurse for the resident and a code blue called over the intercom, 2) all nurses and staff should respond to the room and the crash cart taken to the room, 3) the staff nurse responsible for resident begins an assessment of the resident, applied the (Automated external defibrillators (AED), and implements CPR if the resident was a full code status. Another staff member should be verifying the code status by reviewing the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #205 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] #205 was a full code. The Minimum Data Set 5-day assessment dated [DATE] revealed the resident was severely cognitively impaired. A nursing progress note written [DATE] by Nurse #7 revealed called to resident room by Nursing Aide {Medication Aide #2 working as Nurse Aide}. Upon entering room resident has thick white milky [MEDICATION(S)] running from her mouth, there was no rise or fall of chest movement and no pulse detected. Nurse went to nurses ' station to see if resident was a Do Not Resuscitate (DNR) or a full code and called Emergency Medical Services (EMS). EMS arrived at 5:31 AM; out of facility with resident at 5:35 AM with CPR in progress. Responsible Party (RP) was notified. Reported to emergency room (ER) nurse at hospital. A written statement dated [DATE] from Nurse #7 revealed, in part, Nurse stated she worked with the resident on [DATE] from 7:00 PM to 7:00 AM. Nurse stated the Medication Aide (MA) called for her to come to the resident ' s room and stated she was not breathing. Nurse assessed resident and noted no pulse. Nurse then went to the nurse ' s station to check code status and saw that resident was a full code. Nurse stated she proceeded to call 911 and get paperwork ready for EMS. Nurse then proceeded back to the resident ' s room and then heard the phone ringing and believed it to be EMS calling for door code. She gave the code to EMS to enter the building. Nurse stated (in retrospect) minutes went by so quickly that she felt EMS was there before she could initiate CPR. A review of the EMS Report on [DATE] revealed the call was received at 5:26 AM, dispatched at 5:27 AM, EMS was enroute at 5:28 AM, at resident at 5:31 AM, left facility at 5:43 AM and arrived at hospital at 5:47 AM. Upon arrival to facility, Resident was laying supine (on back) in bed. Carotid and radial pulse were absent. The EMS report indicated nursing staff had reported that the resident was an expected death, nursing staff also stated the resident was a full code and CPR was not started. The note indicated the resident was warm to touch and CPR was started and continued by EMS and monitored and transported to the hospital by EMS without incident. A review of the hospital emergency room (ER) record on [DATE] revealed, in part, resident arrived at 5:53 AM on [DATE] via EMS with CPR in progress. The ER note indicated Resident had no spontaneous breathing, unresponsive and was intubated. Vital signs were recorded as Heart Rate (HR) 136, Respiration Rate (RR) 29, Blood Pressure (BP) ,d+[DATE], 02 saturation 95% on ventilator and she was warm to touch. An interview with Nurse #7 via phone on [DATE] at 2:12 PM revealed on the morning of [DATE] Med Aide #2 who was working as a Nurse Aide came to her and told her Resident #205 had a white foam coming out of her mouth. She stated she assessed Resident #205 and she had no pulse, was warm and grey and non-responsive. She went to the nurse ' s station to see what the resident ' s code status was, saw that she was a full code and called 911. Nurse #7 stated while she was on the phone with EMS, she was getting the paperwork printed and then went to Resident #205 ' s room. Nurse #7 stated the phone rang and she thought it was EMS calling so she left the room to answer the call and give EMS the code to enter the building. Nurse #7 reported she did not recall telling Med Aide #2 to perform CPR. Nurse #7 stated it seemed like only minutes went by before EMS appeared and she walked them down to the resident ' s room after letting them in. She stated when they entered Resident #205 ' s room, MA 2 was in the room with the resident, but she was not performing CPR and EMS determined the resident had no pulse and started CPR. Nurse #7 stated EMS was transporting the resident out of the facility while performing CPR and she learned later the resident was intubated and admitted to the intensive care unit (ICU). During the interview with Nurse #7, she stated in looking back, I should have started CPR on the resident. An interview with the Administrator on [DATE] at 8:55 AM revealed EMS was located behind the facility on the same street and was about 3 minutes away. The Administrator stated Nurse #7 was following the protocol when she went to the nurses ' station to confirm the resident ' s code status and called EMS. The Administrator stated in hindsight she did not know what the nurse was thinking because she should have directed the Med Aide to let EMS in the building while she performed CPR. The Administrator agreed 9 minutes (5:26 AM - 5:35 AM) was a long time to wait for CPR to be initiated. An interview with the Director of Nursing (DON) on [DATE] at 9:30 AM. The DON stated if a resident became unresponsive in the facility, the nurse would be required and expected to assess the resident, confirm their code status and if applicable (full code), to begin or direct the initiation of CPR An interview was conducted with Medication Aide #2 on [DATE] at 4:46 AM. MA #2 reported she was assigned to Resident #205 on the night of [DATE] and this had been the first time she worked with this resident. She stated when she did her first round of care around 12:00 AM she checked on Resident #205 to see if she needed to be changed. MA #2 stated the head of her bed was elevated and she was not incontinent. The MA stated Resident #205 did not verbally speak to her while she was doing her rounds. MA #2 stated she checked on the resident at around 2:00 AM and she was not incontinent. MA #2 stated she seemed about the same and noted no new changes at that time. MA #2 stated at about 5:20 AM she went in to check on Resident #205 and she was incontinent. The MA stated she was gurgling and seemed to be congested, so she left the head of the bed elevated while turning the resident to her side to change her. She stated when she rolled the resident back toward her the gurgling had stopped, and she had white foam coming from her mouth. MA #2 stated the resident was pale and warm to the touch. MA #2 reported she called for Nurse #7 immediately. The nurse assessed the resident and stated she would call 911. The MA reported Nurse #7 called 911 and EMS arrived at the facility quickly because they were located just around the corner. The MA reported she was not instructed to perform CPR on Resident #205, but she remained with the resident until EMS arrived. The MA reported Nurse #7 did not call a code blue ([CONDITION(S)]) to initiate CPR. An interview was conducted with Med Aide #1 on [DATE] at 2:30 PM. MA #1 reported she came in earlier than usual on the morning of [DATE] and when she arrived Nurse #7 was sitting at the nurse ' s station. MA #1 reported Nurse #7 informed her that Resident #205 had passed away and she was waiting for EMS to arrive. She stated about 5:30 AM, EMS arrived, and Nurse #7 walked with EMS to the resident ' s room. MA #1 stated she saw EMS leaving the facility performing CPR on Resident #205 while enroute to the hospital. An interview was conducted with the Nurse Practioner (NP) on [DATE] via phone at 3:25 PM. The NP stated she would have expected Nurse #7 to call a code blue and initiate CPR once learning she was a full code and EMS had been notified. The NP stated every minute counts when a resident was not breathing, and CPR should be initiated as soon as possible. F678 The corrective action for noncompliance completed [DATE] was as follows: · For the resident affected by the deficient practice. Resident #205 experienced a change in condition on [DATE] at approximately 5:20 AM, resident noted to stop breathing while care was being provided by Medication Aide #2. Medication Aide #2 immediately notified Nurse #7 of the change in condition. At approximately 5:23 AM Nurse #7 entered the room and performed an assessment of the resident and could not detect a carotid pulse or respirations. She left the room to check code status and call Emergency Medical Services. Resident ' s code status was Full Code. At approximately 5:28 AM, Nurse #7 returned to the room and exited shortly after due to Emergency Medical Services calling for the code to the door. Cardiopulmonary resuscitation (CPR) was not performed by facility staff. At approximately 5:31 AM, Emergency Medical Services entered the room and initiated CPR. At approximately 5:35 AM, Emergency Medical Services left the facility with the resident to transfer to the hospital for emergency care. Nurse #7 notified the responsible party on [DATE]. Root Cause Analysis completed [DATE] Upon observation of Resident #205 with absence of respirations, fixed pupils, unresponsive, no carotid pulse, and grey pallor, Nurse #7 proceeded to the nurse ' s station to verify code status and then immediately activated Emergency Medical Services to ensure rapid response to the facility. Through investigation of the event, including interviews with staff on duty at the time, interview with the previous nurse and staff on duty the shift prior, review of the employee ' s work records, and the actions initiated by the nurse, the facility did not feel Nurse #7 intentionally withheld a prudent service, but rather was focused on activating emergency services to be enroute, code status validation, and family awareness. Per facility protocol, Nurse #7 should have called a code blue (Cardiac or respiratory arrest) when the resident was noted with a change in condition and started CPR once code status was verified. As an additional measure, the Administrator and Director of Nursing utilized the North Carolina Board of Nursing Complaint Evaluation Tool on [DATE]. This resulted in a recommendation for a Board of Nursing consultation. A call was placed to the North Carolina Board of Nursing on [DATE]. On [DATE] the North Carolina Board of Nursing was consulted. The incident was submitted for board review on [DATE]. · Identification of potentially affected residents and corrective actions taken. All current residents experiencing a change in condition are at risk to be affected. On [DATE] all current residents were assessed by a licensed nurse under the direction of the Director of Nursing (DON) for a change in condition. This was completed by obtaining current vital signs, oxygen saturation, and lung sounds were assessed. No new changes in condition were identified. This was completed and reviewed by the Director of Nursing on [DATE]. On [DATE], the Director of Nursing audited 100% of current licensed staff to ensure valid CPR certifications. A 100% audit was conducted, which included all full time, part-time, ' as needed, and contracted nurses. The results yielded 2 facility employed licensed nurses with expired CPR certifications. Any licensed nurse found without active CPR certification was scheduled for a CPR class [DATE]th or [DATE]th, 2022. Completed: [DATE] By Whom: Regional Staff Development Coordinator · Systemic Changes Review of facility system to track CPR certifications reviewed by Director of Nursing on [DATE]. No current system was in place. On [DATE], a system for tracking CPR certifications for licensed nurses was initiated by the Director of Nursing. Director of Nursing and/or Staff Development Coordinator (or designee) will log each licensed nurse who has active CPR certification, and date of expiration into the electronic scheduling system. The electronic scheduling system will not allow the staff member to be scheduled for a working shift if the CPR certification expired. Agency Nurses will be tracked by this same electronic system when agency nurses are utilized. On [DATE] training was initiated by the Director of Nursing and Nurse Management staff for all full time, part time, and ' as needed ' Nurses, Medication Aides, Certified Nursing Assistants, and agency staff: Topics included: · Change in condition policy · Code status education Required CPR disciplines, i.e., Licensed Nursing Staff On [DATE] all full time, part time, and ' as needed ' Nurses, including agency nurses, were educated by the Director of Nursing and/or Nurse Management staff. Topics included: · Cardiopulmonary Resuscitation policy? Initiating Cardiopulmonary Resuscitation timely. · Education included notification of Nursing Administration and Administrator when nursing concerns arise, assistance was needed, personal illness, or staffing issues arise. On [DATE] training was initiated for the Administrator and the Director of Nursing by the Corporate Clinical Services Consultant. Topic included: System for tracking CPR certifications for licensed nurses and/or agency licensed nurses. Director of Nursing and/or Staff Development Coordinator (or designee) will log each licensed nurse who has an active CPR certification with date of expiration into the electronic scheduling system. The electronic scheduling system will not allow the staff member to be scheduled for a working shift if the CPR certification expired. This training was incorporated into the general orientation program and will be discussed during all general orientation programs that are completed for identified staff. The identified staff who have not received this education by [DATE] will not be allowed to work until the education has been received. This system was immediately implemented by the Director of Nursing on [DATE]. A CPR class was scheduled for [DATE] and [DATE] at the facility and was taught by a cardiopulmonary resuscitation instructor. 100% of licensed nurses validated by Director of Nursing as CPR certified on [DATE]. All newly hired licensed nurses including agency nurses will present an active CPR certification upon hire or upon facility assignment. This will be validated by the Staff Development Coordinator and/or the Director of Nursing in her absence; all newly hired licensed nurses and agency nurses upon assignment, evidence of CPR certification will be entered in the electronic scheduling system for tracking purposes effective [DATE]. Completed: [DATE] and validated by the Director of Nursing. Monitored monthly by the Director of Nursing. Director of Nursing initiated mock CPR drills on [DATE] to monitor and ensure licensed nurse preparedness in the event of resident code blue. The Director of Nursing is monitoring mock CPR drills to provide feedback to the facility Quality Assurance Committee in order to adjust education as needed to meet the needs and opportunities of the licensed team. Mock drills have been scheduled to include day shift and night shift (12 hour shifts for licensed nurses) and have included any designated weekend staff. Mock drills will continue indefinitely on a quarterly basis to include all shifts and weekend only staff. This will be completed under the direction of the Director of Nursing. The mock drills will specifically monitor for timely initiation of CPR. The Quality Assurance (QA) committee will monitor the results of the mock drills quarterly and make education modifications as necessary based on the findings. · Quality Assurance Plan The Director of Nursing or designee will monitor compliance with change in condition by using the QA tool Change in condition. Changes in condition will be identified in the facility ' s clinical review process weekly reviewing progress notes for changes in condition. Beginning on [DATE], this will be completed weekly for 8 weeks then monthly x 2 months. The QA tool will audit a sample of residents for changes in condition and staff response, Physician, and responsible party notification. In addition, mock codes will be completed once on day shift, once on evening shift, and once on night shift then quarterly. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and ongoing auditing program reviewed at the weekly QA Meeting. The Administrator or designee will monitor compliance with CPR certification using the QA tool CPR Certification. This will begin [DATE] and will be completed weekly for 4 weeks then monthly times 2 months. The QA tool will audit to ensure CPR certifications are being tracked in the electronic system and that all nurses are currently CPR certified. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and ongoing auditing program reviewed at the weekly QA Meeting. The Quality Assurance Committee members are as follows: Medical Director Administrator Director of Nursing Admissions Marketing Dietary Manager Maintenance Director Social Services Activities Director Business Office Manager Minimum Data Set Nurse Completion Date: [DATE] As part of the validation process on ,d+[DATE] through [DATE], the plan of correction was reviewed and included a sample of staff which included nurses, medication aides, and nurse aides who were interviewed regarding in services they received related to the deficient practice. All staff interviews stated they had been in serviced regarding the change in condition policy and the CPR policy. Staff stated they were in serviced verbally and in person by the Director of Nursing and provided the policies regarding change of condition and when to call a code blue with [CONDITION(S)] and initiate CPR. Staff stated they were required to participate in mock code blue drills to ensure they were following the CPR policy and procedures. A review of all the documents provided to correct the deficient practice was completed. All facility policy and procedures that were provided to address the deficient practice were reviewed. The facility alleges full compliance with this plan of correction effective [DATE].

Based on observations, record review, and staff interviews, the facility failed to establish infection control policies, reports, testing procedures, to reduce the risk and growth and spread of Legionella in the building water systems that could affect 56 of 56 residents. Findings included: Review of the facility's Emergency Preparedness Plan and Water Safety Policy (effective 12/2021) revealed no information related to a facility water safety management program to minimize the risk of transmission of Legionella Disease (LD) to the residents, staff and visitors. In an interview on 06/23/22 at 1:30 PM. The Administrator stated she was unaware of the requirement to develop a program to minimize the risk of transmission of Legionella through the facility's water system. She stated that she spoke with the facility Maintenance Director, and he was also unaware of the requirement. She further revealed the facility's water was supplied by the city and no water testing had been completed by the facility. In an interview on 06/24/22 at 3:00 PM. The Maintenance Director stated that he had spoken with their local Hospital's Maintenance Director who told him that they sent weekly water samples to a lab that tested for Legionella. He further explained that the nursing facility could get a CDC-toolkit and test their facility's water system himself or send it off to a lab, like they do. The Facility's Maintenance Director stated he was planning to set up a meeting with the Administrator to determine how best to test their water system for Legionella, and not to rely solely on their city water department for testing.

Based on record review and staff interviews the facility failed to 1) complete and transmit Minimum Data Set (MDS) admission assessments within the required timeframe for 2 of 9 residents (Resident #203, #1), 2) failed to complete a discharge with return anticipated assessment within the required timeframe for 1 of 9 residents (Resident #47) and 3) failed to complete a 14-day MDS assessment within the required timeframe for 1 of 9 residents reviewed for Resident Assessments (Resident #103). Findings included. 1) Resident #203 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review on 06/24/22 of Resident #203's admission assessment with the ARD (assessment reference date) of 05/18/22 revealed the assessment was incomplete and was in progress. Resident #1 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review on 06/24/22 of Resident # 1's admission assessment with the ARD of 06/06/22 revealed the assessment was incomplete and was in progress. 2) Resident #47 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review on 06/24/22 of Resident # 47's discharge with return anticipated assessment with the ARD of 05/31/22 revealed the assessment was incomplete and was in progress. An interview was conducted on 06/24/22 at 10:39 AM with the MDS nurse. She stated she transitioned from the Director of Nursing to the MDS position in January 2022, and she continued helping to do other roles. She stated she had to fill in for the wound nurse during the month of May and filled in for the Staff Development Coordinator nurse and also had resident care assignments including passing medications due to short staffing. She stated the MDS assessments were behind due to staffing and having to help with other roles in the facility. An interview was conducted with the DON on 06/24/22 at 4:00 PM. She indicated she was aware the MDS assessments were behind. She stated she expected MDS assessments to be completed and transmitted within the required timeframes. An interview was conducted on 06/24/22 at 3:45 PM with the Administrator. She stated the facility was looking to hire additional staff. She acknowledged that the MDS assessments were behind and stated corporate was going to send someone to assist the MDS Nurse to get the assessments caught up. 3) Resident #103 was admitted to the facility on [DATE]. A review on 06/21/22 of the MDS assessments for Resident #103 revealed a 5-day MDS was not completed by ARD due date 06/14/22, being 7-days overdue. During an interview on 06/21/22 at 4:00 PM MDS Nurse #1 stated the 5-day MDS assessment should have been completed by 06/14/22/22. The MDS Nurse indicated the reason the assessment was late was because the facility was short staffed, and she being the only MDS nurse was often pulled from her duties to work on the floor as the wound nurse or work passing medications on one of their medication carts. Nurse #1 said their corporate MDS Nurse was scheduled to help remotely one-day a week to complete all resident MDS assessments, which was not enough time, resulting in the facility having late MDS assessments. She indicated the facility was currently in the process of hiring new nurses. An interview on 06/21/22 at 4:15 PM with the Administrator and Director of Nursing (DON) stated they expected all the MDS assessments to be completed in a timely manner per the regulation.

Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14-calendar days of the Assessment Reference Date (ARD, the last day of the look-back period) for 5 of 9 residents reviewed for resident assessments (Resident #5, #6, #7, #8, and #12). Findings included: 1. Resident #5 was admitted to the facility on [DATE]. The most recent quarterly MDS assessment for Resident #5 was reviewed. The assessment had an ARD of 02/15/22 and a completion date of 05/18/22. In an interview conducted with the MDS Nurse on 06/21/22 at 4:00 PM she stated she had not been able to complete the MDS assessments on time, because she had been frequently assigned to work as a staff nurse. She remarked she was currently the only MDS Nurse at the facility and in the past, there had been two MDS nurses to do the same amount of work. She indicated the facility was currently in the process of hiring new nurses. An interview on 06/21/22 at 4:15 PM with the Administrator and Director of Nursing (DON) stated they expected all the MDS assessments to be completed on time. 2. Resident #6 was admitted to the facility on [DATE]. The most recent quarterly MDS assessment for Resident #6 was reviewed. The assessment had an ARD of 02/15/22 and a completion date of 05/18/22. In an interview conducted with the MDS Nurse on 06/21/22 at 4:00 PM she stated she had not been able to complete the MDS assessments on time, because she had been frequently assigned to work as a staff nurse. She remarked she was currently the only MDS Nurse at the facility and in the past, there had been two MDS nurses to do the same amount of work. She indicated the facility was currently in the process of hiring new nurses. An interview on 06/21/22 at 4:15 PM with the Administrator and Director of Nursing (DON) stated they expected all the MDS assessments to be completed on time. 3. Resident #7 was admitted to the facility on [DATE]. The most recent quarterly MDS assessment for Resident #7 was reviewed. The assessment had an ARD of 02/15/22 and a completion date of 05/18/22. In an interview conducted with the MDS Nurse on 06/21/22 at 4:00 PM she stated she had not been able to complete the MDS assessments on time, because she had been frequently assigned to work as a staff nurse. She remarked she was currently the only MDS Nurse at the facility and in the past, there had been two MDS nurses to do the same amount of work. She indicated the facility was currently in the process of hiring new nurses. An interview on 06/21/22 at 4:15 PM with the Administrator and Director of Nursing (DON) stated they expected all the MDS assessments to be completed on time. 4. Resident #8 was admitted to the facility on [DATE]. The most recent quarterly MDS assessment for Resident #8 was reviewed. The assessment had an ARD of 02/16/22 and a completion date of 05/19/22. In an interview conducted with the MDS Nurse on 06/21/22 at 4:00 PM she stated she had not been able to complete the MDS assessments on time, because she had been frequently assigned to work as a staff nurse. She remarked she was currently the only MDS Nurse at the facility and in the past, there had been two MDS nurses to do the same amount of work. She indicated the facility was currently in the process of hiring new nurses. An interview on 06/21/22 at 4:15 PM with the Administrator and Director of Nursing (DON) stated they expected all the MDS assessments to be completed on time. 5. Resident #12 was admitted to the facility on [DATE]. The most recent quarterly MDS assessment for Resident #12 was reviewed. The assessment had an ARD of 03/02/22 and a completion date 06/02/22. In an interview conducted with the MDS Nurse on 06/21/22 at 4:00 PM she stated she had not been able to complete the MDS assessments on time, because she had been frequently assigned to work as a staff nurse. She remarked she was currently the only MDS Nurse at the facility and in the past, there had been two MDS nurses to do the same amount of work. She indicated the facility was currently in the process of hiring new nurses. An interview on 06/21/22 at 4:15 PM with the Administrator and Director of Nursing (DON) stated they expected all the MDS assessments to be completed on time.

Based on record review and staff interviews the facility failed to provide sufficient staff resulting in the Minimum Data Set (MDS) nurse having to perform other duties to include wound care treatments and resident care assignments which resulted in failure to complete and transmit timely MDS assessments for 9 of 9 residents (#203, #1, #47, #5, #6, #7, #8, #12, #103) whose MDS assessments were reviewed. Findings included. This tag is cross referenced to F636-E and F638-E. Based on record review and staff interviews the facility failed to 1) complete and transmit MDS admission assessments within the required timeframe for 2 of 9 residents (Resident #203, #1), 2) failed to complete a discharge with return anticipated assessment within the required timeframe for 1 of 9 residents (Resident #47) and 3) failed to complete a 14-day MDS assessment within the required timeframe for 1 of 9 residents reviewed for Resident Assessments (Resident #103). Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14-calendar days of the Assessment Reference Date (ARD, the last day of the look-back period) for 5 of 9 residents reviewed for resident assessments (Resident #5, #6, #7, #8, and #12). An interview was conducted on 06/24/22 at 10:39 AM with the MDS Nurse. She stated she transitioned from the Director of Nursing to the MDS position in January 2022, and she continued helping to do other roles. She stated she had to fill in for the wound nurse during the month of May and filled in for the Staff Development Coordinator and also had resident care assignments including passing medications due to short staffing. She stated the MDS assessments were behind due to staffing and having to help with other roles in the facility. An interview was conducted on 06/24/22 at 3:45 PM with the Administrator. She stated the facility was looking to hire additional staff. She acknowledged that the MDS assessments were behind and stated corporate was going to send someone to assist the MDS Nurse to get the assessments caught up. She stated it was difficult to retain staff.

Based on observations and staff interviews the facility 1) failed to remove expired medications from 2 of 3 medication carts (100 hall and 200 hall medication carts), 2) failed to record an opened date for a narcotic located in the locked box in 1 of 1 medication refrigerators and 3) failed to secure medications stored on top of 1 of 3 unattended medication carts. (Medication storage cart 300 Hall) Findings included: 1) An observation was conducted on 06/20/22 at 12:20 PM along with Nurse #1 of the 100 hall and 200 hall medications carts. The following expired medications were observed: Geri Tussin (Guaifenesin- an expectorant used to treat cough and colds) with a manufacturer's expiration date of 05/22/22. GI (gastrointestinal) cocktail (liquid antacid) with an expiration date of 06/10/22. An opened [MEDICATION(S)] discus dated 05/10/22 with manufacturer's instructions to discard 30 days after removal from its foiled pouch. 2) An observation was conducted on 06/20/22 at 12:30 PM along with Nurse #1 of the medication storage refrigerator. The locked narcotic box was observed in the refrigerator with [MEDICATION(S)] liquid in the locked box that was opened with no opened date recorded with the label stating the medication would expire 90 days after opening. An interview was conducted on 06/20/22 at 12:30 PM with Nurse #1. She stated she was the Unit Manager and the nurses checked for expired medications at least once weekly. She stated the expired medications should have been removed from the medication carts and stated the nurse should have recorded an opened date on the [MEDICATION(S)] liquid and discarded it after 90 days. An interview was conducted on 06/24/22 at 4:07 PM with the Director of Nursing. She stated she expected expired medications to be removed from the medication carts, and medications should be dated when opened. She stated the nurse should check the carts when taking over the keys to the cart. 3) An observation of an unattended medication cart on the 300 Hall on 06/22/22 at 4:30 PM revealed there were 3 medication cups each containing loose pills stacked upon each other. During the observation, one resident passed the unsecured medications located on top of the medication cart. The resident was in a wheelchair and propelled herself pass the medication cart. The resident did not notice the medications on top of the cart and the medications were out of her reach. Nurse #6 was not in view of the medication cart. An interview with Nurse #6 on 06/22/22 at 4:36 PM revealed she had dispensed the medication to be administered for another Resident and separated his medications into 3 cups per his choice. Nurse #6 stated she did not mean to leave them unattended on the medication cart. She stated she had gone into another room to assist another resident and accidently left the medication on the medication storage cart. Nurse #6 stated she should not have left the medications unsecured because anyone passing by could take them including a resident. An interview was conducted with the Director of Nursing on 06/24/22 at 4:17 PM. The DON reported she expected all the nursing staff who were on a medication cart to secure all medications for the safety of the residents.

Based on observation and staff interviews the facility failed to keep unattended treatment medications (creams and ointments) secured in a locked treatment cart for 1 of 1 treatment carts observed. Findings included: In a continuous observation on 03/10/21 from 8:31 AM-8:34 AM an unattended treatment cart was against the wall outside room [ROOM NUMBER] with the drawers facing the hallway. The lock on the treatment cart did not appear to be engaged and no staff member was seen near the cart. At 8:34 AM a staff member who identified herself as the Wound Technician (Tech) walked up to the treatment cart. In an interview on 03/10/21 at 8:34 AM the Wound Tech verified that the treatment cart was unlocked by opening the cart drawers without having to use a key to unlock the cart. There were creams and ointments that were to be used for resident treatments in the drawer. She stated that the treatment cart should not be left unlocked and unattended because a resident could get into the cart and take something. In an interview on 03/10/21 at 2:46 PM the Director of Nursing (DON) stated that medication and treatment carts needed to be locked at all times unless the cart was in a doorway with the drawers facing into the room. She indicated that unlocked medication or treatment carts needed to be within the line of sight of the responsible staff member at all times. The DON stated that the purpose of keeping the treatment cart locked was to keep residents from getting into things they should not get into.

Based on observation, staff interviews and record review the facility failed to maintain communication and coordination of services provided by Hospice and facility personnel for 1 of 1 sampled resident's (Resident #23). Resident #23 was admitted to the facility on an unannounced annual survey was conducted on 03/08/21 through 03/12/21. The investigation included resident observations, interviews of alert and oriented residents, staff interviews, and record reviews. The sampled resident was not in the facility at the time of the survey. Resident #23 was admitted to the facility on [DATE] with a cumulative [DIAGNOSES REDACTED]. Resident #23's Minimum Data Set (MDS) indicated that resident had severe cognitive impairments. The resident needed extensive assistance with toilet use, bathing, and personal hygiene. Resident #23's care plan, revised 12/31/20 identified Resident #23 had a progressive decline, and Hospice care was provided starting 09/02/20 due to progressive decline. A Medication Administration Record [REDACTED]. A physician progress notes [REDACTED].#23 revealed Hospice nurse report resident had been complaining of back pain. resident had a history of [REDACTED]. A Hospice nursing note dated 02/04/21 from Resident #23's Electronic Medical Record (EMAR) was reviewed with the Director of Nursing (DON) on 03/08/21 at 12:30 PM, confirmed that the last Hospice note entered into the facility's Electronic Medical Record (EMAR) for Resident #23. The 02/04/21 Hospice nursing note read: Hospice nurse in to see patient. Patient resting with eyes closed, easily awakened for assessment. No distress noted, vital signs stable (VSS). Coordinated with the Med Tech. DON said Resident #23's complete assessment with vital signs were not available for her nursing staff or MD to review. DON confirmed on 03/08/21 that in the previous 4 months, there were only 3 Hospice nursing note entries (12/01/20, 12/31/20, and 02/04/21) in Resident #23's electronic medical record. DON said it was her expectation that their Hospice Nurse provide the facility with complete visit notes, MD order updates, labs, medication changes, etc., each week, prior to her leaving the facility, and not just to place a short note in the resident's medical record every month or so. DON said their Hospice nurse needed to communicate better with a facility's nurse, not just with a Medication Aide or Tech, who were not even nurses, especially if there was an emergency, an order change, or significant change in Resident #23's condition. Four additional (late entry) Hospice notes were entered the facility's EMAR on 03/09/21 at 1:24 PM - 1:59 PM by the Hospice nurse for Resident #23. Late entry #1 note dated 03/04/21 at 11:40 AM revealed Hospice nurse in to visit with patient, no distress noted, vital signs were stable (VSS), and coordinated with Medication tech. Late entry #2 note dated 02/25/21 at 10:00 AM revealed Hospice nurse in to see patient, lying in bed in no acute distress, VSS, coordinated with nurse regarding my visit. Late entry #3 dated 02/18/21 at 11:35 AM revealed Hospice nurse in to see patient, coordinated with Medication tech regarding my visit, with instructions to call Hospice with changes in condition. Late entry #4 dated 02/11/21 at 8:45 AM revealed Hospice nurse in to see patient, no acute distress, coordinated with Medication tech, regarding my visit, with instructions to call Hospice with changes. An interview on 03/09/21 at 3:45 PM with the Director of Nursing (DON) revealed that it was her expectation that Hospice should have communicated more fully to facility staff as well as provided Hospice Nurse's complete visit documentation prior to leaving the facility and did not. She said Hospice failed, per their Hospice agreement dated 01/01/2016, to communicate and coordinate of services provided by facility personnel and Hospice personnel and the providing of Hospice services 24 hours per day. And failed to provide Resident #23's Hospice information from Hospice to the facility, which included resident assessments, vital signs, medications, care plan updates, physician order [REDACTED]. The DON said it was her expectation that there be a complete verbal and paper communication process between Hospice and her nursing staff, and there was not. An interview on 03/09/21 at 3:50 PM with the facility Administrator revealed that it was expectation that the Hospice Nurse follow the Nursing Facility Hospice Services Agreement dated 01/01/2016 to provide information from Hospice to the facility to include: Complete Hospice medical information, Hospice orders, and did not. The Hospice Services Agreement stated: Nursing Facility and Hospice shall each prepare and maintain complete, correct and detailed clinical record concerning each Residential Hospice Patient. The Resident's Hospice clinical records shall be made available to the Attending Physician and Hospice staff. Nursing Facility and Hospice shall cause each entry made for services provided hereunder to be legible, clear, complete, and appropriately authenticated and dated in accordance with applicable policy and currently accepted standards of practice. The Hospice Patient Care Coordinator will coordinate all aspects of patient care by assuring an adequate exchange of information and facilitating communication and interaction among the Interdisciplinary Group (IDG), and between IDG and family, and Nursing Facility personnel. Section 4.6 entitled Clinical Record reads: The Hospice Patient's inpatient clinical record shall include a record of all inpatient services furnished and events regarding care that occurred at the Nursing Facility. The Administrator revealed that the facility and their contracted Hospice provider failed to communicate or share Resident #23's documentation with facility's nursing staff, which was not available to facility staff on a 24-hour basis per Hospice agreement. An interview on 03/10/21 at 10:20 AM with Nurse #1 (Hospice Nurse) revealed that it was her expectation that Resident's #23 complete Hospice medical records be available to staff on a 24 hour, 7 days per week, per facility agreement, and were not. The Hospice nurse agreed that a complete communication structure should have been set-up (verbal and written form) between facility and Hospice staff, and be present at the facility, and was not. She said she kept most of the resident's orders, assessments, and notes in her computer. It was her expectation, from now on, she would print off resident #23's complete visit notes, assessments, updated orders and care plans and place them in a notebook, kept by the Director of Nursing (DON). She said she would also document after each visit, a visit summary in writing and place it in the resident's electronic medical chart, titled Hospice Note.

Based on record review and staff interviews, the facility failed to follow physician orders [REDACTED].#38). Findings included: Resident #38 had been admitted on [DATE]. Her [DIAGNOSES REDACTED]. A physician order [REDACTED]. Resident #38 ' s most recent Minimum (MDS) data set [DATE] revealed she had mild cognitive impairment. She had received antianxiety medications daily. Noted to be on Hospice care. A prescription written by a Nurse Practitioner (NP) dated 9/12/18 for [MEDICATION NAME] 0.5 mg; give one tablet twice a day, dispense 60 tablets, with 5 refills. Resident #38 ' s care plan, most recently updated on 10/3/18, indicated use of anti-anxiety medications and a [DIAGNOSES REDACTED]. A review of Resident #38 ' s (MONTH) (YEAR) medication administration record (MAR) revealed [MEDICATION NAME] 0.5 mg, one tablet to be given at 9 AM, one tablet to be given at 5 PM and two tablets at 9 PM for a total of four tablets daily. Review of the (MONTH) (YEAR) MAR also revealed Resident #38 had not received any doses of [MEDICATION NAME] on 10/2/18 at 9 PM, 10/3/18 at 9 AM, 5 PM or 9 PM and 10/4/18 at 9 AM or 5 PM. On 12/04/18 at 9:13 AM an interview with Nurse #1 was conducted. She stated she had cared for Resident #38 during the time Resident #38 had been out of [MEDICATION NAME]. The nurse stated she had been unsure why there had been a delay in receiving the [MEDICATION NAME] from the pharmacy or a new prescription from the physician. On 12/04/18 at 3:34 PM an interview with the Hospice nurse was conducted. The nurse stated the facility had run short of the medication because the dose had changed, the pharmacy was sending fewer tablets and the facility nurses had been administering the medication three times a day as previously ordered. On 12/05/18 at 9:26 AM a telephone interview with the pharmacy technician (PT) who managed the narcotic prescriptions at the facility ' s pharmacy was conducted. She stated when a new prescription was presented, it canceled the previous prescriptions of the same medication. She stated a prescription had been received on 9/12/18 for [MEDICATION NAME] 0.5 mg one tablet twice a day. The PT also stated Resident #38 had been under Hospice care and because of this, only 15 days of medications were dispensed at a time. So because of this new order, and only 15 days of medication dispensed at a time, 30 tablets had been sent. The PT stated this prescription had been refilled on 9/24/18, and because the facility had been administering 4 tablets daily instead of 2, they ran out of medication before the expected refill time. On 12/05/18 at 9:41 AM an interview with Resident #38 ' s physician was conducted. The physician stated the timing of the fax requests may have why there had been a delay in receiving a new prescription. He stated Resident #38 had not suffered any withdrawal symptoms and had no adverse outcome from missing six doses of the [MEDICATION NAME]. On 12/05/18 at 2:57 PM an interview with the Director of Nursing (DON) was conducted. The DON stated the Nurse Practitioner (NP) had written the prescription on 9/12/18 and had not realized Resident #38 also took a bedtime dose of the [MEDICATION NAME]. The DON stated when the discrepancy had been realized, Resident #38 ' s physician had been contacted and the prescription had been corrected. On 12/06/18 at 9:15 AM an interview with the NP was conducted. She stated she did not regularly care for Resident #38 but had been helping the facility because of inclimate weather. She stated when she had received the request for a new prescription for resident #38 ' s [MEDICATION NAME], she reviewed the MAR and had only observed [MEDICATION NAME] 0.5 mg to be given twice a day and had written a prescription reflecting that. She stated if staff had alerted her that this was not Resident #38 ' s complete daily dosing, she would have corrected the prescription.