Every finding on record at Signature Healthcare of Chapel Hill

Based on observations, record review, and interviews with staff, resident, Nurse Practitioner #1, and Medical Director, the facility failed to protect a resident's right to be free from neglect when nurse aides did not reposition and provide incontinence care to a dependent resident. One of the nurse aides was made aware on two occasions that Resident #103 reported she had not been repositioned, needed incontinence care and her buttocks was sore. Resident #103 stated being left all day without being changed or repositioned made her feel sick to her stomach when she thought about it and she felt neglected. The deficient practice occurred for 1 of 3 residents reviewed for neglect (Resident #103). Findings included:Resident #103 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (A-Fib), congestive heart failure, transient ischemic attack (brief blockage of blood flow in the brain).The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #103 was cognitively intact with no rejection of care behaviors during the lookback period. Resident #103 had functional limitation in range of motion on both sides of her upper body. She was coded as always being incontinent of bladder and bowel, and dependent on staff for hygiene and activities of daily living (ADL). She needed substantial to maximal assistance for rolling left and right in bed and was dependent on staff for all other bed mobility.The care plan revised on 6/4/26 revealed Resident #103 had impaired bed mobility as evidenced by decreased ability to position or reposition self in bed related to morbid obesity. The goal stated Resident #103 would maintain her ability to position and reposition self in bed with substantial assistance in 4 out of 15 attempts. This was initiated to maximize self-independence while in bed and decrease risk of pressure areas. Interventions included staff to provide resident substantial level of assistance to perform bed mobility skills including rolling to the right and left, utilizing side rails, notifying the nurse and restorative of any decline with assistance, and to position and reposition resident in bed for comfort, joint support, and skin integrity.Resident #103 also had a care plan for elimination issues, which stated she had incontinence due to decreased mobility, and needed assistance with ADL. It further explained she was at risk for impaired skin integrity, impaired dignity, social isolation, discomfort, urinary tract infections (UTIs), falls and increase in incontinence. The goal stated Resident #103 would receive assistance from staff to be kept clean, dry, and comfortable and would have no signs or symptoms of impaired skin integrity, social isolation, UTIs, or falls. Interventions included checking the resident for incontinent episodes ongoing and provide incontinence-peri care as needed while maintaining dignity and privacy. It also included monitoring skin for redness or breakdown and for staff to inform doctor, physician's assistant, and/or nursing of changes.Also included in Resident #103's care plan, it stated she was at risk for pressure ulcers and impaired skin integrity related to decreased mobility, fall risk (skin injury), morbid obesity, incontinence, and muscle weakness. The goal for this problem stated the resident's skin would remain intact, free of redness, blisters, discoloration, or open areas over bony prominences through next review. Interventions included the resident was to wear off-loading boots as ordered, staff to keep her clean and dry as possible to minimize skin exposure to moisture, keep bony prominences from direct contact with one another, avoid shearing resident's skin during positioning, transferring, and turning, conduct systematic skin inspections weekly (paying attention to the bony prominences), encourage use of side to assist with turning in bed, and turn and reposition ongoing.A review of the weekly skin assessment documentation on the Treatment Administration Record (TAR) dated 8/4/26, initialed Nurse #3 indicated Resident #103 had no skin impairment. There were no accompanying notes regarding this skin assessment in Resident #103's medical record.A review of the weekly skin assessment documentation on the TAR dated 8/11/26, initialed Nurse #1 indicated Resident #103 had no skin impairment. There were no accompanying notes regarding this skin assessment in Resident #103's medical record. An observation was conducted on 8/18/25 at 10:05 AM of Resident #103 lying in her bed positioned on her back with the head of the bed slightly elevated.A subsequent observation was conducted on 8/18/26 at 12:25 PM and noted Resident #103 was positioned on her back with the head of the bed slightly elevated.An interview and observation with Resident #103 occurred on 8/18/26 at 1:00 PM. Resident #103 stated she had not been repositioned or washed up all day and that she had been wet a long time. She stated her buttocks was getting very sore. She further explained she had been positioned on her buttocks all day long. Resident #103 indicated she had turned her call light on to notify staff, but nobody came to help her. She was unable to state the time she turned her call light on. Resident #103 recalled Medication Aide (MA) #2 and Nurse Aide (NA) #1 had come in with breakfast and lunch meal trays but were both in a rush and did not offer her to get washed up. She further stated the staff were usually pretty good to her. The Surveyor asked the resident to try to turn her call light on and Resident #103 pressed the call light and it did not turn on. At 1:03 PM on 8/18/26, the Surveyor stepped out of Resident #103's room into the hallway and requested NA #1 to come assist with the call light. On 8/18/26 at 1:04 NA #1 entered Resident #103's room with Surveyor and attempted to turn the call light on. The call light did not work. NA #1 stated she would let someone know. Surveyor informed NA #1 that Resident #103 had stated she had not been changed or repositioned all day long and that her buttocks was getting very sore. NA# 1 stated, I will let someone know. Surveyor clarified with NA #1 who the assigned NAs were for Resident #103's hall and she stated she and MA #2 both were both the assigned NAs to take care of the residents on that hall and left the room.On 8/18/26 at 1:30 PM, Surveyor spoke with Resident #103. The resident stated she still had not had her brief changed and her buttocks was very sore. Resident #103 was lying on her back with the head of the bed slightly elevated.At 1:31 PM on 8/18/26, the Surveyor stepped out of Resident #103's room, into the hallway and asked NA #1 if she or MA #2 had changed Resident #103's brief as she was still complaining that her buttocks were very sore. NA #1stated she had told MA #2 and they were planning to change her brief when they bathed her 'in just a little while'. A follow up interview and observation were conducted with Resident #103 on 8/18/26 at 2:00 PM. She stated she had not been repositioned yet or had her incontinence brief changed. The resident was still positioned on her back with the head of the bed slightly elevated and Resident #103 indicated her buttocks was very sore. Resident #103 further stated her call light had been switched out, and she activated her call light and the surveyor waited with the resident.On 8/18/26 a continuous observation and interviews were conducted from 2:25 PM to 2:44 PM. NA #1 and MA #2 entered Resident #103's room and they informed Resident #103 that they were going to provide her with a bed bath. MA #2 stated that Resident #103 did not have any open areas on her body prior to the bath other than the known wound on her right lower leg that the facility had been treating. At 2:40 PM the NA and MA removed the resident's heavily saturated brief which had a strong odor of urine present. MA #2 cleaned the resident's buttock, the Resident stated, Ow, that hurts! Resident #103 flinched and grimaced, and complained of pain each time MA #2 touched a specific area on her left buttock. Resident #103 had a pea-sized open area noted on her left buttock below her coccyx. There was also slight swelling noted to this area. There was a second pink area also pea-sized, near the open area but the second area was not as tender to touch as the open area was. Surveyor asked NA #1 and MA #2 if Resident #103 had been changed at all today since they had been on shift and NA #1 stated no. MA #2 stated they usually would have rounded on Resident #103 at least one time by then, but that they were busy and just had not gotten to it. Resident #103 stated that she did not have any pain to her buttock prior to today (8/18/26). Surveyor asked MA #2 and NA #1 what the process was when they found a new open area on a resident's buttock. MA #2 stated they would apply barrier cream to the resident's buttock and complete a Stop and Watch. MA #2 explained that a Stop and Watch was a way staff notified the Unit Manager (UM) of a concern so the concern could be watched more closely. She stated they would let UM #2 know about the open area on Resident #103's buttock.On 8/21/26 at 3:45 PM an interview was conducted with MA #2. She revealed that she often stayed late to finish caring for the residents. She stated that she will not leave for the day until she knows she had 'laid hands on each of her residents at least once.' She clarified that she meant each resident had hygiene completed and at least their draw sheet changed. MA #2 stated when she began the shift she would try to get as many as she could before breakfast and usually focused on the residents who she knew would have appointments or therapy that day. MA #2 stated when the meal carts came, no resident care could continue until the trays were all served. She then stated the heavier care residents would usually be last for their baths and care. She stated she was able to ask for help and would often ask a specific NA from the other hallway to help them if they were struggling to complete all of their resident care. MA #2 further explained she was able to ask the nurses as well and stated some nurses would help and others would not. MA #2 stated on 8/18/26 she and NA #1 did not ask for help because the NA they liked wasn't working. NA #1 was not available for a follow-up interview.During an interview with Resident #103 on 8/21/26 at 1:20 PM she revealed that being left all day on 8/18/26 without being changed or repositioned made her feel sick to her stomach when she thought about it. She stated she felt like her wound was something that should not be there and that she felt neglected.An interview with UM #2 was conducted on 8/18/26 at 2:45 PM. She was informed by the surveyor that MA #2 and NA #1 had stated that Resident #103 had not been repositioned or changed during their entire shift and had developed an open area on her buttock. UM #2 stated she would complete a change in condition and notify the provider of the open area. UM #2 further stated it was not acceptable for the resident not to receive incontinence care or be repositioned for that amount of time and she would have expected the NAs to change her immediately when notified that she was complaining of having a sore buttock and not being changed and repositioned.On 8/21/26 at 3:08 PM a follow up interview was conducted with UM #2. She stated that she helped the NA #1 and MA #2 on 8/18/26, after the surveyor had made her aware that they had stated they had not changed or repositioned Resident #103 all day and had an open area on her buttock. UM #2 further explained she went to NA #1 and MA #2 and asked them what was going on. She stated NA #1 and MA #2 told her they were just very busy. An interview and observation were conducted on 6/18/26 at 6:00 PM with Resident #103, UM #2, and the Wound Care Nurse. The Wound Care Nurse rolled Resident #103 to her right side and positioned her brief so the resident's buttock was able to be visually inspected. The resident's room was dimly lit and the Surveyor requested a flashlight to see the resident's buttock better. UM #2 provided additional light via her cell phone flashlight. It was observed that Resident #103 had an open area to her left buttock below the coccyx which had a shallow wound bed that was light pink, darker pink, and white in color. There was no visible drainage. The area was very sore to touch and there was slight swelling around the wound bed. The Wound Care Nurse measured the wound bed with a paper ruler and stated it was 0.3 centimeters by 0.4 centimeters. A second pea-sized pink area was also still present on the same buttock, in close proximity to the open area and it was intact. The Wound Care Nurse did not measure this area. The Wound Care Nurse then applied barrier cream to the residents' buttock and replaced her brief. The Wound Care Nurse stated a provider would be in to look at the wound the next day (8/19/26). The surveyor requested to be present when provider examined the resident's buttock and UM #2 stated they would let the provider know.A review of Resident #103's medical record revealed a progress note written by the Wound Care Nurse dated 8/18/26 at 9:40 PM which stated, Resident has 3 pale pink scar areas to bilateral buttocks and coccyx. One area has a firm lump under the pink area, no drainage noted with epithelial tissue. C/o (complain of) of pain when palpated. Provider made aware. Orders for Zinc daily and PRN and lidocaine cream to firm area every 6 hours. Provider will evaluate. Son aware. A review of Resident #103's medical record revealed a physician order dated 8/18/26 for Zinc Oxide 22% to be applied to bilateral buttocks and coccyx daily and lidocaine 4% gel applied four times daily to her left buttock. During an interview with the Director of Nursing (DON) with the Federal Surveyor present on 8/19/26 at 10:12 AM, the DON was notified that NA #1 and MA #2 had stated they had not repositioned or changed Resident #103 all day and that she had an open area on her buttock. The DON stated she was made aware of the concern with Resident #103 and stated it sounded like the resident had a lump on her buttock. She stated she had not seen the wound or spoken to the resident. The DON further explained that the provider would be in to evaluate the resident that day (8/19/26). DON reviewed the note written by the Wound Care Nurse on 8/18/26 and stated the Wound Care Nurse documented the wound was not open and they were applying barrier cream and pain cream every 6 hours. The DON stated she would look at the area with the provider when he came. The Federal Surveyor asked DON if he and surveyor could be present and DON replied yes. The DON indicated she made her rounds and spoke to everyone first thing in the morning and then looked at any events created and any observation created in the medical record. She stated if there was an event or observation noted then she would look at orders and progress notes. She stated she then pulled that report and any new pressure wound orders were on the report, they would go over the orders as a nursing leadership team.An interview was conducted with Nurse Practitioner (NP) #1 on 8/19/26 at11:35 AM. NP #1 stated that it was communicated that the Federal Surveyor had requested to view Resident # 103's wound with him, but that he wanted to view it himself first. He stated he was called by the Wound Care Nurse the night prior at about 7:00 PM and he did not want to treat the wound without seeing it first so he focused on pain management and ordered the pain gel to be applied until he could assess it in person. NP #1 further explained that he did not think the wound was open and stated it was not draining. He stated it could be an abscess and that it was superficial and not ready to be lanced. He stated that Resident #103 did not have any chills or fever, so he planned to treat with pain management and reevaluate it on 8/21/26. He stated he was certain there was something going on because he could feel it, but he could not say if it was an ingrown hair, or a blister. An order written for Resident #103 on 8/20/26 indicated she was to have doxycycline hyclate (antibiotic)100 milligrams twice a day for 14 days for Pilonidal cyst with abscess.During an interview with Nurse #1, on 8/21/26 at 12:28 PM she stated she had never seen Resident #103 out of bed and believed the resident was a 2-3 person assist for repositioning and providing incontinence care. Nurse #1 further revealed she had never seen Resident #103 refuse care but stated she had seen her be a little confused at times. Nurse #1stated that they do not keep any sort of documentation regarding repositioning and offloading residents. Nurse #1 stated that no staff made her aware in the past week, that Resident #103 had refused any care or repositioningDuring an interview on 8/21/26 at 12:34 PM with NP #1, he revealed that the Wound Care Nurse had called him that morning and let him know that Resident #103 had drainage from her wound, and he had told her to get a wound culture. He further explained that he had put the resident on an antibiotic the day before (8/20/26). The NP stated the Wound Care Nurse told him it was a blister that was red on top and draining a little bit but was not ready to be drained. NP #1 stated today when he viewed the wound it had purulent drainage and the open area was the size of a dime and the reddened area around the open area was about the size of a half-dollar. He further stated he thought the resident had an infection and he wanted to see if she had a history of this resident getting infections like that. NP #1 also revealed that he had ordered a Complete Blood Count on 8/19/26 and had told the staff to start treating the area as a pressure ulcer by keeping pressure off it and to be sure she was being turned. He stated Resident #103 was lying on her back when he arrived to assess her today. Surveyor asked NP #1 if he thought a resident lying in the same position and in the same incontinence brief for over 8 hours could have contributed to the current skin issue Resident #103 was experiencing. NP #1 stated Yes, if she laid in urine or feces or staying in the same position all that time, can contribute to skin breakdown and based on her immobility, can contribute to pressure injury as well. A telephone interview was conducted with the Medical Director on 8/21/26 at 4:45PM. He stated NP #1 had reached out to him and let him know Resident #103 had a skin concern on her buttocks. The Medical Director stated his understanding was that the wound was closed and that an antibiotic had been ordered. Medical Director was made aware by the surveyor, that the wound was open and draining and that NP #1 had ordered a wound culture to be completed on the drainage. The Medical Director Stated he would have the wound care provider take a look at it and keep an eye on it. The Medical Director further stated a decubitus ulcer could develop in 30 minutes if the conditions were right. He further explained with a known mobility issue, Resident #103 would have needed to have continuous maintenance to try to keep her dry and be repositioned frequently. He stated not repositioning was just as bad or worse than the urine being on skin, for someone who was at risk for developing pressure ulcers.An interview was conducted with the DON with the Administrator present during part of the interview on 8/21/26 at 3:22 PM. The DON revealed she usually made her rounds in the facility between 7:00 AM and 7:30 AM. She stated she always asked the staff if they needed help and how they were doing and on 8/18/26 she did ask the NAs and nurses who were working down all hallways if they needed any help and they all told her no. She stated she specifically asked MA #2 and NA #1 if they needed any help and they told her no as well. She stated MA #2 who was taking care of Resident #103 was usually a very good employee. She stated she expected all the staff to work as a team including the UMs and ADON as well. She stated she would expect the NAs to tell her or the UMs if they were too busy and struggling to get residents done and that it was not acceptable to not change and reposition a resident all day. The DON continued to say she was visible to staff, and they should have come and talked to her if they needed help.During an interview with the Administrator on 8/21/26 4:05 PM she stated she would have expected her staff to ask for help if they ever needed it and stated there were plenty of people in the building willing to help.

Based on observations, record reviews, and interviews with the Consultant Pharmacist, Medical Director, and staff, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of psychotropic medications prior to the administration of psychotropic medications or prior to increasing the dosage of psychotropic medications for 4 of 5 residents reviewed for unnecessary medications (Resident #5, #7, #10, and #12).Findings included:a. Resident #5 was admitted to the facility on [DATE] with diagnoses that included depression, dementia with behavioral disturbances, and anxiety.Review of Resident #5's orders revealed an active order initiated on 5/28/2026 for trazodone (an antidepressant medication that could cause drowsiness) 50milligrams (mg) once a day at night for depression.Review of Resident #5's May 2026 Medication Administration Record (MAR) showed trazodone 50mg was administered 5/28/2026 - 5/31/2026.Review of Resident #5's orders revealed an active order initiated on 6/18/2026 for quetiapine (an antipsychotic medication that could help with severe agitation, unusual thoughts, or behaviors) 100mg once a day at night and 50mg twice daily in the morning and afternoon for dementia with behavioral disturbances.Review of Resident #5's June 2026 MAR showed quetiapine 100mg and 50mg was administered 6/18/2026 - 6/30/2026.Resident #5's quarterly Minimum Data Set (MDS) dated [DATE] showed she had moderate cognitive impairment; received the high-risk antianxiety, antidepressant, and antipsychotic medications; and received hospice care.Resident #5's care plan dated 7/8/2026 identified the use of psychotropic medications and included interventions for education regarding the risks, benefits and side effects of psychotropic medications, as well as monitoring and documenting for behaviors and adverse reactions.Review of Resident #5's orders revealed an order initiated by Unit Manager #2 on 7/8/2026 ordered verbally by the Medical Director for lorazepam (a benzodiazepine medication used to relieve anxiety) 0.5 milligrams (mg) every 4 hours as needed for anxiety and restlessness.Review of Resident #5's July 2026 MAR showed lorazepam 0.5mg was administered once on 7/11/2026, 715/2026, 7/16/2026, and 7/25/2026.Review of Resident #5's August 2026 MAR showed lorazepam 0.5mg was administered twice on 8/2/2026, 8/5/2026; and once on 8/8/2026, 8/9/2026, 8/10/2026, 8/13/2026, 8/14/2026, and 8/17/2026.A record review of Resident #5's electronic medical record revealed no consent for trazodone, lorazepam, or quetiapine.An interview with the Regional Nurse Consultant on 8/20/2026 at 8:40AM confirmed they could also not retrieve the psychotropic medication consents for trazodone, lorazepam, or quetiapine in Resident #5's medical records. She confirmed the consents were never completed.b. Resident #7 was admitted to the facility on [DATE]. Her cumulative diagnoses included depression.Resident #7's care plan dated 7/10/2026 identified the use of psychotropic medications and included interventions for education regarding the risks, benefits and side effects of psychotropic medications, as well as monitoring and documenting for behaviors and adverse reactions.Resident #7's 5-day MDS assessment dated [DATE] showed Resident #7 was cognitively intact. It also confirmed Resident #7 was on a high-risk antidepressant medication.A review of Resident #7's medication orders revealed the resident had a current order initiated by the DON that was ordered by the Medical Director on 7/10/2026 for bupropion (a medication that increased dopamine to help improve mood) 300mg extended release (XL) tablet to be administered once daily in the morning.Review of Resident #7's July 2026 Medication MAR showed bupropion 300mg XL tablet was administered once daily in the morning 7/10/2026 - 7/31/2026.A review of Resident #7's medical records showed a consent for use of psychotropic medications form with the description for Wellbutrin (bupropion) 300mg XL recorded, observed, and completed on 7/30/2026 by the DON.c. Resident #10 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (MDD), recurrent, severe with psychotic symptoms.Review of Resident #10's orders revealed an active order initiated by Nurse Practitioner (NP) #2 on 6/13/2026 for a mirtazapine (an antidepressant used to improve mood, sleep, and appetite) 15mg tablet to be administered as a half tablet once daily at bedtime for MDD.Review of Resident #10's June 2026 MAR showed mirtazapine 15mg was administered as a half tablet once daily at bedtime 6/13/2026 - 6/30/2026.Resident #10's care plan dated 6/17/2026 identified the use of psychotropic medications and included interventions for education regarding the risks, benefits and side effects of psychotropic medications, as well as monitoring and documenting for behaviors and adverse reactions.Resident #10's quarterly MDS assessment dated [DATE] showed that Resident #10 had moderate cognitive impairment. The MDS also included that Resident #10 was taking a high-risk antidepressant medication.Review of the monthly Medication Regiment Review (MRR) completed by the Consultant Pharmacist on 6/16/2026 showed the Consultant Pharmacist recommended to ensure informed consent was documented in Resident #10's chart for the mirtazapine order that was started on 6/13/2026. The recommendation was signed and dated 7/1/2026 by NP #2.Review of Resident #10's medical record revealed no consent for mirtazapine.An interview with the Regional Nurse Consultant on 8/21/2026 at 9:09AM confirmed they could not retrieve the consent for mirtazapine in Resident #10's medical records. She confirmed the consent was never completed.d. Resident #12 was admitted to the facility on [DATE] with diagnoses that included dementia with behaviors.Review of Resident #12's orders revealed an order initiated on 11/17/2025, and discontinued on 2/19/2026, for quetiapine (a medication that could be used to treat schizophrenia, dementia behaviors, and bipolar disorder) 25mg tablet to be administered as one-half tablet twice daily in the morning and evening for audio and visual hallucinations.Review of Resident #12's orders revealed an active order initiated by NP #3 on 2/19/2026 for quetiapine 25mg tablet to be administered as 1 tablet twice daily in the morning and evening for audio and visual hallucinations.A review of Resident #12's medical records showed a consent for use of psychotropic medications form with the description for quetiapine observed and recorded on 4/16/2026 but never scheduled or completed. The entire form was blank, which included: Resident/Resident Representative notification; non-pharmacological interventions attempted prior to prescribing; Resident and or Resident Representative was informed of the benefits, risks, and alternatives for the medication, including any black box warnings for psychotropic medications; consent being completed related to resident admitting with psychotropic medication; consent to initiate or increase; name of Resident or Resident Representative; name of medication, dose of medication, number of times per day; and if provider was notified of acceptance or declination. Resident #12's care plan dated 6/3/26 identified the use of psychotropic medications and included interventions for education regarding the risks, benefits and side effects of psychotropic medications, as well as monitoring and documenting for behaviors and adverse reactions.Resident #12's quarterly MDS assessment dated [DATE] showed the interview was not performed to assess her cognitive level and her ability to understand others was rated as rarely never understands others. The MDS also confirmed Resident #12 was taking a high-risk antipsychotic medication.After review of Resident #12's medical chart revealed no complete consent for quetiapine, an interview with the Regional Nurse Consultant on 8/21/2026 at 9:09AM confirmed they could not retrieve any other consents except the one dated 4/16/2026. She confirmed the consent was never fully completed. An interview was conducted with Unit Manager #2 on 8/20/2026 at 2:00PM with the assistant DON present. Unit Manager #2 stated that they obtained consent for psychotropic medications when a provider prescribed a new psychotropic medication. Unit Manager #2 said if the resident was unable to give the consent, they would call family to get verbal consent and understanding of the side effects and reason for the medication. It was stated by Unit Manager #2 that consent was needed before the resident starts taking the medication in case the resident or resident representative does not want the resident to take it. Unit Manager #2 also stated that if the resident had been on the medication before coming to the facility, they would still need to get a consent, and she stated it would usually take within 24 - 48 hours. She was unsure how the consents were missed for Resident #5, # 7, #10, and #12.An interview with NP #1 on 8/19/2026 at 2:00PM was conducted to inquire about the process of receiving consent for psychotropic medications. NP #1 stated he would visit a new admission either on day of arrival or the next day. At that time, he would review all medications and if necessary, obtain consent for psychotropic medications right then. NP #1 was confident he would obtain consent from the resident or resident representative the day of admission or the next day. He said if he was not there, NP #2 would be on site, or he would call the facility and tell the nurse to obtain the consent. NP #1 confirmed the consent should be received before the medication was administered, it was an immediate thing and should not have been weeks later.A phone interview with NP #2 was conducted on 8/21/2026 at 8:23AM and a discussion occurred about the need to have consent from the resident or resident representative for psychotropic medications. NP #2 stated she was aware of the regulation that psychotropics need confirmation of consent in the resident's medical chart. NP #2 said the staff should have followed the regulation for obtaining consents and she could not speak to why any resident did not have one in their medical chart. An interview was conducted with the DON on 8/20/2026 at 3:10PM with Unit Manager #2 and the Assistant DON present. During the interview the DON stated they would let the resident or resident representative know that consent was required if the resident had an order for psychotropic medications. The DON confirmed if there was a change in dose for the medication, a new consent would have been needed. She revealed she liked to see the consent completed before the resident was administered the medication. The DON noted she had only been at the facility since June 2026, and she was unsure why some of the consents for psychotropic medication were not in the residents' chart. She was confident that with her presence in the facility, they could streamline the process to ensure they were not missed in the future.An interview with the Administrator was conducted on 8/20/2026 at 4:08PM. The Administrator stated that it was probably human error that the consents for psychotropics were not obtained.

Based on observations and staff interviews, the facility failed to store food in 1 of 1 walk-in freezer that was not open to air and without freezer burn, failed to label and date food stored for use in 1 of 1 walk-in freezer and 1 of 2 reach-in refrigerators (Refrigerator #2), failed to maintain a clean microwave and ensure an ice scoop was stored without the potential for cross-contamination. The facility also failed to remove dented canned goods from service in the dry goods storage room and failed to maintain clean freezers, microwaves and refrigerators in 2 of 2 nourishment rooms (Red and Blue hallway nourishment rooms). These practices had the potential to affect food served to residents. The findings included:a. During the initial tour of the kitchen with the Assistant Kitchen Manager on 8/17/26 from 9:20 AM to 10:00 AM, the following concerns were identified:- The microwave had debris in and under the microwave and built-up food splatters on the inside door, top, and perimeters,- The ice machine scoop was stored in a clear plastic container with the scoop pointed up and exposed above the container. The Assistant Kitchen Manager paused cutting cheese, attempted to place the scoop handle up while wearing the gloves she was wearing to cut the cheese. She did not remove the ice scoop or disinfect after touching the scoop with her gloves.b. During the same initial tour of the kitchen with the Assistant Kitchen Manager on 8/17/26 from 9:20 AM to 10:00 AM the following concerns in the walk-in freezer were identified:- An open undated cardboard box labeled 20 pounds of burger patties; the box was open to air and there were 30 burgers with visible freezer burn,- An open undated cardboard box labeled 20 pounds of vegan burger patties; the box was open to air and there were 10 burger patties with visible freezer burn, - An open undated cardboard box labeled 20 pounds of chicken patties; the box was open to air and there were 4 chicken patties with visible freezer burn,- An open undated cardboard box labeled 20 pounds of chicken breasts; the box was open to air and there were 40 chicken breasts with visible freezer burn,- A clear plastic bag identified by the Assistant Kitchen Manager as ravioli was open and was not dated or labeled,- A clear plastic bag identified by the Assistant Kitchen Manager as bread sticks was not dated or labeled. c. During the same initial tour of the kitchen with the Assistant Kitchen Manager on 8/17/26 from 9:20 AM to 10:00 AM the following concerns in the dry goods storage area were identified:- two 7-pound fruit cocktail cans each with an approximately 2 inch long by 1 inch depth dent on the front label,d. Inside Refrigerator #2 was a clear plastic bin with sandwiches in plastic sandwich bags, 11 of 17 sandwich bags were open to air and not labeled. These findings were discussed with the Assistant Kitchen Manager on 8/17/26 at 10:00 AM. She stated the ice scoop handle should be upright in the holder but stated the scoop was too large to fit with handle up. She stated she should have removed her gloves and disinfected the scoop before returning it to the container. She shared that dented cans should be removed from service and placed in a separate area of the storage area and that all of us look at issues and if an item is not labeled or stored correctly the person who sees it should address the issue. The Assistant Kitchen Manager reported she did not know when the freezer, refrigerator, or dry storage room had been audited but stated all food should be sealed and marked with the date it was opened and removed if damage was seen. During an interview on 8/17/26 at 10:22 AM with the Kitchen Manager, she stated all dietary staff were responsible for discarding any food that was expired, not labeled, covered with frost or freezer burn or had visible damage as well as dented cans. She stated the findings were unacceptable as they had the potential to affect the food served to residents. The Kitchen Manager further shared that staff turnover in the past few months may have contributed to the findings.An interview was conducted on 8/20/26 at 10:41 AM with the facility Registered Dietitian (RD). She stated she had been employed at the facility since July 2026 and during that time had conducted one kitchen audit which was in July. She shared her findings in July included dirty floors throughout the kitchen but no dented cans in service and no undated, open foods in the freezer or refrigerators. e. On 8/20/22 at 11:11 AM, the following observations were made with the Kitchen Manager in the Red-Hall nourishment room: - Inside the nourishment room freezer, a brown residue sticky to touch covering the entire freezer floor. Disposable ice packs for resident use were lying on top of the brown, sticky residue; the disposable ice packs had visible splatters of brown material that were sticky to touch. Two sides of the freezer bins in the door of the freezer had visible brown residue that was sticky to touch. The disposable ice packs in the lower bin had visible brown splatters. - The nourishment room microwave was observed and inside the door, sides, and ceiling of the microwave were dirty with food stains.- Inside the nourishment room refrigerator, 3 of the shelves and the crisper drawer in the refrigerator were dirty with sticky to touch yellow substances. f. On 8/20/22 at 11:29 AM the following observations were made with the Kitchen Manager in the Blue-Hall nourishment room: - Inside the nourishment room Refrigerator 2 of the shelves were dirty with red and yellow sticky to touch substances. Food splatters were present on all walls of the refrigerator and were dirty with yellow sticky substances. The crisper drawer bottom was covered with a yellow liquid spill. - The nourishment room microwaves were observed inside, the doors, sides, and ceilings of both microwaves were dirty with food stains.- The countertop was covered with splatters of red and yellow substances. An interview was conducted on 8/20/26 from 2:02-2:20 PM with the Kitchen Manager. She stated dietary staff were responsible for supplying supplements and snacks in both nourishment rooms which were checked twice per day (between 9:00 a.m.-10:00 a.m. and 2:00 p.m.-3:00 p.m.). She further stated that when dietary staff delivered items to a nourishment room, they should clean the counters, microwaves, refrigerator, and freezer at that time. She was unsure when the nourishment rooms had been audited and the sticky refrigerator and freezer shelves and bins, the dirty countertops, and dirty microwaves were unacceptable and were due to staff not paying attention.On 8/19/26 at 2:36 PM, an interview was conducted with Administrator. She stated the issues in the kitchen were a combination of new staff, less than ideal staffing levels, lack of training, and lack of routine scheduling of deep cleaning but were not acceptable.

Based on record review and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the Covid-19 booster vaccination for 4 of 5 residents reviewed for immunizations (Residents #9, #5, #79, and #3).The findings included:A review of the facility's Vaccines and Immunizations policy revealed the Policy Statement indicated, Minimize the risk of residents acquiring, transmitting, or experiencing complications from communicable diseases through immunizations by following Centers for Disease Control (CDC) Guidance found utilizing the link below. https://www.cdc.gov/vaccines/hcp/current-vis/. The policy's origination date/effective date was 2/2/24. The policy was last revised and reviewed on 1/30/26. Review of the CDC website revealed the CDC recommended everyone 6 months of age and older to receive an age-appropriate FDA-approved or authorized updated 2024-2025 COVID-19 vaccine. A. Residents #9 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, acute respiratory failure, and noninfective gastroenteritis and colitis. Review of Resident #9's electronic and hardcopy health record revealed the last education and vaccine declination was dated 9/19/24 for the Covid-19 vaccine. There was no signed consent indicating the vaccine had been offered, no record of administration, or refusal documentation for the Covid-19 vaccine for 2025/2026. Further review of the medical record also revealed no documentation of the benefits or potential side effects of the Covid-19 vaccine. B. Residents #5 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance or lack of energy supply in the blood due to an underlying systemic illness), congestive heart failure, and dementia. Review of Resident #5's electronic and hardcopy health record revealed resident representative consented to the Covid-19 vaccine on 4/3/26. However, there was no documentation indicating the vaccine had been administered. C. Residents #79 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke), type 2 diabetes mellitus, and dementia. Review of Resident #79's electronic and hardcopy health record revealed resident received the Covid-19 vaccination on 3/7/24. There was no signed consent indicating the vaccine had been offered, no record of administration, or refusal documentation for the Covid-19 vaccine for 2025/2026. Further review of the medical record also revealed no documentation of the benefits or potential side effects of the Covid-19 vaccine. D. Residents #3 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, neurogenic bladder. Review of Resident #3's electronic and hardcopy health record revealed resident received Covid-19 vaccination on 7/27/22. There was no signed consent indicating the vaccine had been offered, no record of administration, or refusal documentation for the Covid-19 vaccine for 2025/2026. Further review of the medical record also revealed no documentation of the benefits or potential side effects of the Covid-19 vaccine. On 8/21/26 at 10:37 AM, an interview was conducted with the Infection Control Preventionist/Staff Development Coordinator (ICP/SDC). She stated the facility offered Covid-19 vaccines to residents on an annual basis, in addition to offering Covid-19 vaccines upon admission. She stated education was provided to all residents regarding all vaccines verbally and via the vaccine information sheets. The ICP/SDC also stated she tried to include family members in the conversations regarding vaccines. If the resident refused, documentation of resident declination should be documented in the resident's record. However, the IPC/SDC could not state why the residents reviewed for immunizations did not have current documentation available for review as her employment with the facility began in June 2026. On 8/21/26 at 1:48 PM, an interview was held with the Administrator and Regional Nurse Consultant. The Regional Nurse Consultant stated vaccines are offered annually to all residents. A follow-up interview was held with the ICP/SDC on 8/21/26 at 4:30 PM. She indicated she had ordered the Covid-19 vaccine for Resident #5. During a follow-up interview with the Administrator on 8/21/26 at 6:26 PM, the Administrator confirmed the facility offered vaccines annually to residents for Covid-19. If residents declined the vaccination, declination forms should be completed by the resident (or representative). There was no current documentation available for review for 2025/2026 showing that the 4 residents were offered and either consented or declined the Covid-19 vaccinations.

Based on observation, record review, and staff interviews, the facility failed to treat resident (Resident #14) in a dignified manner by providing resident's lunch in a clear plastic bag that resembled a trash bag. This practice caused Resident #14 to feel disrespected and embarrassed. This example was reviewed for 1 of 2 residents for dignity.Resident#14 was admitted to the facility on [DATE] with diagnosis that included Renal insufficiency and Renal Failure. A review of Resident #14 Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively intact. Resident #14 was triggered for Dialysis and Hemodialysis. Resident #14's current care plan dated 6/9/2026 included a focus that was for the potential of complications related to hemodialysis, having the diagnosis of End Stage Renal Disease (ESRD). The Goal established was that Resident #14 will not exhibit signs of fluid volume excess and Resident #14 will not develop complications related to hemodialysis. Approaches for this goal included, to assess resident for excess fluid, administering medications as ordered by physician before and after dialysis and follow diet as ordered. An interview with Resident #14 was completed on 8/17/2026 at 4:25 PM when Resident #14 returned from dialysis. Resident #14 stated the facility sends her lunch for dialysis in the clear bags they use in the trash can. Resident #14 stated that having to carry her lunch in the clear bag that appears like a trash bag makes her feel disrespected and was embarrassing. Resident #14 stated she has told staff that she doesn't like it and nothing has changed. Resident #14 stated she had shared this with staff multiple times and stated she had said something to the unit manager today. Resident #14 was unable to recall which other staff she has shared her concern with. A second interview with Resident #14 was conducted on 8/19/2026 at 12:35 PM. Resident #14 stated Tuesday was her normal dialysis day, and she had to carry her lunch again in a clear trash bag again. She stated that she does not want to carry her food in a bag that resembles a trash bag. Resident #14 stated she felt disrespected, especially with the staff knowing she does not like it. She stated she didn't know why the facility could not get a lunch bag or tray for her to carry her lunch in. The Dietary Manager was interviewed on 8/19/2026 at 2:03 PM. She stated the lunches for the dialysis patients are prepared the day before and stored in the refrigerator until going with the resident for their appointment. The Dietary Manager stated the bags are clear bags that are used at the facility. She stated the bags are used for multiple things, and she was not sure if they were used for the trashcans. At this time, she did not have the box or packaging the clear bags came in. The Dietary Manager stated she just had the roll of bags at this time. The dietary manager provided a bag of what the sandwich is put in. An observation on 8/19/2026 at 4:29 PM of the labeled box of the clear bag that the sandwich was packed in was observed. The box was labeled Tuff Gard's Polyethyleal bags. The description stated clear sandwich bag with flip-lock flap. The measurement of the bags was 6 1/2 by 7 1/2. The description box of the larger clear bags was still unavailable for observation at this time. The Unit Manager #1 was interviewed on 8/21/2026 at 8:23 AM. The Unit Manager stated that Resident #14 had made a comment to her on Monday 8/17/2026 about being embarrassed with having to carry a clear bag that has the appearance of a trash bag for her lunch when going to dialysis. Resident #14 told Unit Manager #1 that it was insulting and she felt disrespected. The Unit Manager #1 stated Monday 8/17/2026 was not the first time Resident #14 shared this concern but was unable to recall the other time she had voiced this concern. Unit Manager #1 could not recall whether she had shared this concern with Administration or Dietary. Unit Manager #1 stated she should have informed them of Resident #14's concerns. An interview with the Administrator was completed on 8/21/2026 at 2:23 PM. The Administrator stated she was unaware they were having to use clear non-insulated bags for lunch bags. The Administrator stated she would have gone and bought some lunch bags for the residents to use if she had been aware. The Administrator stated she could understand why Resident #14 felt the way she did. The Administrator stated they have already gotten two lunch bags and three more have been ordered.

Based on record review, resident and staff interviews, the facility failed to honor a resident's choice and provide showers as scheduled for 1 of 3 residents reviewed for choices (Resident #79). The findings included: Resident #79 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke). A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #79 was cognitively intact and required substantial/maximum assist with showers/baths. A review of Resident #79's active care plan updated 6/16/26 included a problem area of Activity of Daily Living (ADL) self-care performance deficit related to impaired mobility. Intervention included assistance with ADLs as needed. Review of active physician orders revealed Resident #79's shower days were scheduled for Wednesdays and Saturdays. Resident #79's Point of Care History for Type of Bath for the dates of 7/20/26- 8/18/26 were reviewed and documented the following: 7/22/26: Complete Bed Bath7/29/26: Complete Bed Bath8/1/26: Complete Bed Bath8/5/26: Complete Bed Bath8/12/26: Partial Bed Bath8/15/26: Complete Bed Bath An interview occurred with Resident #79 on 8/17/26 at 10:14 AM. She stated she had not received showers on her scheduled shower days of Wednesdays and Saturdays. She stated she was not sure who to ask about her showers. Resident #79 stated she received bed baths almost every day, depending on the nurse aide who was assigned to provide care. Resident #79 stated she had not received a shower since at least 7/20/26. On 8/19/26 at 9:20 AM, an interview was conducted with Nurse Aide (NA) #2 who was working with Resident #79 at the time of the interview. NA #2 indicated Resident #79 had not complained to NA #2 about not getting showers. NA #2 confirmed Resident #79's showers were scheduled on 1st shift on Wednesdays and Saturdays. An interview was held with NA #5 on 8/20/26 at 9:32 AM. NA #5 stated when she last worked with Resident #79 on Wednesday, 7/29/26 and Wednesday, 8/12/26, she gave Resident #79 a bed bath. She stated she did not give the resident a shower because Resident #79 was a 2-person assist with showers, and NA #5 did not have enough help to get the resident up for a shower, so she gave her bed baths. An interview with NA #7 on 8/20/26 at 10:16 AM revealed Resident #79 received a bed bath on Saturday, 8/1/26 because the unit had only one mechanical lift for the entire building and staffing was limited that day. NA #7 said they had 4 nurse aides on the hall instead of 5. She stated since Resident #79 required a two person assist, NA #7 explained the situation to the resident, who was agreeable to a bed bath. The NA stated that if another lift and additional staff had been available, Resident #79 would have been able to receive a shower. On 8/20/26 at 10:21 AM, NA #6 reported she had worked with Resident #79 on Saturday, 7/25/26, Wednesday, 8/5/26, and Saturday, 8/15/26, which were the resident's scheduled shower days. The NA stated there were four aides on the floor during those times and only one mechanical lift available (another lift was in the process of being repaired), so staff worked with limited resources. She stated staff communicated with Resident #79 when she could not receive a shower and needed a bed bath instead. NA #6 stated Resident #79 required a two person assist, and they had to make the most of what they had. A follow-up interview was held with Resident #79 on 8/20/26 at 11:44 AM. She reported that she felt concerned and overlooked when she did not receive her scheduled showers and described it as something that slipped through the cracks. Resident #79 stated she felt better about herself when she had a shower, and that bed baths did not always meet her needs. Resident #79 stated when nurse aides informed her she would receive a bed bath instead of a shower, she reminded them it was her shower day. She stated she was not okay with missing her showers because she wanted her hair washed and described herself as very persistent in wanting a shower. On 8/20/26 at 11:59 AM, an interview was completed with the Director of Nursing (DON). The DON stated she had not received any complaints about Resident #79 not getting her showers and that she should be getting them on her scheduled shower days. Interview with the Administrator on 8/21/26 at 6:30 PM indicated showers should be provided according to the resident's schedule for 2 times a week. The Administrator also stated that it was her expectation that staff have resources available to them to provide showers for residents.

Based on record review, resident interview, Resident Representative interview, staff interviews and Nurse Practitioner (NP) interview the facility failed to ensure a resident's code status information was consistent throughout the medical record and failed to completely fill out the MOST (Medical Orders for Scope of Treatment) form for 2 of 5 residents reviewed for advanced directives (Resident #102 and Resident #28).The findings included:1. Resident #102 was admitted to the facility on [DATE] with diagnoses that included acute on chronic systolic congestive heart failure.A review of Resident #102's physician orders revealed on order dated 11/12/25 for a full code (the use of all life-saving rescue efforts if a patient's heart stops). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #102 was moderately cognitively impaired. Review of Resident #102's electronic medical record revealed a MOST form that indicated the following directives: do not resuscitate, limited additional interventions, determine use or limitation of antibiotics when infection occurs, intravenous fluids for a defined trial period and no feeding tube. The MOST form was completed by Social Worker #1 on 7/10/26 and the form indicated Resident #102 Representative's name but was not signed by Resident #102's Representative. Nurse Practitioner #4 signed and dated the MOST form on 7/15/26 but did not list an effective date. An interview was conducted on 8/19/26 at 9:19 AM with Social Worker #1. She stated she spoke to Resident #102's Representative on 7/10/26 by phone and assisted him with completing a MOST form but was not aware that the representative's signature was required. Social Worker #1 indicated she completed the MOST form and either handed the form to Nurse Practitioner #4 or placed the form in the provider's folder to be signed but was not able to recall which occurred. Social Worker #1 indicated the process was once a MOST form was signed and dated by the provider then usually the Unit Managers would enter in the new orders into the electronic medical record. Social Worker #1 further explained once the orders were entered then the MOST form would be given to medical records to load into the electronic medical record. Social Worker #1 did not know why the order was not entered. Multiple attempts were made to interview Nurse Practitioner # 4 however attempts were not successful. An interview was conducted with Unit Manager #1 on 8/19/26 at 9:19 AM and she indicated she was not aware Resident #102's Representative had completed a MOST form. Unit Manager #1 indicated that the process was for the provider to review and sign any new MOST forms and then the Unit Managers would go through the provider's folder and enter in any new orders. Unit Manager #1 indicated she never received Resident #102's MOST form. A telephone interview was conducted with Resident #102's Representative on 8/19/26 at 3:09 PM. Resident #102's Representative indicated he spoke to Social Worker #1 by telephone on 7/10/26 and agreed to have a MOST form created on behalf of Resident #102. He indicated that he requested the MOST form to include a new order for do not resuscitate, limited additional interventions, determine use or limitation of antibiotics when infection occurs, intravenous fluids for defined trial period, and no feeding tube. Resident #102's Representative stated he gave verbal consent and was not asked by Social Worker #1 to come to sign the MOST form. An interview was conducted with the Director of Nursing on 8/21/26 at 11:26 AM. She indicated the process was once the provider signs and dates a MOST form the provider will leave the form for the Unit Managers to go through and then enter any new orders into the electronic medical record. The DON indicated she did not know why this occurred and that it was an oversight. An interview was conducted with the Administrator on 8/21/26 at 3:10 PM and she stated it was her expectation for all staff to follow the change in code status process, and she did not know why it was not followed.2. Resident # 28 was admitted to the facility on [DATE]. Resident #28's diagnoses included orthopedic surgery and neurocognitive disorder with Lewy bodies. Review of Resident #28's Electronic Medical Record (EMR) revealed a physician's order dated 10/8/25 for full code status.Review of Resident #28's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact. Review of Resident # 28's electronic medical record revealed a MOST form that was completed by Social Worker #1 and signed by Resident #28 which indicated the following directives: attempt resuscitation, full scope of treatment, antibiotics as needed, intravenous fluids if indicated, feeding tube long term if indicated. The MOST form was not signed or dated by the provider and did not note an effective date.An interview was conducted with Resident #28 on 8/21/26 at 10:05 AM and she indicated she did not recall when she met with Social Worker #1 to complete the MOST form but confirmed that the stated the directives about her wanting full resuscitative efforts were still correct. An interview was conducted with Social Worker #1 on 8/21/26 at 11:17 AM. She indicated she did not recall when she assisted Resident #28 in completing the MOST form and did not know why the form was not signed or dated by the provider. An interview was conducted with the Director of Nursing on 8/21/26 at 11:21 AM and she indicated she expected Social Worker #1 to give the provider the completed MOST form to be reviewed, signed, dated, and then the Unit Managers would usually enter in any new orders. The DON indicated she did not know why this was not done and felt it was an oversight. An interview was conducted with the Administrator on 8/21/26 at 3:08 PM. She stated she expected Social Worker #1 to have provided the completed MOST form to the provider for review and for the Unit Managers or someone from the nursing department to enter any new orders. She indicated

Based on record review and interviews with staff and resident's Responsible Party (RP), the facility failed to notify the resident's Responsible Party (RP) when Resident #44 received a PICC line (a peripherally inserted central catheter that is used to deliver medicines and other treatments directly to the large central veins near the heart) and intravenous (IV) antibiotics. This deficient practice occurred for 1 of 3 residents reviewed for notification of change (Resident #44).Findings included:Resident #44 was admitted on [DATE] with diagnoses which included cellulitis of right toe, non-pressure chronic ulcer of right foot, diabetes, adult failure to thrive, and severe vascular dementia.Review of Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had severely impaired cognition.Review of Resident #44's electronic health record revealed a physician order dated 3/24/26 received by the Wound Care Nurse for a PICC line to be placed for antibiotics. A second order with same date and receiver indicated the resident was to have vancomycin 1 gram mixed in 200 milliliters of 0.9% sodium chloride per her IV twice daily until 4/28/26.A review of the Vascular Services PICC worksheet noted Resident #44 had a PICC line placed in her right arm on 3/25/26 at 3:00 PM.Progress notes were reviewed from 3/23/26 through 3/26/25 and there was no documentation that Resident #44's RP was notified of the new orders or the placement of the PICC line.During an interview with Resident #44's RP on 8/17/26 at 4:20 PM he stated he was never notified that Resident #44 had received an order for a PICC line to be placed or to receive IV antibiotics. He stated he didn't find out about the PICC line being placed until a day after the PICC line was already placed in Resident #44's body and she had already received IV antibiotics. He further explained the way he found out a PICC line had been placed was because he came to visit her at noon on 3/25/26 and she did not have the PICC line. The next day (3/26/26) when he visited in the afternoon and saw the PICC line in her arm and an IV pole next to her bed with IV bags hanging on it. The RP stated he went and asked UM #2 what was going on with Resident #44 and she referred him to the Wound Care Nurse. He indicated the Wound Care Nurse explained to him what the PICC line and antibiotics were for, but he was still very upset that nobody had discussed it with him prior.An interview was conducted on 8/21/26 at 8:18 AM with UM #2. UM #2 stated she recalled that Resident #44's RP had approached her in the facility (she could not recall the specific date) and told her he did not know anything about the PICC line being ordered and placed in Resident #44. UM #2 stated she then explained the purpose of a PICC line to him and told him she would have the Wound Care Nurse talk with him. She stated she then sent the Wound Care Nurse to talk to him immediately. UM #2 stated normally the order for a PICC line would have been received and the RP would be called immediately with the update. She stated the Wound Care Nurse should have notified the RP.During an interview on 8/21/26 at 8:29 AM with the Wound Care Nurse, she revealed that she remembered doing rounds with the provider on 3/25/26 and received the order for Resident #44 to have a PICC line placed. She stated she was not the full-time Wound Care Nurse at that time, so she didn't think that it was her responsibility to notify the Responsible Party. After reviewing the order for the PICC line in the resident's electronic medical record, she confirmed she transcribed the order and she should have notified the Responsible Party when she received the order. The Wound Care Nurse further explained that she had made a few changes with her nursing roles at the facility and when that had occurred it was a busy time for her. An interview with the Director of Nursing (DON) was conducted on 8/21/26 at 9:07 AM. The DON stated it was expected that the nurse who received the order would notify a resident's Responsible Party as soon as possible after receiving new orders like a PICC line placement and IV antibiotics. She stated Resident #44's RP should have been notified right away by the nurse who received the order. An interview was conducted with the Administrator on 8/21/26 at 10:00 AM. The Administrator stated she would have expected Resident #44's RP to have been notified immediately after the Wound Care Nurse received the order for the PICC line and IV antibiotics.

Based on observation, staff interviews, and review of the facility maintenance log, the facility failed to maintain ceiling tiles in good repair for 1 of 9 resident rooms (Resident #94) in 1 of 2 halls reviewed for homelike environment. (Hall #2). The findings included: An initial observation completed on 8/18/26 at 12:46 PM of Resident #94's room revealed brown- and rust-colored rings on the ceiling tile above Resident #94's bed An additional observation completed on 8/19/26 10:02 AM revealed the brown- and rust-colored rings remained on the ceiling tiles in Resident #94's room. Review of maintenance log was completed from 6/1/26 to 8/18/26, and no maintenance requests were completed during this time regarding Resident #94's room. Review of look back documentation for room inspections completed by the Maintenance Director on 6/25/26 indicated all resident rooms were inspected with no concerns noted regarding Resident 94's room. An interview was conducted with the Maintenance Director on 8/19/26 at10:06 AM and he revealed he completed the last quarterly inspection of all resident rooms which included checking the ceilings on 6/25/26 and was not aware of any current roofing concerns. The Maintenance Director indicated he did not observe any rooms at that time or any time since the inspection had brown- and rust-colored rings on the ceiling tiles and did not receive any maintenance requests from staff regarding this issue. An interview was conducted with Nurse # 2 on 8/20/26 at 3:03 PM and she indicated she had not noticed any brown- and rust-colored rings on the ceilings and if she had noticed anything she would have reported the concern to the Maintenance Director for follow up. An interview was conducted with Unit Manager #1 on 8/20/26 at 2:55 PM and she indicated that she had not seen any brown- and rust- colored rings on the ceilings. She stated if she had any observed maintenance concerns she would report them to the Maintenance Director. An interview was conducted with the Administrator on 8/21/26 at 3:17 PM and she indicated she expected the Maintenance Director to identify and address any maintenance needs within the facility either by inspections or by staff notification.

Based on record review and interviews with staff, Pharmacy Consultant, Nurse Practitioner, and Medical Director, the facility failed to ensure a resident's medication order for an as needed psychotropic medication had a stop date of 14 days for 1 of 5 residents reviewed for unnecessary medications (Resident #5). Findings included:Resident #5 was admitted to the facility on [DATE] with diagnoses that included anxiety.Resident #5's quarterly Minimum Data Set, dated [DATE] showed she had moderate cognitive impairment, received a high-risk antianxiety medication, and received hospice care. Resident #5's care plan dated 7/8/2026 identified the use of psychotropic medications and included interventions for education regarding the risks, benefits and side effects of psychotropic medications, as well as monitoring and documenting for behaviors and adverse reactions.Review of Resident #5's orders revealed an order initiated by Unit Manager #2 on 7/8/2026 ordered verbally by the Medical Director for lorazepam (a benzodiazepine medication used to relieve anxiety) 0.5 milligrams (mg) every 4 hours as needed for anxiety and restlessness. There was no stop date.Review of Resident #5's July 2026 Medication Administration Record (MAR) showed lorazepam 0.5mg was administered once on 7/11/2026, 7/15/2026, 7/16/2026, and 7/25/2026.Review of the monthly Medication Regimen Review (MRR) completed by the Pharmacist on 7/17/2026 showed a recommendation that stated to add a stop date for psychotropic medications regarding the lorazepam 0.5mg every 4 hours as needed. The Pharmacist also noted that hospice orders were not exempt.Review of Resident #5's August 2026 MAR on 8/19/2026 at 1:36PM showed lorazepam 0.5mg was administered twice on 8/2/2026, 8/5/2026; and once on 8/8/2026, 8/9/2026, 8/10/2026, 8/13/2026, 8/14/2026, and 8/17/2026.Review of the monthly MRR completed by the Pharmacist on 8/15/2026 showed another pharmacy recommendation that stated to add a stop date for psychotropic medications that regarded the lorazepam 0.5mg every 4 hours as needed order. The Pharmacist also noted that hospice orders were not exempt.Review of Resident #5's orders revealed the order initiated on 7/8/2026 for 0.5mg every 4 hours as needed for anxiety and restlessness was discontinued on 8/19/2026.Review of Resident #5's orders revealed an active order initiated by the Director of Nursing (DON) on 8/19/2026 at 7:46PM ordered verbally by the Medical Director for lorazepam 0.5mg every 4 hours as needed for anxiety and restlessness. There was no stop date, and the order was open ended. An interview was conducted with Unit Manager #2 on 8/20/2026 at 2:00PM with the assistant DON present. Unit Manager #2 stated that as needed orders for lorazepam needed a stop date. The orders could have been extended beyond fourteen days if the provider provided documentation. Unit Manager #2 stated that the providers would normally document the rational to continue beyond fourteen days in their progress note.An interview with Nurse Practitioner (NP) #1 on 8/19/2026 at 2:00PM was conducted to inquire why the lorazepam as needed order for Resident #5 did not have a stop. NP #1 stated he would always put a stop date on a lorazepam as needed order even if the resident was a hospice resident.A phone interview with NP #2 was conducted on 8/21/2026 at 8:23AM and a discussion occurred about as needed psychotropic medications. NP #2 stated she was aware of the regulation that psychotropics need a stop date for as needed orders. NP #2 could not speak to why Resident #5's lorazepam as needed order did not have a stop date.The Consultant Pharmacist was contacted for a phone interview on 8/20/2026 at 2:17PM. The Consultant Pharmacist confirmed that there should have been a stop date on as needed psychotropic medications, including lorazepam and hospice residents. The Pharmacist confirmed she sent a pharmacist recommendation to the providers about Resident #5's lorazepam order in July 2026 and August 2026 for lorazepam as needed not containing a stop date.An interview was conducted with the Director of Nursing (DON) on 8/20/2026 at 3:10PM with Unit Manager #2 and the Assistant DON present. During the interview, the DON stated psychotropic as needed medication orders required a stop date and should not go beyond fourteen days unless the provider added a reason. The DON stated the reason would have been in the residents' notes. The DON was unsure why Resident #5 did not have a stop date.The Medical Director in a phone interview on 8/20/2026 at 3:15PM stated that based on the regulations lorazepam as needed orders should have a stop date. The Medical Director stated that any time he writes an as needed psychotropic order he would do a two-week stop date with a note to reevaluate. He would add rationale for longer than fourteen days as needed psychotropic orders in the progress notes. He does not think hospice residents would follow this regulation. The Medical Director, after hearing the Consultant Pharmacist's 7/17/2026 recommendation, then understood why Resident #5 would need a stop date.An interview with the Administrator was conducted on 8/20/2026 at 4:08PM. The Administrator stated that it was probably human error that Resident #5 did not have a stop date on the lorazepam as needed order.

Based on observation, record review, staff interviews and resident interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of tobacco use for 1 of 3 residents reviewed for smoking (Resident #7). The Findings Included;Resident #7 was admitted to the facility on [DATE] with diagnoses that included contracture of right hand.Review of admission Observation Report dated 7/9/26 revealed Resident #7 was noted to smoke cigarettes, did not want to participate in a cessation program and was assessed to be a safe smoker.Review of the most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact and was not a tobacco user. Resident #7's care plan completed on 7/23/26 by MDS Nurse #1 did not include any identified problems or interventions related to smoking.An observation was conducted on 8/17/26 at 9:46 AM of Resident #7 in the designated smoking area smoking a cigarette safely.An interview was conducted with Resident #7 on 8/17/26 at 9:47 AM, and she indicated that she had been smoking at the facility every day since her admission.An interview was conducted with MDS Nurse #1 on 8/20/26 at10:40 AM. She indicated that she completed Resident #7's admission MDS assessment on 7/15/26, and she was not aware at that time that Resident #7 was a smoker. MDS Nurse #1 further stated that prior to completing the health conditions section of the admission MDS assessment she reviewed the residents admission Observation Report to see if a resident was noted to be a current tobacco user or not. MDS Nurse #1 stated that she had thought Resident #7's report indicated she was not a tobacco user and therefore had not coded Resident #7 as a current tobacco user. MDS Nurse #1 felt this had been an oversight.An interview was conducted with the Administrator on 8/21/26 at 3:18 PM. The Administrator indicated Resident #7's admission MDS assessment dated [DATE] should have been coded to accurately reflect the resident's smoking status.

Based on staff interviews, Nurse Practitioner interview, Resident Representative interview and record review, the facility failed to enter a provider's verbal order in the medical record for a nicotine patch (adhesive skin patch that delivers a controlled dose of nicotine through the skin to help people quit smoking) for a resident who expressed a desire to quit smoking tobacco. This occurred for 1 of 3 residents reviewed for smoking (Resident #10). Findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses that included hemiplegia affective left dominant side.Review of the smoking assessment completed by Unit Manger #2 on 6/19/26 indicated Resident #10 was assessed to be a safe smoker.Review of the most recent quarterly Minimum Data Set assessment dated [DATE] revealed Resident #10 was moderately cognitively impaired. Review of Resident #10's care plan that was revised on 6/30/26 revealed a smoking care plan that indicated Resident #10 was a smoker. Review of progress note dated 8/7/26 by Unit Manger #2 indicated Resident #10 stated he wanted to stop smoking, a new order for nicotine patch was obtained and the resident representative was notified.Review of progress note dated 8/13/26 by Unit Manager #2 indicated Resident #10 continued to be smoke free at that time.A review of Resident #10's physician orders from 8/7/26-8/17/26 revealed no order for a nicotine patch.A review of the August 2026 Medication Administration Record (MAR) was completed and found no order was listed on the MAR or documented that a nicotine patch had been applied to Resident #10. An interview was conducted with Unit Manager #2 on 8/19/26 at 9:34 AM and she indicated that on 8/7/26 Resident #10 made her aware that he wanted to be discharged to another facility that was smoke free and wanted to try to stop smoking. Resident #10 then asked for a nicotine patch. Unit Manager #2 further revealed that she contacted Nurse Practitioner #2 on 8/7/26 and received a verbal order for a nicotine patch to be applied topically every day. Unit Manager #2 indicated that she removed Resident #10's cigarettes from the nurse's cart and locked them in the Unit Manager's office. Unit Manager #2 stated she applied the nicotine patch each day to Resident #10 from 8/7/26-8/16/26. Unit Manager #2 revealed the morning of 8/17/26 Resident #10 told her that he no longer wished to stop smoking and therefore the patch had not been applied since 8/16/26. Unit Manger #2 stated she thought she had entered the order for the nicotine patch into the electronic medical record when she received the order from Nurse Practitioner #2 and did not know why this was missed.A telephone interview was conducted with Nurse Practitioner #2 on 8/19/26 at 12:01 PM and she indicated that she recalled Unit Manager #2 contacted her to request an order for nicotine patch for Resident #10 and she gave the order as requested. She further revealed that she was not aware that the order had not been entered into the electronic medical record.An interview was conducted with the Director of Nursing on 8/18/26 at 3:24 PM and she indicated that the process when a verbal order was received from a provider was for the nurse to contact the Resident Representative to make them aware and then for the nurse to enter the order into the electronic medical record. The DON indicated Unit Manager #2 should have entered in the order for a nicotine patch for Resident #10 and felt that this was an oversight.A telephone interview was conducted on 8/19/26 at 11:43 AM with Resident #10's Representative. The Resident Representative indicated Unit Manager #2 notified her on 8/3/26 that Resident #10 wanted to stop smoking and that an order had been given for a nicotine patch.An interview was conducted with the Administrator on 8/18/26 at 3:36 PM and she stated Unit Manager #2 should have entered the order for Resident #10's nicotine patch when it was ordered by the provider and felt this was an oversight.

Based on observations, staff interviews and record reviews, the facility to ensure the smoking policy was implemented for 2 of 6 residents reviewed for accidents when a resident who was identified with a decline in condition did not have a new smoking assessment completed (Resident #10) and a known smoker had no smoking assessment completed (Resident #54).The Findings Included: Review of the facility's current smoking policy, undated, revealed the following: On admission residents who desire to smoke will have a smoking assessment completed. The care plan will be reviewed by the interdisciplinary team quarterly and as needed with any change in condition that impacts the residents' ability to safely smoke. 1. Resident #10 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (severe or complete loss of motor function one side of the body that is affected) affective left dominant side, personal history of traumatic brain injury, and contracture of the left hand. Review of the most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was a tobacco user. Review of the smoking assessment completed by Unit Manager #2 on 6/19/26 indicated Resident #10 was assessed to be a safe smoker. An interview was conducted with Unit Manager #2 on 8/17/26 at 9:58 AM and she indicated that the process for evaluating residents for safe smoking was for the admitting nurse to complete the initial smoking assessment upon admission then the Unit Managers were responsible for completing smoking assessments every quarter or as needed. She explained that if a resident showed a decline or a change in any area that might affect their ability to smoke then the Unit Manager would reevaluate the resident to determine if they were still safe to smoke independently. Unit Manager #2 indicated she completed Resident #10's most recent smoking assessment on 6/19/26 and he was assessed to be able to smoke without staff supervision. Unit Manager #2 further revealed that during the smoking assessment Resident #10 was able to manage his cigarettes safely and was not aware of any smoking related safety concerns at that time. Review of a request for therapy evaluation form initiated on 6/24/26 revealed the Director of Nursing (DON) referred Resident #10 for an evaluation due to a recent decline in self-care and positioning needs. The evaluation noted Resident #10 refused the evaluation. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was moderately cognitively impaired, had impaired vision, was dependent on staff for transfers and had an impairment on one side of the upper and the lower extremities. Review of the care plan revised on 6/30/26 revealed Resident #10 was assessed to be a safe smoker. Interventions included staff to complete a safe smoking evaluation on admission, quarterly and as needed. An observation was conducted on 8/17/26 at 9:42 AM of the facility's designated smoking area. During the observation Resident #10 was observed smoking a cigarette with no staff members present at that time. Resident #10 was observed holding a cigarette in his right hand while sitting in his wheelchair and was not wearing a smoking apron. Resident #10 was observed leaning to his left side against the left arm rest of his wheelchair . Resident #10's right arm was observed crossed over both of his legs and dangling down next to the outside of his lower left leg. During the observation Resident #10 dropped cigarette ashes on his left pant leg and did not attempt to remove the ashes at that time. There were no visible holes in Resident #10's clothing. An interview was attempted on 8/17/26 at 9:45 AM with Resident #10; however he was not able to provide appropriate answers due to his cognition. On 8/17/26 at 10:34 AM an additional smoking observation was conducted on Resident #10 with Unit Manger #2 present. During this observation Resident #10 was observed dropping cigarette ashes on the lower part of his right pant leg . During this observation Resident #10 was also observed constantly locking and unlocking his wheelchair brakes. There were no visible holes in Resident #10's clothing. A follow up interview was conducted with Unit Manager #2 on 8/17/26 at 10:56 AM. Unit Manager #2 indicated that during the observation Resident #10 was more distracted than he was during the previous smoking assessment on 6/19/26. She stated she was not aware of any changes or decline in condition prior to the observation. Unit Manager #2 indicated that Resident #10 was unable to manage his cigarette ashes safely and he would require staff supervision and the use of a smoking apron. An interview was conducted with the Director of Nursing on 8/21/26 at 11:44 AM and indicated that she had just started her position at the beginning of June 2026 when she requested a therapy evaluation for Resident #10. The DON indicated she had concerns regarding Resident #10's hand contracture and his positioning as he leaned very far to his left while sitting in wheelchair. The DON indicated she was not sure if Resident #10 had a decline, however she was concerned about how far he leaned to his left while in the wheelchair. She further revealed that she was not aware that Resident #10 was considered a safe smoker and felt that due to his poor positioning in the wheelchair he should have already been assessed to be a supervised smoker. An interview was conducted with the Administrator on 8/21/26 at 3:13 PM. The Administrator explained the morning meetings with department heads and unit managers were used to inform the staff of any changes in residents' conditions which would include referrals to therapy. The Administrator stated she was aware that Resident #10 had been referred to therapy for an evaluation due to positioning concerns and concerns regarding his right-hand contracture. The Administrator indicated that the smoking assessments are to be completed by the Unit Managers on admission, quarterly and as needed and she felt that a referral to therapy due to positioning concerns should have prompted the Unit Manager #2 to reassess Resident #10 to make sure he was still able to safely smoke without supervision. 2. Resident #54 was admitted on [DATE] with diagnoses that included nicotine dependence and cigarettes uncomplicated. A review of the admission assessment dated [DATE] completed by Unit Manager #1 documented Resident #54 as a non-smoker. The admission 5-day Minimum Data Set (MDS) dated [DATE] indicated Resident #54 was cognitively intact, had no upper or lower body impairment with range of motion, and did not use tobacco. A review of the facility's smokers list on 8/17/2026 included Resident #54. Resident #54's medical record 8/17/2026 revealed no care plan related to smoking. On 8/17/2026 at 10:53 AM Resident #54 was observed asking the Director of Nursing (DON) if he had cigarettes and the DON stated she thought she had a pack of his cigarettes in her office. An interview and observation with Resident #54 was completed on 8/18/2026 at 9:54 AM. Resident #54 was observed pulling a cigarette out of his pocket. He asked another resident that was smoking for a lighter and Resident #54 was able to light his own cigarette. The resident denied having cigarettes in his room and stated he had to ask the nurse for them when he wanted to smoke. Resident #54 stated his cigarettes were kept locked in the medication cart. Resident #54 denied needing to use a smoking apron. He stated he did not have any restrictions with his smoking. During the interview Resident #54 was observed to hold the cigarette in his hand away from himself and others and disposed of ashes and his cigarette with no safety concerns. Resident #54 stated he has always smoked. An interview on 8/19/2026 at 8:32 AM was completed with Unit Manager #1. She stated that she had worked with Resident #54 previously in other facilities and Resident #54 had always been a smoker. Unit Manager #1 stated in the first week of admission Resident #54 was unable to get out of bed to smoke. Unit Manager #1 was unable to recall the exact date that Resident #54 started smoking, the date that cigarettes for Resident #54 were brought into the facility, or when they started being kept in the nursing cart. When Unit Manager #1 was asked if a smoking assessment had been completed for Resident #54 she indicated that an assessment had been completed. The Surveyor informed Unit Manager #1 the smoking assessment was unable to be located in the medical record. Unti Manager #1 explained that due to a limitation with the Surveyor's viewing access of the electronic medical record the smoking assessments were not able to be seen by the Surveyors; however, she indicated she would provide a hard copy of the smoking assessment. A second interview with Unit Manager #1 was completed on 8/19/2026 at 9:45 AM. She provided a hard copy smoking assessment for Resident #54 with an event date of 8/17/2026 at 11:33 AM and a completion date of 8/19/2026 at 9:28 AM. The assessment indicated he was a safe smoker and required no supervision. Unit Manager #1 stated she was unaware of why a smoking assessment was not completed previously. She stated that a smoking assessment should have been completed at the time Resident #54 started requesting to smoke. Unit Manager #1 indicated that Resident #54 should have had a smoking assessment completed before being allowed to smoke. The Director of Nursing (DON) was interviewed on 08/19/2026 at10:51 AM. The DON stated a smoking assessment was usually done on admission. She stated the smoking assessment was to observe to see if a resident was safe with smoking or needed supervision while smoking. She stated then a care plan was created for a safe smoker or unsafe smoker. The DON stated she could not recall the exact date Resident #54 started smoking. She stated it was not at the time of admission but sometime after admission. The DON stated the designated smoking area was always monitored by an assigned staff member. The DON stated it was important to complete a smoking assessment, so staff were aware of safety concerns with a resident who smoked. The DON was unable to explain why a smoking assessment had not been completed when Resident #54 started smoking at the facility. She stated that a smoking assessment should have been completed when cigarettes were brought to the facility and were locked in the hall medicine cart. The DON stated once the smoking assessment was completed the care plan should have been updated for Resident #54 being a tobacco user. The DON was not able to provide explanation for why this was not done. The Administrator was interviewed on 8/20/2026 at 4:22 PM. The Administrator stated when Resident #54 was admitted to the facility he was unable to smoke due to his medical condition. She explained that he was always in bed when he was first admitted to facility. The Administrator stated it was not until recently that Resident #54 was able to go out to smoke. The Administrator was unaware of what date Resident #54 started smoking. She stated she had a history of working with Resident #54 in other long term care settings and she knew he had a history of smoking. She reported that they should have followed their policy and when he started smoking and a smoking assessment should have been completed for his safety. The Administrator stated a smoking assessment should have been completed at the time the nurses began keeping the cigarettes locked in the hall medicine cart and providing them to Resident #54. The Administrator stated his care plan should have been updated when Resident #54 started smoking.

Based on observations, record review and staff interviews, the facility failed to ensure ordered weights were obtained for 1 of 3 residents reviewed for weights (Resident #8). The findings included:A review of hospital discharge physician orders for Resident #8 dated 6/12/26 revealed a recommendation for daily weights related to diagnosis of liver failure with ascites (abnormal buildup of excess fluid inside the abdomen). The hospital Discharge summary dated [DATE] noted Resident # 8's most recent hospital weight was 179 pounds. Resident # 8 was admitted to the facility on [DATE] with diagnoses that included liver disease with ascites and muscle weakness with neuropathy (dysfunction of the nerves). The admission Minimum Data Set assessment for Resident #8 dated 6/18/26 revealed Resident #8 was cognitively intact with a diagnosis of medically complex cirrhosis (liver disease), malnutrition. The MDS indicated that the resident was independent with eating after meal tray set up, her weight was 179 pounds and had no chewing or dental problems. The MDS indicated Resident #8 had a weight loss in last 6 months not on a physician-prescribed program.A care plan dated 6/22/26 was in place indicating Resident #8 was at-risk for nutritional decline and altered weight. The care plan goal was to maintain a weight +/-3% of currentweight. The care plan interventions included weighing the resident per facility guidelines and informing the physician, physician's assistant, and family of weight gain or loss. A review of the facility physician orders for Resident #8 showed there was an order dated 6/12/26 for a weight on admission and an order dated 6/19/26 for a weekly weight for 2 weeks transcribed to the Medication Administration Record (MAR). Additionally, there were physician orders dated 6/12/26 for furosemide and spironolactone (medications to help eliminate extra fluid).A review of Resident #8's electronic medical chart revealed an admission weight on 6/12/26 of 179 pounds entered in the vital signs section by Minimum Data Set (MDS) Coordinator #2.An interview was conducted with MDS Coordinator #2 on 8/21/26 at 10:02 AM who confirmed he had entered the weight of 179 pounds for Resident #8 on 6/12/26 into the vital signs section of Resident #8's electronic medical record. He shared that the facility had not obtained a weight at the time, so he put the weight obtained on 6/11/26 per the hospital discharge summary as a placeholder for the initial MDS. MDS Coordinator #2 shared that when he must use the hospital weight, he shares this in the facility Clinical Meeting the following day and informs the team that a facility weight is needed. He confirmed that he had communicated this to the facility clinical staff on 6/13/26 and did not know why the facility did not obtain an admission weight.Review of Resident #8's electronic medical chart revealed there were no weights recorded for the period of 6/13/26 through 7/6/26 in the vital signs section or MAR. Resident #8's electronic medical record revealed a documented weight on 7/7/26 of 170.2 pounds. (This represented a 4. 9 % weight loss based on admission weight). The medical record contained a system alert next to the weight that stated, value is out of range from previous weight.Further review of Resident #8's electronic medical chart revealed there were no weights recorded for the period of 7/8/26 through 8/20/26 in the vital signs section or MAR. An interview with Unit Manager #1 was conducted on 8/21/26 at 11:00 AM. She shared that when obtaining a resident's weight if there was a 3 or more pounds difference from the last weight the facility policy required the resident to be immediately reweighed and that weight would be recorded in the chart and the Director of Nursing would be notified. She confirmed that monthly weights for August had been completed. Unit Manager #1 stated she had entered the weight into the electronic medical record for Resident #8 on 7/7/26 but did not notice the system alert that indicated the weight was out of range from the previous weight. She further stated she had not compared the admission weight of 179 pounds on 6/12/26 with the weight of 170.2 pounds obtained on 7/7/26. Unit Manager #1 stated she should have reweighed the resident immediately since there was a 9-pound loss and she must have been busy and overlooked it. The Unit Manager explained she could not account for why the weekly weights for the first two weeks after admission and the monthly weights for August were not obtained for Resident #8. She confirmed Resident #8 had been weighed using the same scale for the weights obtained on 7/07/26 and 8/21/26. Unit Manager #1 shared that weights are not recorded in a log; the nurse documents the weight obtained by the Nurse Aide (NA) directly on the MAR. Additionally she shared that the facility does not have a weight team. When the order for a weight is on the MAR, the nurse communicates to the NA to obtain a weight and then records the reported weight in the resident's electronic chart.An observation was conducted on 8/21/26 at 1:32 PM in which Resident #8 was weighed by NA #9 using the hydraulic lift scale. After the lift was tared (to set the weight at 0.0 pounds despite the weight of the sling) for the lifting sling by the NA, the resident's weight read to be 158.6 pounds on the digital panel on the lift. This represented a 6.82% weight loss from the previous weight recorded on 7/07/26 of 170.2 pounds. NA #9 and Unit Manager #1 confirmed this was the same scale used to obtain the weight on 7/07/26. An interview was conducted on 8/21/26 at 1:40 PM with NA #9 who stated nurse aides are told each day by the nurse which residents require a weight and if the resident should be weighed in their wheelchair on the wheelchair scale or with the digital scale on the hydraulic lift. NA #9 shared that the facility only has one hydraulic lift scale. He stated that he immediately told the nurse after he obtained weights for residents. NA #9 further shared he had used the hydraulic lift scale to weight Resident #8 on 8/21/26 as directed by the nurse. The Director of Nursing (DON) was interviewed on 8/21/26 at 12:05 PM. She shared that the facility policy for obtaining routine weights was on admission, twice weekly for two weeks, then monthly on the 5th day of each month. The DON said during the morning clinical meeting the clinical team discussed if there were any concerns about a resident losing weight, not eating, or showing decline and if there were any concerns she notified the RD to see the resident. The DON indicated Unit Manager # 1 helped oversee the weekly weights.

Based on observation, record review, staff interviews and Medical Director interview, the facility failed to provide a way for nursing staff to measure the head of bed elevation for residents receiving tube feedings. In addition staff was unable to ensure the head of residents beds were elevated at least 30 degrees according to physician orders for 1 of 2 residents reviewed for tube feeding (Resident's #78's). The findings included:Resident #78 was admitted to the facility on [DATE] with diagnosis that included cerebral infarction (stroke), dysphagia (difficulty swallowing), and gastro-esophageal reflux.Review of Resident #78's physician orders revealed an order for Glucerna 1.5 (an enteral feeding) with a flow rate of 70 milliliters for 21 hours with start date of 6/25/26 written by the Medical Director. The physician orders also revealed an order for elevate the head of the bed at least 30 degrees every shift day and night with a start date of 6/25/26 written by the Medical Director. Resident #78's comprehensive Minimum Data Set (MDS) dated on 7/9/26 revealed he was severely cognitively impaired. The MDS indicated Resident #78 was coded as dependent for rolling left to right, chair/bed-to-chair transfer, tub/shower transfer, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing , lower body dressing, putting on and taking of footwear, and personal hygiene. Resident #78 was coded not applicable for sit to lying, lying to sitting on side of bed, sit to stand, toilet transfer and eating. The MDS also indicated Resident #78 was coded for a feeding tube. Resident #78's care plan last revised on 7/13/26 indicated a potential for complications secondary to using a feeding tube. The interventions included keep head of the bed elevated at least 30 degrees while tube feeding is infusing. An observation was conducted on 8/18/26 at 1:20 PM of Resident #78 in bed lying on his back. Resident #78 appeared to be positioned, with his head and chest almost level with the trunk his body. A slight angle was observed at the head of Resident #78's bed. Resident #78's tube feeding was infusing at the time of the observation. An interview/observation was conducted on 8/18/26 at 1:25 PM with Nurse #1. Nurse #1 was assigned to Resident #78 at the time of the observation. Nurse #1 stated she had started working at the facility in June 2026. Nurse #1 stated that she started Resident #78's tube feeding at 10:00 AM. Nurse #1 observed the head Resident #78's bed and turned his tube feeding off. Nurse #1 reached for Resident #78's bed remote, when she was stopped by the surveyor. Nurse #1 stated that the head of the bed was too low and needed to be raised. Nurse #1 stated when she left out of the room at 10:00 AM, the head of the bed was elevated above 30 degrees. Nurse #1 indicated that Medication Aide (MA) #1 must have given him a bath or changed him and moved the head of the bed. Nurse #1 stated the head of the bed was lower than it was when she left out of Resident #78's room at 10:00 AM. When Nurse #1 was asked how she knew the head of the bed was above 30 degrees when she left the room at 10:00 AM , she indicated that she could tell by looking at the head of the bed. Nurse #1 indicated when she provided care for Resident #78, she determined the level of the head of the bed by eyeballing it. When Nurse #1 was asked what she meant by eyeballing it, she indicated she just looked at head of the bed with her eyes. An interview/observation was conducted on 8/18/26 at 1:30 PM. The Director of Nursing (DON) in the presence of Nurse #1 went to observe the head of Resident #78's bed with the surveyor. The DON went into Resident #78's room and reached for the remote for the bed and was stopped by the surveyor. The DON stated the head of the bed was positioned too low. When the DON was asked how she knew the head of the bed was too low, she stated she just eyeballed it. When the DON asked what degree the head of the bed was positioned at, she indicated about 28 degrees. When the DON was asked if there was a way for staff to determine the actual degree of the head of the bed, she indicated there no other way that she was aware of. The DON stated she could find out and left out of Resident #78's room. The DON returned to Resident #78's room and stated that maintenance was on the way. An interview/observation was conducted on 8/18/26 at 1:35 PM with Medication Aide (MA) #2. The MA #2 walked in Resident #78's room to provide care. When MA #2 was asked if she had provided any care for the resident that day, she indicated no. She stated she had not been able to groom or provide incontinence care for Resident #76 during her shift. When MA #2 was asked if she had repositioned #78's bed during her shift, she stated no. An interview/observation was conducted on 8/18/26 at 1:38 PM in Resident #78's room with the Assistant Director of Nursing (ADON). The ADON stated she started working at the facility June 2026. When the ADON was asked how she determined the level of the head for Resident #78's bed, she stated I just eyeballed it.An interview/observation was conducted on 8/18/26 at 1:40 PM with Unit Manager (UM) #2 and the Maintenance Director. Nurse #1, the ADON, and MA # 2 had left out of Resident 78's room at that time. The Maintenance Director stated he could use an app on his cellphone to determine the degree of Resident #78's head of the bed. The Maintenance Director placed his phone on the head of the bed in the presence of the DON, UM #2, and the surveyor. The Maintenance Director positioned the phone at three places on Resident #78's bed that indicated measurement less than 30 degrees. One position indicated 27.3 degrees, the second position indicated 20.1, and the third position indicated 20.1 degrees. The head of Resident #78's bed was elevated by the DON. Resident #78 was positioned at an angle where his head and chest were elevated above the trunk of his body at the conclusion of the observation.An interview was conducted on 8/18/26 at 1:45 PM with UM #2. UM #2 stated she had been the unit manager since she came back a little over 2 years ago. She stated there was no other method for the staff to measure the degree of Resident #78's head of the bed. UM #2 stated the only way nursing staff could measure the degree of the bed was to eyeball it.Review of a progress noted written on 8/18/26 at 4:30 PM by the Medical Director had been asked to assess Resident #78 for possible aspiration issues. The Medical Director indicated Resident #78 showed no sign of distress while lying in bed. The Medical Director indicated that no signs of coughing, shortness of breath or aspiration were observed during his assessment. He further indicated that Resident #78's lung sounds were clear.An observation was conducted on 8/18/26 at 5:20 PM of Resident #78 lying in bed. There was definite angle in Resident #78's body where his chest and head appeared to be higher than the trunk of his body.An interview was conducted on 8/18/26 at 5:25 PM with the DON. The DON was asked if the head of Resident #78's bed could be measured by maintenance to confirm the head of the bed was elevated above 30 degrees, she stated yes.An interview was conducted on 8/18/26 at 5:45 PM with the Maintenance Director. The Maintenance Director stated he would not be able to measure the bed using the app on his phone. The Maintenance Director indicated that management instructed him not to measure the head of the Resident 78's bed using his phone.An interview/observation was conducted on 8/18/26 at 5:48 PM with the DON in the presence of the UM #2. The DON was asked was it any way that the head of Resident #78's bed could be measured to ensure that he was in a safe position. The DON stated that the facility had ordered a device to put on the bed that would indicate the level the head of the bed. She stated that the device would not be available until 8/21/26. The DON was asked was she indicating that it was no way to measure the head of the bed at that time, she indicated no. During the interview the Maintenance Director brought a level that could measure the degree of the beds. The DON, UM #2, Maintenance Director, and writer went to Resident #78's room. The head of Resident #78's bed was elevated until it reached 30 degrees. UM #2 confirmed that the head of the bed was at 30 degrees.An interview was conducted on 8/18/26 at 2:57 PM with the Medical Director. The Medical Director that he usually followed the recommendation of the hospital when a resident is discharged . The Medical Director was asked the significance of keeping the head of the bed elevated above 30 degrees during tube feeding. The Medical Director indicated that it could put a resident at a lower risk aspiration, acid reflux, nausea and vomiting. When the Medical Director was informed of the observation that was made of Resident #78's head of the bed being positioned below 30 degrees, he asked was Resident #78 lying flat. The Medical Director stated that key factor was that the bed was not lying flat. When asked if the actions of Nurse #1 could have had negative affect on Resident #78, he repeated was the bed flat? An interview was conducted on 8/21/26 at 4:56 PM with the Administrator. The Administrator indicated she would expect staff to provide care according to physician orders.

Based on observations, record review, staff interviews and Medical Director interview, the facility failed to provide tracheostomy (a hole surgeons make through the front of the neck and into the windpipe, also known as the trachea) care consistent with professional standards of practice for 1 of 1 resident observed for tracheostomy care (Resident #9). In addition, the facility administered supplemental oxygen for 5 days without a physician order for 1 of 3 residents investigated for oxygen therapy (Resident #126). The findings included: 1. Resident #9 was admitted to the facility on [DATE] with diagnosis that included anoxic brain damage (a medical condition that happens when the brain is completely cut off from its supply of oxygen) and respiratory failure. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9's cognitive skills for daily decision making were severely impaired. The MDS further revealed Resident #9 was coded for oxygen therapy and tracheostomy care. Resident #9 had care plan with a revision date of 7/7/26 that indicated Resident #9 had the potential for complications related to tracheostomy anoxic brain injury and acute respiratory failure. The care interventions included provide tracheostomy care per policy and change ties, suction the tracheostomy as ordered by physician, and use universal principles of infection control and universal/standard precautions. The care plan further indicted Resident #9 required enhance barrier precaution related to tracheotomy. The interventions included attempt to maintain environmental cleanliness, disinfect high touch surfaces, and wear personal protective equipment as indicated. An observation was conducted of tracheostomy care for Resident #9 on 8/20/26 at 11:02 AM. The tracheostomy care was completed by Nurse #6, and the Infection Control Preventionist/Staff Development Coordinator (ICP/SDC). Nurse #6 was observed performing hand hygiene and applying a pair of clean disposable gloves. Nurse #6 then removed Resident #9's disposable inner cannula with her left hand and threw it in the waste basket. Nurse #6 then opened a rigid oral suction tip. She then connected the rigid oral suction tip to the tubing attached to the suction machine sitting on Resident #9's overbed table. Nurse #6 turned towards Resident #9. Nurse #6 then attempted to suction secretions from Resident #9's tracheostomy opening using the rigid oral suction tip. The rigid oral suction tip was too large to safely fit the tracheostomy stoma. After multiple attempts Nurse #6 was unable to remove any secretions using the rigid oral suction tip. The ICP/SDC was observed opening a flexible suction catheter package towards Nurse #6. Nurse #6 then removed the rigid oral suction tip and placed it back in its original packaging. Nurse #6 took the flexible suction catheter from the ICP/SDC and attached it to the tubing. Nurse #6 then suctioned Resident #9 using the flexible suction catheter. Nurse #6 then removed the dirty disposable gloves and threw them in the wastebasket. Nurse #6 did not perform hand hygiene after removing her gloves. Nurse #6 opened the tracheostomy care tray and applied the sterile gloves that were in the tray. She then opened the normal saline and poured it over the tracheostomy care tray. Nurse #6 then picked up a wet cotton tipped applicator from the tracheostomy care tray. Nurse #6 turned towards Resident #9 and attempted to clean the resident's tracheostomy site when she was stopped by the surveyor. Nurse #6 confirmed she was going to clean Resident #9's tracheostomy site at that time. Nurse #6 was then asked if she received training on hand hygiene, and she indicated yes. Nurse #6 was asked if she was trained to perform hand hygiene after removing dirty disposable gloves, she stated yes. Nurse #6 then attempted to clean Resident #9's tracheostomy site again when she was stopped by the surveyor. Nurse #6 was then asked if she had performed hand hygiene according to the facility's training from the start of the observation up until that point, she stated no. Nurse #6 then removed the sterile gloves and threw them in the wastebasket. Nurse #6 performed hand hygiene and returned to Resident #9's beside. She then applied sterile gloves and reached into the contaminated tracheostomy care tray and picked up another wet cotton tip applicator. Nurse #6 was then stopped by the surveyor. Nurse #6 was asked if she was going to use the contaminated tracheostomy care tray, she indicated yes. Nurse #6 stated that the tracheostomy care tray was not contaminated. Nurse #6 was then asked if she had removed a cotton tip applicator from the tracheostomy tray wearing sterile gloves before she was stopped by the surveyor the first time, she indicated yes. The ICP/SDC instructed Nurse #6 to throw the tracheostomy care tray away and start over. Nurse #6 performed hand hygiene, set up another tracheostomy care tray, and began cleaning Resident #9's tracheostomy site. After Nurse #6 completed tracheostomy care for Resident #9, She disposed of the tracheostomy care tray in the wastebasket and performed hand hygiene. Nurse #6 was then asked if Resident #9's tracheostomy care was completed, she stated yes. Nurse #6 then exited the room without cleaning her work surface after providing tracheostomy care. An interview was conducted on 8/21/26 at 12:20 PM with Nurse #6 who was observed during tracheostomy care for Resident #9 on the 8/20/26. Nurse #6 stated she did receive hand hygiene training and tracheostomy care training from the facility. Nurse #6 confirmed she did not complete hand hygiene according to the training she received at the facility. Nurse #6 stated she should have completed hand hygiene each time she changed her disposable gloves. Nurse #6 stated she should not have removed gauze from the package while wearing dirty disposable gloves. Nurse #6 indicated she should have cleaned her work surface before and after proving tracheostomy care for Resident #9. Nurse #6 was asked why she did not clean her work surface after providing tracheostomy care for Resident #9, she was unable to indicate why. Nurse #6 was asked why she did not perform hand hygiene and tracheostomy care according to the training she received from the facility. Nurse #6 was unable to indicate why she did not perform hand hygiene according to the facility policy and procedures. An interview was conducted with the ICP/SDC on 8/21/26 at 11:53 AM, the staff that assisted Nurse #6 during tracheostomy care. The ICP/SDC indicated that the tracheostomy care tray used during the observation was designed for the user to have the ability to utilize clean items from tracheostomy care tray while providing care. The ICP/SDC stated she observed Nurse #6 cross contaminate items multiple times during Resident #9's tracheostomy care. The ICP/SDC stated she could not determine which of Nurse #6's hands were considered clean during Resident #9's tracheostomy care. The ICP/SDC stated that she observed Nurse #6 attempt to suction secretions through Resident #9's tracheostomy site with a rigid oral suction tip. The ICP/SDC stated at that time during the observation she opened a flexible suction catheter for Nurse #6 to use. The ICP/SDC indicated throughout Resident #9's tracheostomy care she attempted to get Nurse #6's attention by clearing her throat multiple times. The ICP/SDC further indicated she did not want to instruct Nurse #6 or intervene too much during the observation. When the ICP/SDC was asked if she observed Nurse #6 remove a gauze from the package with dirty disposable gloves, she indicated yes. The ICP/SDC indicated after the tracheostomy care observation was completed the soiled package of gauze was discarded. An interview was conducted with the Director of Nursing (DON) on 8/21/26 at 3:40 PM. The DON stated she would expect Nurse #6 to follow policy and procedures while providing tracheostomy care for Resident #9. The DON indicated that Nurse #6 should have performed hand hygiene before and after removing gloves and performed hand hygiene between touching clean and dirty items. The DON stated Nurse #6 should have also cleaned the work surface before setting up tracheostomy care supplies and after she performed tracheostomy care. An interview was conducted with the Medical Director on 8/21/26 at 12:55 PM. The Medical Director stated he would expect Nurse #6 to follow the facility's policy and procedures during tracheostomy care. The Medical Director indicated if the policy and procedures were not followed, Resident #9 could have been put at risk for infection. He further indicated it could have put Resident #9 at risk for transmission of bacteria to her airway. The Medical Director stated that there was also a possibility of transmission of bacteria to other residents. An interview was conducted with the Administrator on 8/21/26 at 4:52 PM. The Administrator stated she would expect Nurse #6 to provide tracheostomy care and perform hand hygiene according to policy and procedures. 2. A review of hospital discharge physician orders for Resident #126 revealed an order dated 8/14/26 for supplemental oxygen use at 2 Liters/minute (L/min) per nasal cannula (a flexible plastic tube that delivers extra oxygen through the nose to help people who are having difficulty breathing). Resident #126 was admitted on [DATE] from the hospital with diagnoses that included congestive heart failure, and chronic obstructive pulmonary disease with hypoxia (low oxygen levels). A review of the facility physician orders showed there was no order for supplemental oxygen use. The admission Minimum Data Set assessment for Resident #126 dated 8/17/26 noted that the resident was cognitively intact, had shortness of breath with movement, and was coded for oxygen use. On 8/17/26 at 10:38 AM an interview and observation were conducted with Resident #126. The resident was observed in bed wearing a nasal cannula oxygen tube connected to a portable oxygen unit next to her bed. The oxygen flow was being delivered at 2 L/min. The resident did not show any signs of discomfort or difficulty breathing. Resident #126 stated she had been on 3L/minute continuous oxygen flow at home and at the hospital. A review of the care plan dated 8/18/26 revealed a focus area of oxygen therapy related to congestive heart failure and ineffective gas exchange with interventions that included delivery of oxygen as ordered. A bedside interview and observation of Resident #126 was completed with Nurse #2 on 8/18/26 at 9:01 AM. The nurse observed the oxygen flow rate and stated that it was set to 2 L/min. Nurse #2 confirmed she had admitted the resident on 8/14/26 and had been assigned to the resident on 8/17/26 from 7:00 AM-7:00 PM. She was unable to explain why Resident #126 was on supplemental oxygen at 2L/min and why there was no order for supplemental oxygen. She further explained that she had received report from Nurse #8 on 8/17/26 that the resident was on oxygen but did not verify the order as she saw the hospital discharge orders on 8/14/26 for 2L/min and assumed the order had been confirmed with the facility healthcare provider and an admission order had been put in the system. She further stated oxygen administration required a physician's order. A telephone interview was conducted with the Medical Director on 8/20/26 at 5:10 PM regarding the lack of an order for supplemental oxygen order for Resident #126. He stated he expected the facility nurse to contact him with the hospital discharge orders so he could review and approve them. An interview was conducted with Nurse #3 on 8/21/26 at 8:08 AM regarding the lack of an order for supplemental oxygen for Resident #126. She confirmed she was the primary nurse for Resident #126 on 8/15/26 from 7:00 AM to 7:00 PM. Nurse #3 stated the 24-hour nursing report stated the resident was on 2L/minute of continuous oxygen therapy. She did not recall if an order for oxygen was on the Medical Administration Record (MAR), but she had heard in report and observed Resident #126 to not be in respiratory distress. She further stated that the resident had not reported any respiratory distress during her shift. She could not explain why she did not observe a lack of oxygen orders on the MAR. An interview was conducted with Nurse #10 on 8/21/26 at 6:40 AM regarding the lack of an order for supplemental oxygen for Resident #126. She confirmed she was the primary nurse for Resident #126 on 8/17/26 from 7:00 PM to 7:00 AM. Nurse #10 stated the 24-hour nursing report stated the resident was on 2L/minute of continuous oxygen therapy. She did not recall if an order for oxygen was on the MAR, but she had heard in report and observed Resident #126 to not be in respiratory distress. She could not explain why she did not observe a lack of oxygen orders on the MAR. An interview was conducted with Nurse #11 on 8/21/26 at 8:49 AM regarding the lack of an order for supplemental oxygen for Resident #126. She confirmed she was the primary nurse for Resident #126 on 8/16/26 from 7:00 AM to 7:00 PM. Nurse #11 stated the 24-hour nursing report stated the resident was on 2L/minute of continuous oxygen therapy, but she could not recall if an order for oxygen was on the MAR. She could not explain why she did not observe a lack of oxygen orders on the MAR. An interview was conducted with the Director of Nursing (DON) on 8/18/26 at 9:30 AM regarding a lack of supplemental oxygen orders for Resident #126. She explained it was the nurse's responsibility to validate orders for oxygen, ensure the rate ordered matched what a resident was receiving, and the resident was not experiencing any respiratory distress. The DON stated she was unsure why the discharge orders from the hospital had not been reviewed with the healthcare provider and put on the Medication Administration Record and why Nurse #2, #3, #8, #10, and #11 did not observe there were no orders supplemental oxygen on the MAR. A follow up interview was conducted on 8/21/26 at 10:25 AM with the Director of Nursing (DON). She stated an oxygen order was received from the Medical Director on 8/18/26 at 9:42 AM for Resident #126. The DON stated she expected all admission orders from the hospital to be reviewed with the physician and when approved the nurse should enter them into a resident's electronic record. An interview was conducted on 8/21/26 at 1:40 PM with the Administrator who stated she expected all nurses to follow the facility process for sharing admission orders from the hospital with the physician for approval.

Based on observation, resident and staff interviews, the facility failed to provide lunches for residents that would remain palatable for the dialysis residents transported to the dialysis center.The deficient practice affected 1 of 2 residents reviewed for food (Resident #14). Resident#14 was admitted to the facility on [DATE] with diagnosis that included Renal insufficiency and Renal Failure. A review of Resident #14 Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively intact. Resident #14 was triggered for Dialysis and Hemodialysis. Resident #14 was interviewed on 8/17/2026 at 4:05 PM and shared concerns about her lunch being sent in a clear plastic bag that was unable to keep food cool. Resident #14 stated that often her drinks have gotten warm and not pleasant to drink. Resident #14 stated she has told staff that she doesn't like it and nothing has changed. Resident #14 stated the clear bag has no way to keep the sandwich and her drink cool. A second interview with Resident #14 was conducted on 8/19/2026 at 12:35 PM. Resident #14 stated that on 8/18/2026 that when she tried to remove the cheese it had become sticky and was hard to remove. Resident #14 was not sure if that was due to the time from leaving the facility to when she ate the sandwich it was not as cool. Resident #14 stated with clear bags there was no way to keep the packed lunch cool. Resident stated she had shared with Unit Manager #1 earlier this week. The Dietary Manager was interviewed on 8/19/2026 at 2:03 PM. She stated the lunches for the dialysis patients are prepared the day before and stored in the refrigerator until going with the resident for their appointment. The Dietary Manager was unaware that Resident #14 had a concern about the temperatures of her sandwich and drink. An observation on 8/19/2026 at 4:29 PM of the labeled box of the clear bag that the sandwich was packed in was observed. The box was labeled Tuff Gard's Polyethyleal bags. The description stated clear sandwich bag with flip-lock flap. The measurement of the bags was 6 1/2 by 7 1/2. There was no description with the observed box stating the clear sandwich bag had temperature control. The description box of the larger clear bags was still unavailable for observation at this time. An interview with Unit Manager #1 was completed 8/21/2026 at 8:23 AM. Unit Manager stated that the bags she had previously observed were not bags that would maintain keeping the food cool. Unit Manager #1 stated that she had not shared this information with Administration or Dietary at this time. An interview with the Administrator was completed on 8/21/2026 at 2:23 PM. The Administrator stated she was unaware they were having to use clear non-insulated bags for lunch bags. The Administrator stated she would have gone and bought some lunch bags for the residents to use if she had been aware. The Administrator was unaware of Residents concern with the temperature of the sandwich. The Administrator said they have already gotten two lunch bags and three more have been ordered.

Based on observation, record review, resident interview, Resident Representative interview and staff interviews, the facility failed to provide mental health services to a resident with diagnosed mental health disorder for 1 of 1 resident reviewed for behavioral and emotional needs (Resident #4). The findings included:Resident #4 was admitted to the facility on [DATE] with diagnosis that included dementia.Review of Resident #4's Patient Health Questionnaire (PHQ-9) assessment (depressive symptom scale and diagnostic tool used to assess the presence and severity of depressive symptoms) dated 6/21/26 and completed by MDS Nurse # 2 indicated mood indicators of little interest or pleasure in doing things for nearly every day for the past 12-14 days, feeling down and depressed for nearly every day for the past 12-14 days, trouble falling asleep or sleeping too much for half or more of the days for 7-11 days, feeling tried or having little energy for half or more of the days for 7-11 days, thoughts that you would be better off dead or hurting yourself in some way for several days for the past 2-6 days with a total score of 11 which indicated moderate depressive symptoms.Review of Resident #4's admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 was cognitively intact, had no weight loss and exhibited mood indicators of little interest or pleasure in doing things for nearly every day for the past 12-14 days, feeling down and depressed for nearly every day for the past 12-14 days, trouble falling asleep or sleeping too much for half or more of the days for 7-11 days, feeling tried or having little energy for half or more of the days for 7-11 days, thoughts that you would be better off dead or hurting yourself in some way for several days for the past 2-6 days with a total severity score of 11 which indicated moderate depression.Resident #4s admission care plan dated 6/26/26 completed by MDS Nurse # 3 indicated a focus area for mood state with a problem of signs and symptoms of mood distress as evidenced by verbalizing thoughts he would be better off dead. Interventions included refer to psychiatric (psych) and or psychotherapy as needed.A telephone interview was conducted with Resident #4's Resident Representative on 8/20/26 at 9:44 AM and she indicated that she noticed Resident #4 had a poor appetite and he appeared sad and depressed, but the Resident Representative did not have any concern that Resident #4 wanted to harm himself. The Resident Representative indicated on 7/28/26 she brought her concerns to the facility and got a new order from the provider for an antidepressant medication. The Resident Representative indicated that no staff member offered to refer Resident #4 to psychiatric services and if they had offered, she would have consented to services. Review of nursing progress note dated 7/28/26 indicated Resident #4's Representative contacted the facility with a concern that Resident #4's appetite had decreased and possible depression. The note further revealed that the provider was notified and a new order was given for mirtazapine for depression.Resident #4's active physician's orders included the following psychotropic medications:-7/28/26: mirtazapine Oral Tablet 15 milligram (MG), give 1 tablet by mouth once a day for depressionReview of Resident #4's electronic medical record revealed no physician order for a psych consult. Review of Resident #4's medical record from 6/19/26 through 8/17/26 revealed Resident #4 did not receive a psych consult or other mental health care services. An observation and interview were conducted with Resident #4 on 8/17/26 at 2:09 PM and he was observed to be agitated and indicated that he felt sad and depressed since admission and that he had not been offered to speak to a therapist about his feelings and would have been willing to talk to someone if that was offered. Resident #4 confirmed that since admission he had not ever wished to harm himself but wanted to discharge to an assisted living facility.An interview was conducted with Unit Manager #1 on 8/20/26 at 12:50 PM and she indicated that Resident #4 only demonstrated irritability, agitation, and poor appetite and was not aware that he had reported having thoughts that he would be better off dead. Unit Manager #1 indicated these mood indicators were mild and likely the reason why staff did not document the progress notes. She further revealed that Resident #4 was easily redirected by staff talking with him, taking him outside to sit on front porch with his water or distracting him with a group activity. She indicated that MDS staff would interview the residents regarding their mood and if a concern was noted then the social workers were responsible for referring a resident for psych services.A telephone interview was conducted with MDS Nurse #3 on 8/20/26 at 10:23 AM. MDS Nurse #3 indicated she was a traveling MDS nurse and completed Resident #4's care plan which addressed his mood indicators that were noted in the PHQ-9 assessment and developed the care plan on 6/26/26 to address the mood indicators. MDS Nurse #3 indicated that her understanding was the social workers and other staff members who attended the morning meetings were already made aware of Resident #4's mood indicators prior to the care plan completion. MDS Nurse #3 did not know the process as to how social workers would determine when a psych referral was needed.An interview was conducted with MDS Nurse #2 on 8/20/26 at 10:26 AM and he indicated he completed the PHQ-9 assessment for Resident #4 on 6/21/26 and reported the results of the assessment the following day during the morning meeting on 6/22/26. MDS Nurse #2 indicated a social worker was present and thought social work staff would determine what interventions were needed at that time.An interview was conducted with Social Worker #1 on 8/21/26 at 11:35 AM and she indicated she did not attend the morning meeting on 6/22/26 and was not made aware that Resident #4 had any mood concerns and was not made aware that Resident #4 needed a psychiatric referral. Social Worker #1 indicated if she had been made aware at the morning meeting of Resident #4's mood concerns she would have followed up with Resident #4 that morning to get consent and then make the provider aware and request an order for psych services.An interview was conducted with Social Worker #2 on 8/21/26 at 2:53 PM and she confirmed that she attended the morning meeting on 6/22/26 and recalled MDS Nurse #2 reported that a PHQ-9 assessment had been completed for Resident #4 but did not report the score or any details regarding the PHQ-9 results. Social Worker #2 indicated social work staff were responsible for making psych referrals on behalf of residents once they are aware of a mood or behavior concern, but she was not made aware of Resident #4's mood indicators.An interview was conducted on 8/21/26 at 3:26 PM with the Administrator and she indicated that the social workers should have been made aware of Resident #4's mood indicators either in morning meeting and should have referred Resident #4 for psych services with consent.

Based on observations, record reviews, and interviews with the Medical Director, Consultant Pharmacist, and staff, the facility failed to address pharmacy recommendations made by the Consultant Pharmacist based on the monthly Medication Regimen Review (MRR) for 3 of 5 residents reviewed for unnecessary medications (Resident #5, #7, and #10). Findings included:1-a. Resident #5 was admitted to the facility on [DATE] with diagnoses that included anxiety.Review of Resident #5's orders revealed an active order initiated on 5/28/2026 for trazodone (an antidepressant medication that can also be used for insomnia) 50milligrams (mg) once a day at night for depression.Review of Resident #5's May 2026 Medication Administration Record (MAR) showed trazodone 50mg was administered 5/28/2026 - 5/31/2026.Review of Resident #5's orders revealed an active order initiated on 6/18/2026 for quetiapine (an antipsychotic medication that can help with severe agitation, unusual thoughts, or behaviors) 100mg once a day at night and 50mg twice daily in the morning and afternoon for dementia with behavioral disturbances.Review of Resident #5's June 2026 MAR showed quetiapine 100mg and 50mg was administered as ordered 6/18/2026 - 6/30/2026.Review of the monthly MRR completed by the Consultant Pharmacist on 6/19/2026 showed 3 total recommendations for Resident #5. A pharmacy recommendation was made to ensure informed consent was documented in Resident #5's medical chart for trazodone, lorazepam, and quetiapine. The pharmacy recommendation was completed and dated by the Director of Nursing (DON) on 7/1/2026. Review of Resident #5's orders revealed an order initiated by Unit Manager #2 on 7/8/2026 ordered verbally by the Medical Director for lorazepam (a benzodiazepine medication used to relieve anxiety) 0.5 milligrams (mg) every 4 hours as needed for anxiety and restlessness. There was no stop date.Review of Resident #5's July 2026 MAR showed lorazepam 0.5mg was administered once on 7/11/2026, 715/2026, 7/16/2026, and 7/25/2026.Review of the monthly MRR completed by the Consultant Pharmacist on 7/17/2026 showed 3 total recommendations for Resident #5. One of the recommendations stated to add a stop date for an as needed psychotropic medication for the lorazepam 0.5mg every 4 hours as needed order and that hospice orders were not exempt. The recommendation was left unacknowledged. The recommendation was signed and dated 7/31/2026 by Nurse Practitioner (NP) #2.Review of Resident #5's August 2026 MAR showed lorazepam 0.5mg was administered twice on 8/2/2026, 8/5/2026; and once on 8/8/2026, 8/9/2026, 8/10/2026, 8/13/2026, 8/14/2026, and 8/17/2026.Review of the monthly MRR completed by the Consultant Pharmacist on 8/15/2026 showed 1 total recommendation for Resident #5 that was still an open event. It again recommended to add a stop date for an as needed psychotropic medication in regard to the lorazepam 0.5mg every 4 hours as needed order and that hospice orders were not exempt.Review of Resident #5's orders revealed the order initiated on 7/8/2026 for lorazepam 0.5mg every 4 hours as needed for anxiety and restlessness was discontinued on 8/19/2026.Review of Resident #5's orders revealed an active order initiated by the DON on 8/19/2026 at 7:46PM ordered verbally by the Medical Director for lorazepam 0.5mg every 4 hours as needed for anxiety and restlessness. There was no stop date, and the order was open ended. A record review of Resident #5's electronic medical record revealed no consent for trazodone, lorazepam, or quetiapine.1-b. Resident #7 was admitted to the facility on [DATE]. Her cumulative diagnoses included chronic obstructive pulmonary disorder.A review of Resident #7's medication orders revealed the resident had a current order initiated by the DON that was ordered by the Medical Director on 7/9/2026 for a Wixela (fluticasone propion-salmeterol) inhalation device to be administered once daily in the morning for chronic obstructive pulmonary disease (COPD, long term lung damage that makes it harder to move air in and out of the lungs).Flucticasone propion is a corticosteroid that calms down swelling and inflammation in the airways. Fluticasone propion can remain in the mouth/throat and increase the risk for thrush, a fungal infection, so it is recommended to rinse the mouth after administration.Another review of Resident #7's medical record revealed a pharmacy recommendation dated 7/10/2026 from the Consultant Pharmacist's admission MRR that contained 5 total recommendations. One of the recommendations suggested for Wixela, that stated to consider adding rinse and spit after use to the instructions. The recommendation had fixed next to it and no signature and no date on the recommendation.Review of Resident #7's MAR from July 2026 confirmed Resident #7 received the Wixela inhalation device once daily 7/10/2026 - 7/31/2026. The MAR did not state rinse and spit after use in the Wixela inhalation section.Review of Resident #7's MAR from August 2026 confirmed Resident #7 received the Wixela inhalation device once daily 8/1/2026 - 8/19/2026. The MAR did not state rinse and spit after use in the Wixela inhalation section.1-c. Resident #10 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (MDD), recurrent, severe with psychotic symptoms.Review of Resident #10's orders revealed an active order initiated by NP #2 on 6/13/2026 for mirtazapine (an antidepressant used to improve mood, sleep, and appetite) 15mg tablet to be administered as a half tablet once daily at bedtime for MDD.Review of Resident #10's June 2026 MAR showed mirtazapine 15mg was administered as a half tablet once daily at bedtime 6/13/2026 - 6/30/2026.Review of the monthly MRR completed by the Consultant Pharmacist on 6/16/2026 showed 3 total recommendations for Resident #10. The Consultant Pharmacist recommended to ensure informed consent was documented in Resident #10's medical chart for the mirtazapine order that was started on 6/13/2026. The recommendation was signed and dated 7/1/2026 by NP #2.Review of Resident #10's medical record revealed no consent for mirtazapine.An interview with the Regional Nurse Consultant on 8/21/2026 at 9:09AM confirmed they could not retrieve the consent for mirtazapine in Resident #10's medical records. She confirmed the consent was never completed. An interview was conducted with the Unit Manager #2 on 8/20/2026 at 2:00PM with the assistant DON present. Unit Manager #2 stated the pharmacy would send pharmacy recommendations as an event in their electronic medical chart, and it would flag for her to start looking at it. Unit Manager #2 confirmed it would depend on the urgency for how much time it would take the provider to review the pharmacy recommendations. If it was urgent the pharmacy would call. She said they would print the pharmacy recommendations and left them in a box for the providers on their desk. Unit Manager #2 also stated that they used a lot of teamwork here so sometimes she would print them or sometimes the DON would print them. She was unsure how the pharmacy recommendations were missed for Resident #5, #7, and #10.An interview with NP #1 on 8/19/2026 at 2:00PM was conducted to inquire about the process of reviewing pharmacy recommendations. NP #1 stated he or NP #2 conduct the pharmacy recommendations when they were on site. NP #1 stated the staff would print them and left them on their desk. NP #1 stated that if a pharmacy recommendation had more than one recommendation, all of the recommendations needed to be acknowledged, and the sheet should be signed and dated. If a recommendation needed something changed in the residents' medical chart, NP #1 said he would change it himself or oversee that it was completed. NP #1 stated he always signed and dated them. He noted it was not him that saw the pharmacy recommendations that were missed for Resident #5, #7, and #10 and he could not speak to why the recommendations were not addressed.The Consultant Pharmacist was contacted for a phone interview on 8/20/2026 at 2:17PM. The Consultant Pharmacist confirmed she put the pharmacy recommendation into the electronic medical chart. She stated she also emailed a report when all her monthly MRRs were complete. The email was sent to the DON, Administrator, unit managers, and a regional person but unsure who. She stated if a pharmacy recommendation was not answered, she would then repeat the recommendation the following month. The Consultant Pharmacist could not speak to why the providers had not responded to some of the pharmacy recommendations.An interview was conducted with the DON on 8/20/2026 at 3:10PM with Unit Manager #2 and the assistant DON present. During the interview, the DON stated she had only been at the facility since June 2026, and she was unsure why some of the pharmacy recommendations had not been answered. She was confident that with her presence at the facility, they could streamline the process to ensure they were not missed in the future.A phone interview with NP #2 was conducted on 8/21/2026 at 8:23AM and a discussion occurred about the process of receiving and responding to a pharmacy recommendation. NP #2 confirmed she would see pharmacy recommendations on her desk, complete them and signed and dated them, and then the DON would scan them back into the residents' medical chart. She could not speak to why any pharmacy recommendation was not completed. NP #2 did note that their electronic medical record takes like 50 clicks to save an order so perhaps an order was not saved.A discussion about pharmacy recommendations was conducted with the Medical Director during a phone interview on 8/20/2026 at 3:15PM. The Medical Director stated that he had Nurse Practitioners handle them. He stated the Nurse Practitioners should have been taking care of them.An interview with the Administrator was conducted on 8/20/2026 at 4:08PM. The Administrator stated that the not completed pharmacy recommendations were due to human error. She also stated their process seemed to have too many people who looked at them and passed the pharmacy recommendation papers around.

Based on observations, record review, review of an online reference service for medical professionals, and interviews with the Medical Director, Consultant Pharmacist, and staff, the facility failed to monitor for therapeutic levels of divalproex (a medication which may be used to treat seizures or mood disorders, Resident #3) and levothyroxine (a medication used to treat hypothyroidism, Resident #12) for 2 of 5 residents reviewed for unnecessary medications.Findings included:1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder.Review of Resident #3's orders revealed an order that was discontinued on 7/9/2025 for divalproex 250milligrams (mg) delayed release (DR) to be administered as 3 tablets once nightly for bipolar disorder.Review of Resident #3's orders revealed an active order initiated on 7/9/2025 for divalproex 250mg DR to be administered as 2 tablets once nightly for bipolar disorder.Review of Resident #3's July 2025 Medication Administration Record (MAR) showed Resident #3 was administered 3 tablets of divalproex 250mg DR nightly 7/1/2025 - 7/8/2025 and was administered 2 tablets of divalproex 250mg DR nightly 7/9/2025 - 7/31/2025.Resident #3's quarterly Minimum Data Set, dated [DATE] showed she was cognitively intact and showed Resident #3 was on a high-risk anticonvulsant medication. Review of Resident #3's orders revealed an active order initiated on 5/18/2026 for divalproex 250mg DR to be administered as 1 tablet once daily in the morning.Review of Resident #3's May 2026 MAR showed Resident was administered 2 tablets of divalproex DR 250mg nightly 5/1/2026 - 5/31/2026 and was administered 1 tablet once daily in the morning 5/19/2026 - 5/31/2026.An interview with the Regional Nurse Consultant on 8/21/2026 at 9:09AM was conducted to inquire about the status of Resident #3's valproic acid lab results. She stated the only valproic acid levels for Resident #3 was from 12/16/2024 with a valproic acid level reported as 68.1 micrograms (ug - one-millionth of a gram) per milliliters (mL) (normal range 50.0 - 100.0 ug/mL).According to Lexidrug, an online reference service for medical professionals containing a comprehensive electronic medication database accessed on 8/21/2026, confirmed divalproex acid should have valproic acid levels drawn for monitoring. If dose adjustments are made, then valproic acid levels should be drawn within 3 to 4 days.The Consultant Pharmacist was contacted for a phone interview on 8/20/2026 at 2:17PM. The Consultant Pharmacist confirmed they use Lexidrug as their primary pharmacy source for medication information. She could not speak to why Resident #3 did not have a more recent valproic acid level in her chart. The Consultant Pharmacist confirmed divalproex required routine monitoring of valproic acid levels.An interview was conducted with the Director of Nursing (DON) on 8/20/2026 at 3:10PM with Unit Manager #2 and the assistant DON present. During the interview medications requiring labs were discussed. The DON stated the Nurse Practitioner or Medical Director would decide if labs were necessary for a specific medication and the provider would put the order into the electronic medical record system themselves or give a verbal order to a nurse. The DON stated the order would go on the MAR but once the order was drawn, they submit it to the lab company. She stated the lab company would not report directly to their electronic medical chart, but they would receive faxes to the nursing station or the administration office of the results. The staff was supposed to call the provider if they were critical. The DON could not speak to why the valproic acid labs were not drawn more recently for Resident #3 because she started at the facility in June 2026.A phone interview with the Medical Director on 8/20/2026 at 3:15PM was conducted to discuss lab orders for monitoring Resident #3's use of divalproex. The Medical Director stated if Resident #3 was stable on her divalproex, then he would draw a valproic acid level yearly. The Medical Director stated based on a resident's diagnoses he would want to ensure the valproic acid level was in the therapeutic window. The Medical Director was unsure why Resident #3's valproic acid level had not been drawn since 12/16/2024.An interview with the Administrator was conducted on 8/20/2026 at 4:08PM to discuss lab orders. The Administrator stated staff should follow the order and obtain the blood necessary to obtain the corresponding lab. The Administrator stated that medications requiring labs should have the lab results in the resident's medical chart. She believed it was an oversight by staff that Resident #3's valproic acid levels had not been drawn since 12/16/2024.2. Resident #12 was admitted to the facility on [DATE] with diagnoses that included hypothyroidism.Review of Resident #12's orders revealed an order initiated on 8/7/2025 for levothyroxine (a medication that would replace thyroid hormone when the body does not make enough) 25micrograms (mcg) tablet to be administered once a morning for hypothyroidism that ended on 11/17/2025. Resident #12 also had an active order that was initiated on 11/17/2025 for levothyroxine 25mcg tablet to be administered once a morning for hypothyroidism.Review of Resident #12's August 2025 Medication Administration Record (MAR) showed levothyroxine 25mcg was administered once daily in the morning 8/7/2025 - 8/31/2025.Review of Resident #12's November 2025 MAR showed levothyroxine 25mcg was administered once daily in the morning every day as ordered.Review of Resident #12's orders revealed a Thyroid Stimulating Hormone (TSH) lab (a blood test used to see if the thyroid is making the right amount of thyroid hormone and help determine if a thyroid medication dose is appropriate) order initiated on 2/3/2026 to start and end on 2/4/2026.Review of Resident #'s February 2026 MAR showed an empty box for 2/4/2026 for the TSH lab order.Resident #12's quarterly Minimum Data Set, dated [DATE] showed the interview was not performed to assess her cognitive level and her ability to understand others was rated as rarely never understands others.After review of Resident #12's medical chart revealed no TSH lab results, an interview with the Regional Nurse Consultant on 8/21/2026 at 9:09AM confirmed they could also not retrieve the TSH lab results for Resident #12. She confirmed the TSH labs were never completed.Review of Lexidrug confirmed once a resident was in the maintenance phase of levothyroxine, levels may be rechecked at 4 to 6 months and then annually if the levels remained within the goal range.The Consultant Pharmacist was contacted for a phone interview on 8/20/2026 at 2:17PM. The Consultant Pharmacist confirmed they use Lexidrug as their primary pharmacy source for medication information. She could not speak to why Resident #12 did not have a TSH level in her chart.An interview was conducted with the Director of Nursing (DON) on 8/20/2026 at 3:10PM with Unit Manager #2 and the assistant DON present. During the interview medications requiring labs were discussed. The DON stated the Nurse Practitioner or Medical Director would decide if labs were necessary for a specific medication and the provider would put the order into the electronic medical record system themselves or give a verbal order to a nurse. The DON stated the order would go on the MAR but once the order was drawn, they submit it to the lab company. She stated the lab company would not report directly to their electronic medical chart, but they would receive faxes to the nursing station or the administration's office of the results. The staff was supposed to call the provider if they were critical. The DON could not speak to why the TSH labs were not drawn for Resident #12 because she started at the facility in June 2026.A phone interview with the Medical Director on 8/20/2026 at 3:15PM revealed if Resident #12 was stable on her medications a TSH lab would need to be drawn yearly. The Medical Director said that when orders are put in, they would have indicators to remind them to pull labs for certain medications. The Medical Director was unsure why Resident #12's TSH levels were not completed.An interview with the Administrator was conducted on 8/20/2026 at 4:08PM to discuss lab orders. The Administrator stated staff should follow the order and obtain the blood necessary to obtain the corresponding lab. The Administrator stated that medications requiring labs should have them in the resident's medical chart. She believed it was an oversight by staff that Resident #12's TSH level was not drawn in February.

Based on record reviews, staff interviews and paramedic interview the facility failed to initiate any care to a resident (Resident #67) that was gasping for air after eating an ice cream cone before emergency medical services arrived. Immediate jeopardy began on [DATE] when Resident #67 was out of the facility on an activity outing to a local ice cream shop and began gasping for air after eating an ice cream cone. The nursing home staff left the resident unattended and did not initiate emergency medical services immediately. Resident #67 required treatment by Emergency Medical Services (EMS) and was hospitalized . The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings Included: Resident #67 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. A review of the [DATE] physician orders [REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] for Resident #67 revealed her cognition was intact and she required supervision and one person physical assist with eating. An entry in the nursing notes dated [DATE] revealed Resident #67 had an episode of choking while taking her medications which were crushed in vanilla pudding. Code blue was called and cardiopulmonary resuscitation (CPR) was initiated. She was able to start breathing normally again. An order was received to obtain a chest x-ray which came back negative for aspiration. An entry in the nursing notes on [DATE] revealed Resident #67 was on an outing today with activities. No nurse was made aware that resident was going. Scheduled pm meds held until return. An entry in the nursing notes on [DATE] revealed Resident #67 was sent by ambulance to the hospital from an activity outing at a local ice cream shop due to potential aspiration. A review of the EMS patient care report dated [DATE] for Resident #67 revealed that they arrived at the ice cream shop at 2:45 pm. The report stated that EMS was dispatched for [MEDICAL CONDITION]. The Fire Rescue (FR) arrived on scene prior to ambulance and obtained history of the event from bystanders (the facility Activity Assistant and intern volunteer). Patient (Resident #67) had just gotten ice cream with a group from her care facility when her bystanders stated she became apneic (temporary suspension of breathing) and unresponsive. CPR was initiated by bystanders at that time. FR arrived at the scene and found the patient breathing but responsive only to painful stimuli and discontinued CPR. At that time FR placed resident on 10 liters of oxygen and status [REDACTED]. Patients baseline level of responsiveness was not known, but better than this per bystanders. Per FR bystanders knew very little about resident. Assessment of patient by Medic revealed upon arrival patient was sitting in her wheelchair. She was non-verbal and responsive to painful stimuli. Her breathing was shallow and abnormally slow with a respiration rate of 8 per minute. She had strong radial pulses present and her skin appeared pale and waxy. Treatments administered to patient were documented as placement on 10 liters of oxygen, respirations assisted via bag valve mask, administration of 5 milligrams (mg) of [MEDICATION NAME], intravenous administration of 300 cubic centimeters (cc) of normal saline and transport to the hospital emergency department. A phone interview was conducted with Paramedic #1 on [DATE] at 10:40 am. She confirmed that she had responded to the call on [DATE] at the ice cream parlor for Resident #67. She stated that when she arrived on the scene Resident #67 was sitting in her wheelchair and was minimally responsive. She stated that Resident #67 looked very bad. She stated that she had been started on oxygen and intravenous fluids. She stated that Resident #67 required manual help with respirations and that was conducted during the ambulance trip to the hospital. She stated that she did not observe the resident receiving CPR and that it was not indicated because Resident #67 was breathing, not well, but was breathing and did not require CPR. She stated that she did not observe that the resident was choking and did not perform any suctioning or treatment for [REDACTED].#67 did not seem to know anything about her health condition and they were trying to get someone from the facility to bring her medical records. She stated that it was 5 to 10 minutes before anyone from the facility arrived with her medical records. A review of the hospital admission records dated [DATE] for Resident #67 revealed she presented unresponsive in the emergency room . It stated that Resident #67 was at an ice cream parlor on [DATE] with her friends from her facility when she suddenly became unresponsive. She received bystander CRP - unknown if she ever lost a pulse. When EMS arrived, she had a respiration rate of 5 and was bagged for ,[DATE] minutes. A review of the hospital discharge summary dated [DATE] for Resident #67 revealed a [DIAGNOSES REDACTED]. An interview on [DATE] at 10:30 am with the Activity Director revealed that she was not working at the facility on [DATE]. She stated that when she returned to work on [DATE] she learned that the Activity Assistant and 2 volunteers had taken Resident #67 on an outing to the ice cream shop on [DATE]. She stated that they had written statements of the incident and the statements were provided to the Director of Nursing (DON). She stated that typically when residents are taken out of the facility for an activity she would provide a list of residents that were going to the DON. She stated that a nurse or nursing assistant (NA) did not always accompany them on the outings and that it depended on the type of outing they were going on. She stated that the Activity Assistant and the intern volunteers went through general orientation when they started at the facility. An interview on [DATE] at 10:45 am with the Assistant Activity Director revealed she had been on the outing with Resident # 67 on [DATE]. She stated that she had come in to work at 1:00 pm on [DATE] and decided to take a few residents to the ice cream shop. She was accompanied by 2 volunteer interns that were recreational therapy students at a local college. She stated that Resident #67 ordered butter pecan ice cream in a waffle cone and they all sat outside to eat their ice cream. She stated Resident #67 did not appear to have any trouble eating her ice cream cone. When they finished they started to walk back to the facility as it was national walking day (Resident #67 and the other 2 residents were in wheel chairs and the activity assistant and 2 volunteers were pushing them). She stated that Resident #67 started to gasp for air and she asked her if she needed something to drink and Resident #67 said yes. The Activities Assistant went to a drugstore to get her a bottle of water which took approximately 5 minutes. She stated when she came out of the store Resident #67 was opening her mouth, gasping for air, was not able to speak and seemed to be less responsive. She stated one of the interns was calling 911 and the 911 operator asked for medical information about Resident #67. She called the facility to try and get the information. She stated the 911 operator told them to try and get her laying down and they were able to lay her wheelchair back. She stated EMS arrived and they placed a tube down her throat and sucked out a piece of waffle cone. A nursing assistant from the facility arrived about 5 to 10 minutes after she had called the facility and then a nurse from red hall came (didn ' t know her name). She stated that Resident #67 seemed fine all day. She stated that she had not let Resident #67 ' s nurse know that she was taking her out. She stated that she did not have any training in emergency medical response. A review of the Off-Premise Activities policy provided by the Activity Director on [DATE] revealed procedure #3 stated At least one or more members of nursing services will accompany the activity director / coordinator on field trips. An interview with the DON on [DATE] at 4:20 pm revealed that she was not in the facility on [DATE] and was not aware of the details of what happened with Resident #67 that day. She referred me to the Unit Manager #1. An interview with Unit Manager #1 on [DATE] at 4:32 pm revealed that she was returning to the facility from her lunch break on [DATE] and a facility staff member (could not remember who) stopped her and told her that Resident #67 was unresponsive down the street at the ice cream shop. She stated she obtained Resident #67 ' s medical information and brought it to the EMS staff. She stated Resident # 67 had already been put in the ambulance by that time. She provided the medical information, including that she was a full code, to EMS. She stated that she was not aware of any further interventions or follow-up by the facility after the incident. An interview on [DATE] at 1:00 pm with the activities intern / volunteer revealed that she had accompanied Resident #67 on the outing to the ice cream shop. She stated that everyone had finished their ice cream and they were walking the residents back to the facility when Resident #67 was gasping for air. She stated that the Activity Assistant went to get Resident #67 something to drink. While she was gone Resident #67 seemed to be getting worse and she called 911. She stated the resident did not stop breathing. She stated that she had been volunteering at the facility since [DATE] and that she did attend the facility general orientation. She stated that she did not receive any training at the facility on emergency medical response or the [MEDICATION NAME] maneuver. The facility new hire orientation agenda, provided by the Staff Development Coordinator, was reviewed. The general orientation agenda for all staff (Parts 1 and 2) did not include training in the areas of CPR, [MEDICATION NAME] maneuver or medical emergency response. Parts 3 and 4 of the general orientation agenda did include training in CPR and the [MEDICATION NAME] maneuver, this was for Nurses and Nursing Assistants. An interview on [DATE] at 2:00 pm with the Staff Development Coordinator revealed that the activity staff are not trained in the [MEDICATION NAME] technique or how to respond in medical emergencies because they don ' t work in a clinical capacity. She stated that volunteers do attend the facility general orientation, but this does not include any medical emergency training such as the [MEDICATION NAME] maneuverer. A follow-up interview on [DATE] at 2:30 pm with the Assistant Activity Director revealed that she had not received any training on the [MEDICATION NAME] maneuver or any emergency medical training. An interview on [DATE] at 3:45 pm with the Administrator revealed that he was somewhat aware of the incident that occurred on [DATE] involving Resident #67. He stated that they had discussed Resident #67 ' s swallowing difficulty the next day in the morning meeting. He stated that this was an isolated incident and that no additional investigation was completed. He stated that he assumed that the Activity Assistant and the intern volunteers went through general orientation, but that he was not the Administrator at that time. He was not aware of any other training in the area of emergency medical response for them. On [DATE] at 4:25 pm, the administrator was informed of the immediate jeopardy. The facility provided a credible allegation on [DATE] at 2:00 pm. The allegation of compliance indicated: On [DATE] Resident # 67 went on outing with activity assistant and two interns, resident # 67 began gasping for air, activity assistant went to obtain water approximately 100 feet away, intern called 911, emergency personnel arrived noted the resident with agonal breathing. EMS initiated emergency protocol which included bagging the resident. Resident #67 was transported to the hospital by EMS. Activity assistant was educated by the Staff Development Coordinator on [DATE] on identifying an emergency situation which included recognizing an emergency situation episode that maybe characterized by apnea, difficulty breathing, respiratory distress, color change, change in muscle tone, choking or gagging, calling 911 immediately and staying with the resident. All other residents that went on the outing were assessed by the DON, ADON, Unit Managers, Nursing Supervisor or Charge nurse by [DATE] to ensure that they had not been negatively affected and had no health or safety concerns. No other concerns were identified. All current residents that reside in the facility could be affected by this deficient practice at any time. Residents currently residing in the facility were assessed for any signs and symptoms of distress by the Director of Nursing, Staff Development Coordinator, Charge Nurse, or Regional Nurse Consultant on [DATE] for any possible need for emergency medical assistance. No residents were identified with the need for emergency services Change of condition policy was reviewed on [DATE] regarding life threatening events which may be characterized by apnea, difficulty breathing, respiratory distress, color change, change in muscle tone, choking or gagging. Education was initiated on [DATE] regarding the policy to Administrator, nursing staff, nursing assistants, business office staff, rehabilitation staff, dietary staff, maintenance, housekeeping and activities staff by the Staff Development Coordinator, Director of Nursing, or Regional Nurse Consultant regarding the immediate notification of emergency services by dialing 911 in an emergency situation for a resident. Staff members that are on an outing will be required to have a cell phone at all times. Staff education also included remaining with the resident until the arrival of Emergency Management Services personnel. Licensed Nursing staff are certified in the [MEDICATION NAME] maneuver. All staff were notified by the Staff Development Coordinator or Human Resources on [DATE] that they could not work until receiving above education. Education regarding the above stated policies and procedures along with processes will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education has been obtained. The credible allegation was verified on [DATE] at 5:02 PM. The Activity Assistant was interviewed on [DATE] at 4:16 PM and was able to describe the education she received. Assessments of the residents who attended the activity, as well as those who had not attended the activity were reviewed. Communication forms (SBAR) were created for every resident that was assessed. The change of condition policy was reviewed and it was noted life threatening events were defined. In-service topics included elder outings and emergency events. Sign-in sheets. Random staff in the nursing home including a unit secretary, licensed nurse, nurse aide/activity assistant were interviewed between 4:32 PM and 4:56 PM to confirm they had received in-services. The Staff Development Coordinator was interviewed to confirm there was a system to train all staff prior to reporting to duty. The immediate jeopardy was removed on [DATE].

Based on observations, record review, staff interviews and paramedic interview the facility neglected to provide immediate emergency medical services for a resident (Resident #67) that was gasping for air and becoming less responsive. The facility failed to identify the cause of the front door alarm being activated as a resident with exit-seeking behavior exited the building for 1 of 1 sampled resident (Resident #166) identified to be at risk for elopement. Immediate jeopardy began on [DATE] when Resident #67 was out of the facility on an activity outing to a local ice cream shop. After consuming the ice cream cone she began gasping for air and becoming less responsive. The nursing home staff left the resident unattended and did not initiate emergency medical services immediately. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. The findings included: 1) Resident #67 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] for Resident #67 revealed her cognition was intact and she required supervision and one person physical assist with eating. A care plan dated [DATE] revealed Resident #67 was active and at risk for behavior problems as evidenced by refusal to follow Medical Doctor (MD)/Nurse Practitioner (NP) orders related to dysphagia due to neuralgia. Resident #67 refused diet texture downgrade and a swallow study. The goal was that Resident #67 would have fewer episodes of choking/aspiration as evidenced by behavior occurring less than weekly. Interventions included report to physician changes in behavioral status. Anticipate care needs and provide for the resident. Refer to Registered Dietitian (RD) and Speech Therapist (ST) as needed. A review of the [DATE] physician's order [REDACTED]. An entry in the nursing notes dated [DATE] revealed Resident #67 had an episode of choking while taking her medications which were crushed in vanilla pudding. Code blue was called and cardiopulmonary resuscitation (CPR) was initiated. She was able to start breathing normally again. An order was received to obtain a chest x-ray which came back negative for aspiration. A telephone interview on [DATE] at 9:45 am with the ST that treated Resident #67 revealed she had last treated her in late January for about a week. She stated that Resident #67 had a history of [REDACTED]. An entry in the nursing notes on [DATE] revealed Resident #67 was sent by ambulance to the University of North Carolina (UNC) hospital from an activity outing at an ice cream shop due to potential aspiration. A review of the emergency medical services (EMS) patient care report dated [DATE] for Resident #67 revealed that they arrived at local ice cream shop at 2:45 pm. The report stated that EMS was dispatched for [MEDICAL CONDITION]. The Fire Rescue (FR) arrived on scene prior to ambulance and obtained history of the event from bystanders (the facility Activity Assistant and intern volunteer). Patient (Resident #67) had just gotten ice cream with a group from her care facility when her bystanders stated she became apneic (temporary suspension of breathing) and unresponsive. Cardiopulmonary resuscitation (CPR) was initiated by bystanders at that time. FR arrived at the scene and found the patient breathing but responsive only to painful stimuli and discontinued CPR. At that time FR placed resident on 10 liters of oxygen and status [REDACTED]. Patients baseline level of responsiveness was not known, but better than this per bystanders. Per FR bystanders knew very little about resident. Assessment of patient by Paramedic revealed upon arrival patient was sitting in her wheelchair. She was non-verbal and responsive to painful stimuli. Her breathing was shallow and abnormally slow with a respiration rate (RR) of 8 per minute. She had strong radial pulses present and her skin appeared pale and waxy. Treatments administered to patient were documented as placement on 10 liters of oxygen, respirations assisted via bag valve mask, administration of 5 milligrams (mg) of [MEDICATION NAME], intravenous administration of 300 cubic centimeters (cc) of normal saline and transport to the hospital emergency department. A phone interview was conducted with Paramedic #1 on [DATE] at 10:40 am. She confirmed that she had responded to the call on [DATE] at the ice cream parlor for Resident #67. She stated that when she arrived on the scene Resident #67 was sitting in her wheelchair and was minimally responsive. She stated that Resident #67 looked very bad. She stated that she had been started on oxygen and intravenous fluids. She stated that Resident #67 required manual help with respirations and that was conducted during the ambulance trip to the hospital. She stated that she did not observe the resident receiving CPR and that it was not indicated because Resident #67 was breathing, not well, but was breathing and did not require CPR. She stated that she did not observe that the resident was choking and did not perform any suctioning or treatment for [REDACTED].#67 did not seem to know anything about her health condition and they were trying to get someone from the facility to bring her medical records. She stated that it was 5 to 10 minutes before anyone from the facility arrived with her medical records. A review of the hospital admission records dated [DATE] for Resident #67 revealed she presented unresponsive in the emergency room . It stated that Resident #67 was at an ice cream parlor on [DATE] with her friends from her facility when she suddenly became unresponsive. She received bystander CRP - unknown if she ever lost a pulse. When EMS arrived, she had a RR of 5 and was bagged for ,[DATE] minutes. A review of the hospital discharge summary dated [DATE] for Resident #67 revealed a [DIAGNOSES REDACTED]. An interview on [DATE] at 10:30 am with the Activity Director revealed that she was not working at the facility on [DATE]. She stated that when she returned to work on [DATE] she learned that the Activity Assistant and 2 volunteers had taken Resident #67 on an outing to the ice cream shop on [DATE]. She stated that they had written statements of the incident and the statements were provided to the Director of Nursing (DON). She stated that typically when residents are taken out of the facility for an activity she would provide a list of residents that were going to the DON. She stated that a nurse or nursing assistant (NA) did not always accompany them on the outings and that it depended on the type of outing they were going on. A review of the Off-Premise Activities policy dated August, 2007; revision date [DATE] provided by the Activity Director on [DATE] revealed procedure #3 stated At least one or more members of nursing services will accompany the activity director / coordinator on field trips. An interview on [DATE] at 10:45 am with the Assistant Activity Director revealed she had been on the outing with Resident # 67 on [DATE]. She stated that she had come in to work at 1:00 pm on [DATE] and decided to take a few residents to the ice cream shop. She was accompanied by 2 volunteer interns that were recreational therapy students at a local college. She stated that Resident #67 ordered butter pecan ice cream in a waffle cone and they all sat outside to eat their ice cream. She stated Resident #67 did not appear to have any trouble eating her ice cream cone. When they finished they started to walk back to the facility as it was national walking day (Resident #67 and the other 2 residents were in wheelchairs and the activity assistant and 2 volunteers were pushing them). She stated that Resident #67 started to gasp for air and she asked her if she needed something to drink and Resident #67 nodded yes. The Activities Assistant went to a drugstore to get her a bottle of water which took approximately 5 minutes. She stated when she came out of the store Resident #67 was opening her mouth, gasping for air, was not able to speak and seemed to be less responsive. She stated the intern volunteer was calling 911 and the 911 operator asked for medical information about Resident #67. She called the facility to try and get the information. She stated the 911 operator told them to try and get her laying down and they were able to lay her wheelchair back. She stated EMS arrived and they placed a tube down her throat and sucked out a piece of waffle cone. A nursing assistant from the facility arrived about 5 to 10 minutes after she had called the facility and then a nurse from red hall came (didn ' t know her name). She stated that Resident #67 seemed fine all day. She stated that she had not let Resident #67 ' s nurse know that she was taking her out. She stated that she did not have any training in emergency health procedures. An interview on [DATE] at 1:30 pm with Nurse #3 revealed she was the nurse for Resident #67 on [DATE]. She stated that the resident had been fine all day. She stated that she went to find her to provide her afternoon medications and found out that activities had taken her out to get ice cream. She stated that they didn ' t even tell her that they were taking her out. She stated that everyone (did not elaborate on who everyone was) knew that Resident #67 had trouble swallowing and had choked once or twice in the past. An interview with the DON on [DATE] at 4:20 pm revealed that she was not in the facility on [DATE] and was not aware of the details of what happened with Resident #67 that day. She referred me to the Unit Manager #1. An interview with Unit Manager #1 on [DATE] at 4:32 pm revealed that she was returning to the facility from her lunch break on [DATE] and a facility staff member (could not remember who) stopped her and told her that Resident #67 was unresponsive down the street at the ice cream shop. She stated she obtained Resident #67 ' s medical information and brought it to the EMS staff. She stated Resident # 67 had already been put in the ambulance by that time. She provided the medical information, including that she was a full code, to EMS. She stated that she was not aware of any further interventions or follow-up by the facility after the incident. An interview on [DATE] at 1:00 pm with the activities intern / volunteer revealed that she had accompanied Resident #67 on the outing to the ice cream shop. She stated that everyone had finished their ice cream and they were walking the residents back to the facility when Resident #67 started gasping for air. She stated that the Activity Assistant went to get Resident #67 something to drink. While she was gone Resident #67 seemed to be getting worse and she called 911. She stated the resident did not stop breathing. She stated that she had been volunteering at the facility since [DATE] and that she did attend the facility general orientation. She stated that she did not receive any training at the facility on emergency medical response. A follow-up interview on [DATE] at 2:30 pm with the Assistant Activity Director revealed that she had not received any training on the [MEDICATION NAME] maneuver or any emergency medical training. A review of the statements dated [DATE] written by the Activity Assistant and the activities intern volunteers provided by the DON confirmed the events as obtained in their interviews. An interview on [DATE] at 2:00 pm with the Staff Development Coordinator revealed that the activity staff are not trained in the [MEDICATION NAME] technique or how to respond in medical emergencies because they don ' t work in a clinical capacity. She stated that volunteers do attend the facility general orientation, but this does not include any medical emergency training such as the [MEDICATION NAME] maneuverer. An interview on [DATE] at 3:45 pm with the Administrator revealed that he was somewhat aware of the incident that occurred on [DATE] involving Resident #67. He stated that they had discussed Resident #67 ' s swallowing difficulty the next day in the morning meeting. He stated that this was an isolated incident and that no additional investigation was completed. On [DATE] at 4:25 pm, the administrator was informed of the immediate jeopardy. The facility provided a credible allegation on [DATE] at 2:00 pm. The allegation of compliance indicated: On [DATE] Resident # 67 went on outing with activity assistant and two interns, resident # 67 began gasping for air, activity assistant went to obtain water approximately 100 feet away, leaving Resident # 67 with two activity interns, one intern called 911. EMS arrived, suctioned Resident # 67, applied O2 and bagged resident, and transported Resident # 67 to Hospital. Resident was admitted to hospital. All residents on the outing were assessed for any change in condition by the DON, ADON, on [DATE] no other concerns identified. All residents with a sudden change in condition have the potential to be affected by this alleged deficient practice. Residents with a change in condition have been reviewed by the DON, ADON, Staff Development Coordinator to ensure that any changes have been identified and appropriate follow up completed. Activity assistant was educated by the Staff Development Coordinator on [DATE] on identifying an emergency situation which included recognizing an emergency situation episode that maybe characterized by apnea, difficulty breathing, respiratory distress, color change, change in muscle tone, choking or gagging, calling 911 immediately and staying with the resident. The facility Administrator, DON, ADON, Unit Managers, Nursing Supervisor, MDS Coordinator, Staff Development Coordinator, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions Director, Rehab Services Manager, and Medical Records Staff were educated by the Regional Nurse Consultant on [DATE] on the policies and procedures regarding life threatening events. 1) Call 911 if initial assessment indicates such action is necessary and 2) Notify MD and facility pending location of life threatening event. The above training was performed face to face in order to facilitate discussion and question on policies, procedures and processes. Department administrative managers can ' t return to work until education is provided. Once the facility Administrator, DON, ADON, Unit Mangers, Nursing Supervisors, MDS coordinator, SDC, Director of Dining Services, Business office manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, and medical records were educated on the above policies and procedures and processes they were then assigned to re-educate, Nursing staff, nursing assistants, Dietary Staff, Activities, Maintenance and House Keeping staff which started on [DATE]. No employee will be allowed to work until education is provided. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided. The credible allegation was verified on [DATE] at 5:02 PM. The Activity Assistant was interviewed on [DATE] at 4:16 PM and was able to describe the education she received. Assessments of the residents who attended the activity, as well as those who had not attended the activity were reviewed. Communication forms (SBAR) were created for every resident that was assessed. The change of condition policy was reviewed and it was noted life threatening events were defined. In-service topics included elder outings and emergency events. Sign-in sheets were reviewed. Random staff in the nursing home including a unit secretary, licensed nurse, nurse aide/activity assistant were interviewed between 4:32 PM and 4:56 PM to confirm they had received in-services. The Staff Development Coordinator was interviewed to confirm there was a system to train all staff prior to reporting to duty. The immediate jeopardy was removed on [DATE]. 2. Immediate jeopardy began on [DATE] at 10:28 PM when Resident #166 exited the building unattended through the front door of the facility. The resident had been identified as having exit-seeking behavior and was wearing a wander guard (a small transmitting device placed on a resident's wrist or ankle, which would trigger an alarm when it comes in close proximity to an exit door). The door alarm sounded, but a staff nurse turned off the alarm from a remote location (the 200 Hall Nursing Station) using a reset button without identifying the reason why the alarm had been activated. Immediate jeopardy was removed on [DATE] for F224. The facility remained out of compliance at a lower scope and severity of D (isolated with no actual harm with the potential for more than minimal harm that is not immediate jeopardy), for the facility to complete staff training and to monitor its corrective action to ensure appropriate procedures are put into place for responding to a door alarm when it is activated. The findings included: Resident #166 was in the hospital from [DATE] - [DATE]. The Hospital Discharge Summary of [DATE] indicated the resident had a discharge [DIAGNOSES REDACTED]. He had a secondary [DIAGNOSES REDACTED]. The resident was discharged from the hospital and admitted to the facility on [DATE]. His cumulative [DIAGNOSES REDACTED]. A review of Resident #166's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognitive skills for daily decision making. No wandering behaviors were noted; one fall was reported within the last month prior to admission. The resident required extensive assistance for all of his Activities of Daily Living (ADLs), with the exception of being independent for eating. A review of the resident's Care Area Assessment (CAA) Summary dated [DATE] revealed the resident had a history of [REDACTED]. No wandering behaviors were noted. On [DATE], a Situation-Background-Appearance-Review (SBAR) Communication Form indicated the resident had a change in condition. The SBAR noted Resident #166 had a positive urinalysis for a urinary tract infection, with symptoms first noted on [DATE]. The resident's mental status evaluation reported there was an increase in confusion or disorientation at that time. On [DATE], an Elopement Risk Evaluation was completed. At that time, the resident was determined to be at risk for elopement. A review of Resident #166's medical record revealed a physician's telephone order was received on [DATE] to use a wander guard for the resident, check its placement and function every shift, and monitor the resident's whereabouts throughout the facility every 2 hours. Further review of the resident's medical record included an SBAR Communication Form dated [DATE] and written by Nurse #4. The SBAR form reported Resident #166 had become combative and was attempting elopement. Nursing notes on the form indicated this change started on [DATE] and had gotten worse. The resident's Mental Status Evaluation noted the resident had an increase in confusion or disorientation; memory loss; and other symptoms or signs of [MEDICAL CONDITION]. The resident was noted to be uncooperative with staff and care and had tried to exit the facility unassisted in his wheelchair with no shoes on. The Nursing Narrative on the SBAR read as follows: Resident became combative this AM (morning) with ADL care and started swinging at staff refusing any assist but was incontinent at the time. Two staff members were able to transfer Resident to wheelchair and get him to the restroom to provide AM care and put clothes on. Once getting into wheelchair resident took his shoes and sock back off and proceeded to front door to leave and redirected back inside facility where he began kicking at staff but able to get him to move away from front door. Resident then went to another exit door and proceeded to go out again and staff tried to redirect him telling him to wait for his family and he said he hadn't seen them in years and he was leaving now to go out. Resident continued to be barefoot at that time and kicked, hit and spit at staff. Resident was transferred back to bed with 3 staff members assist and PRN (as needed) given while staff sat at bedside until medication began to work and resident became quiet and sleepy. Once asleep family informed of events and wander guard placed on resident's leg. A review of Resident #166's care plan revealed the care plan had been updated on [DATE] to include an area of focus which indicated the resident was at risk for elopement as evidenced by exit seeking behaviors and attributed to cognitive deficits. Interventions listed on the care plan included: Use audible monitoring system to alert staff of exit seeking behavior (dated [DATE]); Check audible monitoring system for proper functioning per policy (dated [DATE]); and, 11:00 PM-7:00 AM sitter (not dated). Further review of the resident's medical record included an Interdisciplinary Note dated [DATE] at 2:43 PM, which read: The resident is being reviewed by IDT (Interdisciplinary) Team for Elopement/Wandering at this time as the resident due to current medical status and cognitive deficits tends to speak of leaving this place now and therefore has the wander guard in place with good results at this time. Continue with wander guard at this time. A review of Resident #166's medical record included an SBAR Communication Form dated [DATE]. The SBAR form reported a change in the resident's condition occurred on [DATE], noting he had increased agitation, confusion and elopement. The SBAR reported the condition started on [DATE]; the condition/symptom/sign had occurred before; and the treatment for [REDACTED]. Resident #166's Mental Status Evaluation reported increased confusion or disorientation; memory loss; and other symptoms or signs of [MEDICAL CONDITION]. The Nursing Narrative for the SBAR read as follows: Resident noted with increased agitation and confusion and even refused hour of sleep care. Resident noted with incoherent speech and was unable to follow directions. Resident scattered his belongings on the floor and then propelled himself out of the room. He apparently eloped through the main entrance. One of the staff members was going to her car at about 10:30 PM when she noted the resident trying to cross (Street Name) on a wheelchair. She brought the resident back to the building and informed this writer of what had transpired. Resident had wander guard to left ankle intact. Wander guard working well. Staff were asked to keep a close eye on the resident. (Name of practitioner service) on call paged and informed of resident's change in status. She gave an order for [REDACTED]. Resident offered the medication and he took it. Resident's family called and notified of the proceedings and said that the companion would be here. The companion never showed up. Family called at 11:10 pm. At 11:15 pm, resident was observed propelling himself along the hallway towards the rehab hall. Resident tried to escape through the rehab hall but was brought back before he could exit the building. He did set off the alarm though. This nurse asked the resident if he was tired and was ready to go to bed. Resident stated he was ready to go to bed. The nurse assisted the resident to bed and he stayed in bed the whole shift. Resident checked on every hour while in bed. Will continue to monitor. Further review of Resident #166's care plan revealed a hand-written notation on the care plan read: [DATE] Resident walked to parking area. An interview was conducted on [DATE] at 4:15 PM with the Assistant Director of Maintenance. The Director of Maintenance was not available for an interview. The Assistant Director stated all exit doors had a key pad adjacent to the door. If the correct code was entered on the key pad, the door would open without activating the door alarm. If the correct code was not entered on the key pad and the release bar on the exit door was pushed, the door alarm would be activated. If the locked exit door's release bar was pushed for 15 seconds, the door would open. He reported the main entrance door was the only exit with a wander guard protection. If a resident with a wander guard came within 2 feet or so of the door, it would lock down. If the door was already open (as when a visitor goes out), the door would alarm. If a resident with a wander guard pushed on the front exit door for 15 seconds, it would unlock and continue to alarm until a code was entered into the key pad adjacent to the door. The Assistant Director of Maintenance stated the main entrance (front exit door) of the facility was locked at 9:00 PM to 5:00 AM daily. During that period of time, whether or not a resident had a wander guard, the front exit door would alarm when the door release bar was pressed. If the release bar was pressed for 15 seconds, the door would unlock to allow someone to exit. Upon inquiry, the Assistant Director reported there had been no problems with the door alarms during the 5 years he had worked at the facility. An observation was conducted on [DATE] from 4:25 PM through 4:39 PM. Accompanied by the Maintenance Assistant Director, the alarms on all 8 facility doors were tested and observed to be in working order. The main entrance door was tested with use of an activated wander guard. The wander guard initiated the door to lock as it was brought close to the doorway. When asked who would be responsible to respond to a door alarm if it was alarming, the Assistant stated, everyone. He noted this was particularly important at night because there was less staffing on those shifts. An observation was conducted of Resident #166 on [DATE] at 5:00 PM. The resident was lying on his bed resting. He was dressed and well-groomed. The resident was noted to have a wander guard around his ankle. An interview was conducted on [DATE] at 7:38 AM with Nurse #1 who worked the evening of [DATE] at the time Resident #166 exited the facility. The nurse stated the resident had anxiety when she first came on the shift and she had asked the Nursing Assistant (NA) to keep an eye on him. At about 9:,[DATE]:00 PM that evening, she recalled going to check on the resident. He was in his room rolling around and pulling on stuff. At that point, she again told the NA to please keep a close eye on him. The nurse stated she was at the 200 Hall nursing station doing an admission for a new resident when she heard the facility's front door alarm go off. She stated that was around the time the next shift of staff came in and explained that if a staff member coming into the facility put in the code and pushed on the door bar too soon, the alarm would sound. Nurse #1 stated she could turn off the facility's front door alarm from the nursing station, so she did without identifying the cause of the alarm and she continued to do her work. The nurse recalled less than 30 minutes later, she saw an NA pushing the resident down the hall in his wheelchair. The NA told the nurse he was outside and was about to cross the road (Street Name). She asked the NA if he had a wander guard on and he did. The nurse stated they figured out he had pushed on the door long enough to make it open. The resident was reported as confused at that time and he was set by the nursing station. The nurse observed the resident propel himself down the Rehab hall. He tried to open that door and it alarmed; however, staff reached him before he was able to actually open the exit door. Resident #166 stated he was tired at that point and the nurse assisted him to bed. When asked how often the front door alarm was activated each night after being locked at 9:00 PM; the nurse stated pretty often. Upon further inquiry, she indicated the alarm was activated more than once a night, and she would have to either reset the alarm from the Nursing Station or enter the code at the door. Upon further inquiry, the nurse reiterated the resident had a wander guard on and the alarm on the door was working. When asked what staff was supposed to do when a door alarm sounded, the nurse stated they were supposed to go and check the door because they need to check on who is going out the facility's door. An interview was conducted on [DATE] at 8:10 AM with the Director of Nursing (DON) upon her request. The DON stated the door alarms could not be deactivated at the Nursing Station. She reported the only way to silence the alarm was by putting in a code at the door itself. A follow-up interview was conducted on [DATE] at 8:15 AM with Nurse #1. Upon request, the nurse pointed out the location of the reset button used to deactivate the facility's front door alarm at the 200 Hall Nursing Station. A follow-up interview was conducted on [DATE] at 9:20 AM with the Assistant Director of Maintenance. Upon inquiry, the Assistant stated he had heard about the incident when Resident #166 exited the building on [DATE]. He reported the Maintenance Director had gotten the camera feed for review. The camera surveillance included only video (no audio). When asked, the Assistant Director confirmed that after 9:00 PM (with or without wearing a wander guard), any push on the door bar would sound the alarm. Upon inquiry as to how the alarm would be silenced, he stated someone would need to enter the code at the door. When asked about the reset button located at the 200 Hall Nursing Station used to silence an alarm, the Assistant Director stated, That would be news to me. An observation was conducted on [DATE] at 9:27 AM. Accompanied by one surveyor, the Maintenance Assistant Director used a wander guard to activate the alarm on the main entrance door. A second surveyor located at the 200 Hall Nursing Station observed when the reset button (identified by Nurse #1) was pushed, the alarm was silenced. However, someone entered the building at that time so it was unclear as to whether or not the alarm was silenced by the guest entry or by pushing the button at the Nursing Station. A second observation was made on [DATE] at 9:30 AM. Accompanied by a surveyor, the Assistant Director of Maintenance again used a wander guard to activate the alarm on the main entrance door. A second surveyor located at the 200 Hall Nursing Station observed when the reset button was pushed, the alarm stopped. The Assistant Director of Maintenance stated at that time, She must have cut it off. On [DATE] at 9:32 AM, the Assistant Maintenance Director and Unit Manager #1 were interviewed in regards to the button used to deactivate the door alarm. The Unit Manager stated she had worked at the facility for 4 years and did not know about the button. The Assistant Director of Maintenance stated, That's not good to have. On [DATE] at 10:45 AM, a telephone interview was conducted with NA #1. NA #1 was identified as the nursing assistant who found the resident outside of the b

Based on record review, staff and paramedic interviews the facility staff left a resident in distress, unattended and failed to initiate emergency medical services for a resident gasping for air (Resident #67). Immediate jeopardy began on [DATE] when Resident #67 was out of the facility on an activity outing to a local ice cream shop, was gasping for air after eating an ice cream cone, and nursing home staff left the resident unattended and did not initiate emergency medical services immediately. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings Included: Resident #67 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] for Resident #67 revealed her cognition was intact and she required supervision and one person physical assist with eating. A care plan dated [DATE] revealed Resident #67 was active and at risk for behavior problems as evidenced by refusal to follow Medical Doctor (MD)/Nurse Practitioner (NP) orders related to dysphagia due to neuralgia. Resident #67 refused diet texture downgrade and a swallow study. The goal was that Resident #67 would have fewer episodes of choking/aspiration as evidenced by behavior occurring less than weekly. Interventions included report to physician changes in behavioral status. Anticipate care needs and provide for the resident. Refer to Registered Dietitian (RD) and Speech Therapist (ST) as needed. An entry in the nursing notes dated [DATE] revealed Resident #67 had an episode of choking while taking her medications which were crushed in vanilla pudding. Code blue was called and cardiopulmonary resuscitation (CPR) was initiated. She was able to start breathing normally again. An order was received to obtain a chest x-ray which came back negative for aspiration. A telephone interview on [DATE] at 9:45 am with the ST that treated Resident #67 revealed she had last treated her in late January for about a week. She stated that Resident #67 had a history of [REDACTED]. An entry in the nursing notes on [DATE] revealed Resident #67 was sent by ambulance to University of North Carolina (UNC) hospital from an activity outing at an ice cream shop due to potential aspiration. A review of the emergency medical services (EMS) patient care report dated [DATE] for Resident #67 revealed that they arrived at local ice cream shop at 2:45 pm. The report stated that EMS was dispatched for [MEDICAL CONDITION]. The Fire Rescue (FR) arrived on scene prior to ambulance and obtained history of the event from bystanders (the facility Activity Assistant and intern volunteer). Patient (Resident #67) had just gotten ice cream with a group from her care facility when her bystanders stated she became apneic (temporary suspension of breathing) and unresponsive. Cardiopulmonary resuscitation (CPR) was initiated by bystanders at that time. FR arrived at the scene and found the patient breathing but responsive only to painful stimuli and discontinued CPR. At that time FR placed resident on 10 liters of oxygen and status [REDACTED]. Patients baseline level of responsiveness was not known, but better than this per bystanders. Per FR bystanders knew very little about resident. Assessment of patient by Paramedic revealed upon arrival patient was sitting in her wheelchair. She was non-verbal and responsive to painful stimuli. Her breathing was shallow and abnormally slow with a respiration rate (RR) of 8 per minute. She had strong radial pulses present and her skin appeared pale and waxy. Treatments administered to patient were documented as placement on 10 liters of oxygen, respirations assisted via bag valve mask, administration of 5 milligrams (mg) of [MEDICATION NAME], intravenous administration of 300 cubic centimeters (cc) of normal saline and transport to the hospital emergency department. A phone interview was conducted with Paramedic #1 on [DATE] at 10:40 am. She confirmed that she had responded to the call on [DATE] at the ice cream parlor for Resident #67. She stated that when she arrived on the scene Resident #67 was sitting in her wheelchair and was minimally responsive. She stated that Resident #67 looked very bad. She stated that she had been started on oxygen and intravenous fluids. She stated that Resident #67 required manual help with respirations and that was conducted during the ambulance trip to the hospital. She stated that she did not observe the resident receiving CPR and that it was not indicated because Resident #67 was breathing, not well, but was breathing and did not require CPR. She stated that she did not observe that the resident was choking and did not perform any suctioning or treatment for [REDACTED].#67 did not seem to know anything about her health condition and they were trying to get someone from the facility to bring her medical records. She stated that it was 5 to 10 minutes before anyone from the facility arrived with her medical records. A review of the hospital admission records dated [DATE] for Resident #67 revealed she presented unresponsive in the emergency room . It stated that Resident #67 was at an ice cream parlor on [DATE] with her friends from her facility when she suddenly became unresponsive. She received bystander CRP - unknown if she ever lost a pulse. When EMS arrived, she had a RR of 5 and was bagged for ,[DATE] minutes. A review of the hospital discharge summary dated [DATE] for Resident #67 revealed a [DIAGNOSES REDACTED]. An interview on [DATE] at 10:30 am with the Activity Director revealed that she was not working at the facility on [DATE]. She stated that when she returned to work on [DATE] she learned that the Activity Assistant and 2 volunteers had taken Resident #67 on an outing to the ice cream shop on [DATE]. She stated that they had written statements of the incident and the statements were provided to the Director of Nursing (DON). She stated that typically when residents are taken out of the facility for an activity she would provide a list of residents that were going to the DON. She stated that a nurse or nursing assistant (NA) did not always accompany them on the outings and that it depended on the type of outing they were going on. A review of the Off-Premise Activities policy dated August, 2007; revision date [DATE] provided by the Activity Director on [DATE] revealed procedure #3 stated At least one or more members of nursing services will accompany the activity director / coordinator on field trips. An interview on [DATE] at 10:45 am with the Assistant Activity Director revealed she had been on the outing with Resident # 67 on [DATE]. She stated that she had come in to work at 1:00 pm on [DATE] and decided to take a few residents to the ice cream shop. She was accompanied by 2 volunteer interns that were recreational therapy students at a local college. She stated that Resident #67 ordered butter pecan ice cream in a waffle cone and they all sat outside to eat their ice cream. She stated Resident #67 did not appear to have any trouble eating her ice cream cone. When they finished they started to walk back to the facility as it was national walking day (Resident #67 and the other 2 residents were in wheelchairs and the activity assistant and 2 volunteers were pushing them). She stated that Resident #67 started to gasp for air and she asked her if she needed something to drink and Resident #67 nodded yes. The Activities Assistant went to a drugstore to get her a bottle of water which took approximately 5 minutes. She stated when she came out of the store Resident #67 was opening her mouth, gasping for air, was not able to speak and seemed to be less responsive. She stated the intern volunteer was calling 911 and the 911 operator asked for medical information about Resident #67. She called the facility to try and get the information. She stated the 911 operator told them to try and get her laying down and they were able to lay her wheelchair back. She stated EMS arrived and they placed a tube down her throat and sucked out a piece of waffle cone. A nursing assistant from the facility arrived about 5 to 10 minutes after she had called the facility and then a nurse from red hall came (didn ' t know her name). She stated that Resident #67 seemed fine all day. She stated that she had not let Resident #67 ' s nurse know that she was taking her out. She stated that she did not have any training in emergency health procedures. An interview on [DATE] at 1:30 pm with Nurse #3 revealed she was the nurse for Resident #67 on [DATE]. She stated that the resident had been fine all day. She stated that she went to find her to provide her afternoon medications and found out that activities had taken her out to get ice cream. She stated that they didn ' t even tell her that they were taking her out. She stated that everyone (did not elaborate on who everyone was) knew that Resident #67 had trouble swallowing and had choked once or twice in the past. An interview with the DON on [DATE] at 4:20 pm revealed that she was not in the facility on [DATE] and was not aware of the details of what happened with Resident #67 that day. She referred me to the Unit Manager #1. An interview with Unit Manager #1 on [DATE] at 4:32 pm revealed that she was returning to the facility from her lunch break on [DATE] and a facility staff member (could not remember who) stopped her and told her that Resident #67 was unresponsive down the street at the ice cream shop. She stated she obtained Resident #67 ' s medical information and brought it to the EMS staff. She stated Resident # 67 had already been put in the ambulance by that time. She provided the medical information, including that she was a full code, to EMS. She stated that she was not aware of any further interventions or follow-up by the facility after the incident. An interview on [DATE] at 1:00 pm with the activities intern / volunteer revealed that she had accompanied Resident #67 on the outing to the ice cream shop. She stated that everyone had finished their ice cream and they were walking the residents back to the facility when Resident #67 started gasping for air. She stated that the Activity Assistant went to get Resident #67 something to drink. While she was gone Resident #67 seemed to be getting worse and she called 911. She stated the resident did not stop breathing. She stated that she had been volunteering at the facility since [DATE] and that she did attend the facility general orientation. She stated that she did not receive any training at the facility on emergency medical response. A follow-up interview on [DATE] at 2:30 pm with the Assistant Activity Director revealed that she had not received any training on the [MEDICATION NAME] maneuver or any emergency medical training. A review of the statements dated [DATE] written by the Activity Assistant and the activities intern volunteers provided by the DON confirmed the events as obtained in their interviews. An interview on [DATE] at 2:00 pm with the Staff Development Coordinator revealed that the activity staff are not trained in the [MEDICATION NAME] technique or how to respond in medical emergencies because they don ' t work in a clinical capacity. She stated that volunteers do attend the facility general orientation, but this does not include any medical emergency training such as the [MEDICATION NAME] maneuverer. An interview on [DATE] at 3:45 pm with the Administrator revealed that he was somewhat aware of the incident that occurred on [DATE] involving Resident #67. He stated that they had discussed Resident #67 ' s swallowing difficulty the next day in the morning meeting. He stated that this was an isolated incident and that no additional investigation was completed. On [DATE] at 4:25 pm, the administrator was informed of the immediate jeopardy. The facility provided a credible allegation on [DATE] at 2:00 pm. The allegation of compliance indicated: On [DATE] Resident # 67 went on outing with activity assistant and two interns, resident # 67 began gasping for air, activity assistant went to obtain water approximately 100 feet away, leaving Resident # 67 with two activity interns, one intern called 911. EMS arrived, suctioned Resident # 67, applied O2 and bagged resident, and transported Resident # 67 to Hospital. Resident was admitted to hospital. All residents on the outing were assessed for any change in condition by the DON, ADON, on [DATE] no other concerns identified. All residents with a sudden change in condition have the potential to be affected by this alleged deficient practice. Residents with a change in condition have been reviewed by the DON, ADON, Staff Development Coordinator to ensure that any changes have been identified and appropriate follow up completed. Activity assistant was educated by the Staff Development Coordinator on [DATE] on identifying an emergency situation which included recognizing an emergency situation episode that maybe characterized by apnea, difficulty breathing, respiratory distress, color change, change in muscle tone, choking or gagging, calling 911 immediately and staying with the resident. The facility Administrator, DON, ADON, Unit Managers, Nursing Supervisor, MDS Coordinator, Staff Development Coordinator, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions Director, Rehab Services Manager, and Medical Records Staff were educated by the Regional Nurse Consultant on [DATE] on the policies and procedures regarding life threatening events. 1) Call 911 if initial assessment indicates such action is necessary and 2) Notify MD and facility pending location of life threatening event. The above training was performed face to face in order to facilitate discussion and question on policies, procedures and processes. Department administrative managers can ' t return to work until education is provided. Once the facility Administrator, DON, ADON, Unit Mangers, Nursing Supervisors, MDS coordinator, SDC, Director of Dining Services, Business office manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, and medical records were educated on the above policies and procedures and processes they were then assigned to re-educate, Nursing staff, nursing assistants, Dietary Staff, Activities, Maintenance and House Keeping staff which started on [DATE]. No employee will be allowed to work until education is provided. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided. The credible allegation was verified on [DATE] at 5:02 PM. The Activity Assistant was interviewed on [DATE] at 4:16 PM and was able to describe the education she received. Assessments of the residents who attended the activity, as well as those who had not attended the activity were reviewed. Communication forms (SBAR) were created for every resident that was assessed. The change of condition policy was reviewed and it was noted life threatening events were defined. In-service topics included elder outings and emergency events. Sign-in sheets were reviewed. Random staff in the nursing home including a unit secretary, licensed nurse, nurse aide/activity assistant were interviewed between 4:32 PM and 4:56 PM to confirm they had received in-services. The Staff Development Coordinator was interviewed to confirm there was a system to train all staff prior to reporting to duty. The immediate jeopardy was removed on [DATE]

Based on observations, staff interviews, and medical record review, the facility failed to identify the cause of the front door alarm being activated and failed to intervene as a resident with exit-seeking behavior exited the building for 1 of 1 sampled resident (Resident #166) identified to be at risk for elopement. The facility failed to maintain the receptacle for extinguishing cigarettes free of potentially flammable items in the designated resident smoking area. This had the potential to impact 6 of 6 residents that were currently identified as smokers. 1. Immediate jeopardy began on 4/10/17 at 10:28 PM when Resident #166 exited the building unattended through the front door of the facility. The resident had been identified as having exit-seeking behavior and was wearing a wander guard (a small transmitting device placed on a resident's wrist or ankle, which would trigger an alarm when it comes in close proximity to an exit door). The door alarm sounded when Resident #166 pushed on the facility's front door, but a staff nurse turned off the alarm from a remote location (the 200 Hall Nursing Station) using a reset button without identifying the reason why the alarm had been activated and without intervening to protect the resident. A credible allegation of correction was accepted. Immediate jeopardy was removed on 4/22/17 at 7:23 PM for F323. The facility remains out of compliance at a lower scope and severity of E (pattern with no actual harm with the potential for more than minimal harm that is not immediate jeopardy), for the facility to complete staff training and to monitor its corrective action to ensure appropriate interventions are put into place for residents at risk for elopement and procedures for responding to a door alarm when it is activated. The facility remains out of compliance to complete corrective actions regarding the maintainence of the receptacle for extinguishing cigarettes in the smoking area. Findings included: Resident #166 was in the hospital from 2/23/17 - 3/6/17. The Hospital Discharge Summary of 3/6/17 indicated the resident had a discharge [DIAGNOSES REDACTED]. He had a secondary [DIAGNOSES REDACTED]. The resident was discharged from the hospital and admitted to the facility on [DATE]. His cumulative [DIAGNOSES REDACTED]. A review of the resident's medical record included a Nursing Admission Assessment completed on 3/6/17. The assessment included an Elopement Risk Evaluation, which indicated the resident was independently mobile, had the ability to exit the facility, but was determined to not be at risk for elopement. Resident #166 was assessed to be alert and oriented. A review of Resident #166's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognitive skills for daily decision making. No wandering behaviors were noted; one fall was reported within the last month prior to admission. The resident required extensive assistance for all of his Activities of Daily Living (ADLs), with the exception of being independent for eating. A review of the resident's Care Area Assessment (CAA) Summary dated 3/14/17 revealed the resident had a history of [REDACTED]. No wandering behaviors were noted. On 3/29/17, a Situation-Background-Appearance-Review (SBAR) Communication Form indicated the resident had a change in condition. The SBAR noted Resident #166 had a positive urinalysis for a urinary tract infection, with symptoms first noted on 3/25/17. The resident's mental status evaluation reported there was an increase in confusion or disorientation at that time. On 4/1/17, an Elopement Risk Evaluation was completed by Nurse #4. At that time, the resident was determined to be at risk for elopement. A review of Resident #166's medical record revealed a physician's telephone order was received on 4/1/17 to use a wander guard for the resident, check its placement and function every shift, and monitor the resident's whereabouts throughout the facility every 2 hours. A review of the resident's medical record included an SBAR Communication Form dated 4/2/17 and written by Nurse #4. The SBAR form reported Resident #166 had become combative and was attempting elopement. Nursing notes on the form indicated this change started on 3/30/17 and had gotten worse. The resident's Mental Status Evaluation noted the resident had an increase in confusion or disorientation; memory loss; and other symptoms or signs of delirium. Additional notes revealed the resident was more confused and unaware of where he was or why. The resident was noted to be uncooperative with staff and care and had tried to exit the facility unassisted in his wheelchair with no shoes on. The Nursing Narrative on the SBAR read as follows: Resident became combative this AM (morning) with ADL care and started swinging at staff refusing any assist but was incontinent at the time. Two staff members were able to transfer Resident to wheelchair and get him to the restroom to provide AM care and put clothes on. Once getting into wheelchair resident took his shoes and sock back off and proceeded to front door to leave and redirected back inside facility where he began kicking at staff but able to get him to move away from front door. Resident then went to another exit door and proceeded to go out again and staff tried to redirect him telling him to wait for his family and he said he hadn't seen them in years and he was leaving now to go out. Resident continued to be barefoot at that time and kicked, hit and spit at staff. Resident was transferred back to bed with 3 staff members assist and PRN (as needed) given while staff sat at bedside until medication began to work and resident became quiet and sleepy. Once asleep family informed of events and wander guard placed on resident's leg. A review of Resident #166's care plan revealed the care plan had been updated on 4/3/17 to include an area of focus which indicated the resident was at risk for elopement as evidenced by exit seeking behaviors and attributed to cognitive deficits. Interventions listed on the care plan included: Use audible monitoring system to alert staff of exit seeking behavior (dated 4/3/17); Check audible monitoring system for proper functioning per policy (dated 4/3/17); and, 11:00 PM-7:00 AM sitter (not dated). Further review of the resident's medical record included an Interdisciplinary Note dated 4/10/17 at 2:43 PM, which read: The resident is being reviewed by IDT (Interdisciplinary) Team for Elopement/Wandering at this time as the resident due to current medical status and cognitive deficits tends to speak of leaving this place now and therefore has the wander guard in place with good results at this time. Continue with wander guard at this time. A review of Resident #166's medical record included an SBAR Communication Form dated 4/11/17. The SBAR form reported a change in the resident's condition occurred on 4/10/17, noting he had increased agitation, confusion and elopement. The SBAR reported the condition started on 4/10/17; the condition/symptom/sign had occurred before; and the treatment for [REDACTED]. Resident #166's Mental Status Evaluation reported increased confusion or disorientation; memory loss; and other symptoms or signs of delirium. The Nursing Narrative for the SBAR read as follows: Resident noted with increased agitation and confusion and even refused hour of sleep care. Resident noted with incoherent speech and was unable to follow directions. Resident scattered his belongings on the floor and then propelled himself out of the room. He apparently eloped through the main entrance. One of the staff members was going to her car at about 10:30 PM when she noted the resident trying to cross (Street Name) on a wheelchair. She brought the resident back to the building and informed this writer of what had transpired. Resident had wander guard to left ankle intact. Wander guard working well. Staff were asked to keep a close eye on the resident. (Name of practitioner service) on call paged and informed of resident's change in status. She gave an order for [REDACTED]. Resident already had Ativan 0.5 mg po ordered. Resident offered the medication and he took it. Resident's family called and notified of the proceedings and said that the companion would be here. The companion never showed up. Family called at 11:10 pm. At 11:15 pm, resident was observed propelling himself along the hallway towards the rehab hall. Resident tried to escape through the rehab hall but was brought back before he could exit the building. He did set off the alarm though. This nurse asked the resident if he was tired and was ready to go to bed. Resident stated he was ready to go to bed. The nurse assisted the resident to bed and he stayed in bed the whole shift. Resident checked on every hour while in bed. Will continue to monitor. Further review of Resident #166's care plan revealed a hand-written notation on the care plan read: 4/11/17 Resident walked to parking area. An interview was conducted on 4/20/17 at 4:15 PM with the Assistant Director of Maintenance. The Director of Maintenance was not available for an interview. The Assistant Director stated all exit doors had a key pad adjacent to the door. If the correct code was entered on the key pad, the door would open without activating the door alarm. If the correct code was not entered on the key pad and the release bar on the exit door was pushed, the door alarm would be activated. If the locked exit door's release bar was pushed for 15 seconds, the door would open. He reported the main entrance door was the only exit with a wander guard protection. If a resident with a wander guard came within 2 feet or so of the door, it would lock down. If the door was already open (as when a visitor goes out), the door would alarm. If a resident with a wander guard pushed on the front exit door for 15 seconds, it would unlock and continue to alarm until a code was entered into the key pad adjacent to the door. The Assistant Director of Maintenance stated the main entrance (front exit door) of the facility was locked at 9:00 PM to 5:00 AM daily. During that period of time, whether or not a resident had a wander guard, the front exit door would alarm when the door release bar was pressed. If the release bar was pressed for 15 seconds, the door would unlock to allow someone to exit. Upon inquiry, the Assistant Director reported there had been no problems with the door alarms during the 5 years he had worked at the facility. An observation was conducted on 4/20/17 from 4:25 PM through 4:39 PM. Accompanied by the Maintenance Assistant Director, the alarms on all 8 facility doors were tested and observed to be in working order. The main entrance door was tested with use of an activated wander guard. The wander guard initiated the door to lock as it was brought close to the doorway. When asked who would be responsible to respond to a door alarm if it was alarming, the Assistant stated, everyone. He noted this was particularly important at night because there was less staffing on those shifts. An observation was conducted of Resident #166 on 4/20/17 at 5:00 PM. The resident was lying on his bed resting. He was dressed and well-groomed. The resident was noted to have a wander guard around his ankle. On 4/20/17 at 5:15 PM, an interview was conducted with the facility's Administrator. Upon inquiry, the Administrator reported he was aware the resident exited the building the previous week. The Administrator stated the resident had a lot going on and was very anxious. The Administration stated, It was an isolated incident. He reported the resident had a sitter but the sitter had called in and was not present at the time of the exit. When asked what was done after the elopement, the Administrator stated the resident's anxiety level was the first issue to be addressed. Next, he reported the facility staff had to be sure to check on him more often. He stated the resident had settled down quite a bit since. He also reported the exit of the building was discussed in the staff's morning meeting. When asked if anything else was implemented to protect other residents, the Administrator stated No, and reiterated this was an isolated incident. An interview was conducted on 4/20/17 at 6:05 PM with the facility's Director of Nursing (DON). Inquiry was made regarding the incident on 4/10/17 when Resident #166 exited the building unattended. The DON stated that based on camera surveillance, the resident went to the facility's front door and pushed on it, the alarm sounded, then he came back up the hallway, turned around again and came back to the door 3-4 minutes later. She stated the alarm had not been reset with a code so it did continue to alarm. The DON reported that shortly after the alarm sounded, a Nursing Assistant (NA) went out the door, reset the alarm, and then saw the resident outside. When asked how many minutes had elapsed between when Resident #166 went outside and when he was seen, the DON reported she would need to check on the time frame. When asked if an investigation was done of the incident, she stated, of sorts. An interview was conducted on 4/21/17 at 7:38 AM with Nurse #1 who worked the evening of 4/10/17 at the time Resident #166 exited the facility. The nurse stated the resident had anxiety when she first came on the shift and she had asked NA #2 to keep an eye on him. At about 9:30-10:00 PM that evening, she recalled going to check on the resident. He was in his room rolling around and pulling on stuff. At that point, she again told NA #2 to please keep a close eye on him. The nurse stated she was at the 200 Hall nursing station doing an admission for a new resident when she heard the facility's front door alarm go off. She stated that was around the time the next shift of staff came in and explained that if a staff member coming into the facility put in the code and pushed on the door bar too soon, the alarm would sound. Nurse #1 stated she could turn off the facility's front door alarm from the nursing station, so she did without identifying the cause of the alarm and she continued to do her work. The nurse recalled less than 30 minutes later, she saw NA #1 pushing the resident down the hall in his wheelchair. NA #1 told the nurse he was outside and was about to cross the road (Street Name). She asked the NA if he had a wander guard on and he did. The nurse stated they figured out he had pushed on the door long enough to make it open. The resident was reported as confused at that time and he was placed in his wheelchair by the nurse's station for supervision. The nurse observed the resident propel himself down the Rehab hall. He tried to open that exit door and it alarmed; however, staff reached him before he was able to actually open the exit door. Resident #166 stated he was tired at that point and the nurse assisted him to bed. When asked how often the front door alarm was activated each night after being locked at 9:00 PM; the nurse stated pretty often. Upon further inquiry, she indicated the alarm was activated more than once a night, and she would have to either reset the alarm from the Nursing Station or enter the code at the door. Upon further inquiry, the nurse reiterated the resident had a wander guard on and the alarm on the door was working. When asked what staff was supposed to do when a door alarm sounded, the nurse stated they were supposed to go and check the door because they need to check on who is going out the facility's door. An interview was conducted on 4/21/17 at 8:10 AM with the DON upon her request. The DON stated the door alarms could not be deactivated at the Nursing Station. The only way to silence the alarm was by putting in a code at the door itself. A follow-up interview was conducted on 4/21/17 at 8:15 AM with Nurse #1. Upon request, the nurse pointed out the location of the reset button used to deactivate the facility's front door alarm at the 200 Hall Nursing Station. A follow-up interview was conducted on 4/21/17 at 9:20 AM with the Assistant Director of Maintenance. Upon inquiry, the Assistant stated he had heard about the incident when Resident #166 exited the building on 4/10/17. He reported the Maintenance Director had gotten the camera feed for review. The camera surveillance included only video (no audio). When asked, the Assistant Director confirmed that after 9:00 PM (with or without wearing a wander guard), any push on the door bar would sound the alarm. Upon inquiry as to how the alarm would be silenced, he stated someone would need to enter the code at the door. When asked about the reset button located at the 200 Hall Nursing Station used to silence an alarm, the Assistant Director stated, That would be news to me. An observation was conducted on 4/21/17 at 9:27 AM. Accompanied by one surveyor, the Maintenance Assistant Director used a wander guard to activate the alarm on the main entrance door. A second surveyor located at the 200 Hall Nursing Station observed when the reset button (identified by Nurse #1) was pushed, the alarm was silenced. However, someone entered the building at that time so it was unclear as to whether or not the alarm was silenced by the guest entry or by pushing the button at the Nursing Station. A second observation was made on 4/21/17 at 9:30 AM. Accompanied by a surveyor, the Assistant Director of Maintenance again used a wander guard to activate the alarm on the main entrance door. A second surveyor located at the 200 Hall Nursing Station observed when the reset button was pushed, the alarm stopped. The Assistant Director of Maintenance stated at that time, She must have cut it off. On 4/21/17 at 9:32 AM, the Assistant Maintenance Director and Unit Manager #1 were interviewed in regards to the button used to deactivate the door alarm. The Unit Manager stated she had worked at the facility for 4 years and did not know about the button. The Assistant Director of Maintenance stated, That's not good to have. On 4/21/17 at 10:45 AM, a telephone interview was conducted with NA #1. NA #1 was identified as the nursing assistant who found the resident outside of the building. NA #1 reported on 4/10/17, she worked from 7:00 AM to 11:00 PM. NA #1 recalled hearing the loud alarm that evening (the sound that occurs past the warning beeps during the first 15 seconds upon activation of the door alarm). She was in the back of the 100 Hall at the time. The NA stated within 1-2 minutes after the alarm sounding, she went to the front door to specifically put in the code and turn off the alarm. She stated she was not going to her car. No one was around the main entrance door, so she went outside to look around. She reported seeing a man in a wheelchair on the sidewalk, just past the Rehab awning facing (Street Name.). The NA stated she discovered it was Resident #166 so she brought him back into the building. When asked how long the resident would have been out of the building (between the time the alarm sounded and when she brought him back in), she stated, 1-2 minutes. Upon inquiry about the longer time frame noted by the facility (based on camera surveillance), the NA stated she, didn't know about that and stated she responded to the loud door alarm in a couple seconds. On 4/21/17 at 11:24 AM, a telephone interview was conducted with the Nurse #4. Nurse #4 had worked with the Resident #166 on 1st shift on 4/1/17 and 4/2/17. Nurse #4 recalled Resident #166 had tried to exit from the front door. At that time, he did not have a wander guard. However, there were people in the lobby and he was redirected. He then tried to exit near Rehab and activated the door alarm there. Nurse #4 stated staff were able to stop him from going out the door. However, based on what she had seen, the nurse stated she went ahead and updated the resident's Elopement Evaluation, and also called the family and Nurse Practitioner (NP). The NP reported the resident already had an order for [REDACTED]. A telephone order was received to initiate the use of wander guard. During the interview, the nurse was asked how she could deactivate a door alarm. Nurse #4 stated, The only way I know is to go to the door to (enter the code and) deactivate the alarm. That's how we knew he was trying to exit the door. Accompanied by the Assistant Maintenance Director and the Corporate Nurse Consultant, the camera surveillance video from evening of 4/10/17 was viewed on 4/21/17 at 1:26 PM. The Assistant Maintenance Director reported while the date on the camera surveillance monitor was correct, the time stamp was off and 32 minutes needed to be added to the time stamp to get the correct time from the surveillance. The camera surveillance video from 4/10/17 (with the corrected times) revealed the following: --At 10:25 PM (corrected time), Resident #166 was observed as he pushed on the front entrance door. Upon viewing this portion of the video, the Assistant Director of Maintenance stated the alarm would have gone off at that time. --Resident #166 was observed as he sat in his wheelchair in front of the door for 1-2 minutes. --At 10:27 PM (corrected time), the resident was observed as he proceeded back down the facility hallway. --At 10:27 PM (corrected time), Resident #166 re-approached the front entrance door. --At 10:28 PM (corrected time), the resident was observed as he opened the front exit door and went through first door, then the second door to get outside of the facility. --At 10:32 PM (corrected time), a staff member (identified as NA #1 by the Corporate Nurse Consultant) opened both doors and stood outside of the facility's front entrance door. The NA was observed with a purse over her shoulder, a light jacket tied around her waist, and holding her cell phone. Initially upon exiting the building, the NA was observed to be using and/or viewing a cell phone. She was out of view of the camera for brief periods of time. --At 10:36 PM (corrected time), an unidentified man came to the front entrance door and entered the building. --At 10:36 PM (corrected time), NA #1 was observed as she came back in the building, pushing the resident in his wheelchair. On 4/21/17 at 1:45 PM, the facility's DON joined the Assistant Director of Maintenance as the camera surveillance and timeline from 4/10/17 were being discussed. An interview was conducted with the DON at that time. During the interview, the DON stated she had worked at the facility for [AGE] years and did not know there was button at the Nursing Station to disarm the door alarm. At that time, the Assistant Director of Maintenance was asked in the presence of the DON if the reset button at the 200 Hall Nursing Station worked to silence the alarm. He stated, Yes it did. When the DON asked him if it actually deactivated the alarm, the Assistant Director of Maintenance confirmed the button did deactivate the alarm when it was tested . Upon inquiry, the DON stated the reset button should Never, ever be used. She reported her expectation would be for the staff to immediately investigate why a door alarm was activated. An observation was made on 4/22/17 at 9:52 AM as NA #1 identified the location of Resident #166 when he was found outside on 4/10/17. At that time, the Assistant Director of Maintenance measured how far the resident was from the front door entrance where he exited the facility, and how far the resident was from the street when he was found. Measurements determined the resident had traveled 108 feet from the front entrance of the facility. The resident was reported to be facing a 5-lane street directly in front of the facility at the time he was found. Measurements revealed Resident #166 was 109 feet from the curb adjacent to the street. A telephone interview was conducted on 4/22/17 at 11:47 AM with NA #2. NA #2 was the 2nd shift nursing assistant assigned to care for Resident #166 at the time he exited the facility on the evening of 4/10/17. Upon inquiry as to what she recalled about the evening of 4/10/17, the NA reported she knew the resident kept going to the front door of the facility. However, she did not know Resident #166 actually got out of the facility. When asked if the door alarm went off that evening, NA #2 stated, Yes, that's how we knew he was going to the door. Upon inquiry, the NA recalled the door alarm only went off for a few seconds at a time that evening (not minutes). On 4/21/17 at 2:32 PM, the Administrator was informed of the immediate jeopardy. The facility provided a credible allegation on 4/22/17 at 4:05 PM. The allegation of compliance indicated: Credible Allegation for F323 A. Resident # 166 was noted by staff to be outside on the sidewalk by the rehab side of the building on 4/10/2017. Resident # 166 was assisted back to the facility by the Certified Nursing Assistant on 4/10/2017 at approximately 10:04 PM. and placed at the nurses' station for closer monitoring at approximately 10:05 PM. The Charge Nurse assisted the resident to bed. The Charge Nurse changed the bed linens and provided incontinent care for the resident. The nurse performed an assessment on resident #166 during care, no new injuries were noted at this time. The Resident's responsible party and physician were notified of incident by the charge nurse on 4/10/17. Resident #166 was monitored every hour for the rest of the night by the charge nurse. B. A head count of the entire facility was conducted on 4/11/2017 at 12:00 midnight by the charge nurses. All residents were accounted for and were safe. On 4/11/2017 all exits were checked by the plant operations assistant. All exit doors were found to be functioning properly. On 4/11/17, all resident wander guards were checked for placement and functioning by the Charge Nurses and Central Supply Clerk and all were properly functioning. All residents were reassessed for risk of elopement on 4/12//2017 by Assistant Director of Nursing, and Director of Nursing. No new residents were identified as being at risk for elopement. Care plans and care cards were reviewed and updated as indicated for the 8 residents identified as being at risk for elopement on 4/21/2017 by Social Services Director, or Staff Development Coordinator. The binders which identify residents who are at risk for elopement were reviewed by the Administrator and Social Services Director to ensure that they were updated and in place at each nurse's station and at the receptionist's desk on 4/13/2017, all were found to be in place and correct. On 4/21/2017, Plant Operations Assistant contacted an outside vendor for service to dismantle the reset button located at the red hall nursing station. The service call for dismantling the reset button will be a part of the plan of correction. In the meantime, the reset button at red hall nursing station was covered and a sign was placed informing staff Do Not Use Button on 4/22/2107 at 1145 am, by Staff Development Coordinator and Plant Operations Assistant. C. Education on elopement policy including how to respond to door alarms, complete head counts, check wander guard for function and placement, functioning of doors, and implementation of care plans related to triggered areas including elopement risk assessments, was initiated to all staff on duty on 4/21/2017 and will continue prior to all staff working next shift by Administrator, Director of Nursing, Staff Development Coordinator, Quality of Life Director, Social Services Director, Social Services Assistant, Chaplain, Customer Experience Director, Dietary Services Manager, Admissions Director, Plant Operations Director, Plant Operations Assistant, or Business Office Manager. The Administrator and Director of Nursing trained these educators on the material to cover for the education on 4/21/17. Education and return demonstration on use of Accutech transmitter (device to check function of wander guard) to ensure staff competency of wander guard function and battery checks was initiated on 4/22/2017 by the Plant Operations Director, Plant Operations Assistant, Central Supply Clerk/Certified Nursing Assistant, SDC, or Regional Nurse Consultant for licensed nurses and nurse aides. A post-test will be given to staff that received the education in which a passing score of 100% must be obtained. If staff did not receive a score of 100% on test the staff member will be re-educated on the spot and a new post-test will be given. Staff that were not working on 4/22/2017 will be educated on the elopement policy and procedure, care plan and use of the Accutech by Administrator, Director of Nursing, Staff Development Coordinator, Quality of Life Director, Social Services Director, Social Services Assistant, Dietary Services Manager, Chaplain, Customer Experience Director, Admissions Director, Plant Operations Director, Plant Operations Assistant, or Business Office Manager prior to taking their assignment upon return to work. A posttest will be given in which a passing score of 100% must be obtained. If 100% was not obtained the staff member will be re-educated and a post test will be reissued. The Administrator, DON, or Signature Care Consultant or regional team will review the Post Tests given daily until immediacy removed and then weekly for any noted concerns. Any concerns will be addressed immediately. Staff who are As Needed, on the Family Medical Leave Act or on leave will not be allowed to return to work until received Elopement training, the post-test is administered and 100% score obtained, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. No newly hired employee will be allowed to work until education is provided, post-test administered and 100% score obtained, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. Assistant Directors of Nursing, and MDS Coordinators were reeducated by the Administrator and Director of Nursing on 4/21/2017 on completion of care plans on admission, quarterly, and with changes of condition, including that care plans should reflect nursing assessments. Assistant Directors of Nursing, and MDS Coordinators were reeducated by the Administrator and Director of Nursing on 4/21/2017 on completion of care plans on admission, quarterly, and with changes of condition, including that care plans should reflect nursing assessments. Beginning 04/22/2017 daily audits will be completed each shift for wander guard functioning on all identified residents. Beginning 4/21/2017, the Plant Operations Director or the Plant Operations Assistant will check the exit doors in the facility daily for correct functioning and place on their log until immediacy removed. Door function checks will continue to be checked seven days a week for two weeks, then three times a week for 3 weeks by Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Business Office Assistant, Human Resources Director, Dietary Services Manager, Quality of Life Director, Admissions Director, Chaplain, Environmental Services Director, Social Services Director, Business Office Manager, Plant Operations Director or Social Services Assistant. Beginning 4/21/2017, the Plant Operations Director or Plant Operations Assistant Department or nursing will check functioning of Wander guards on all identified residents daily for two weeks. A Code Green Drill (Elopement Drill) was completed on 4/13/17 by the Maintenance Director, and will continue to be completed by the Maintenance Director, Administrator, Director of Nursing, or Staff Development Coordinator as follows: 1 daily on