Every finding on record at Skyland Care Center

Based on record review, and Physician and staff interviews, the facility failed to implement an infection surveillance plan for monitoring and tracking infections in the facility. This practice had the potential to affect 89 of 89 residents in the facility. Findings included: The Surveillance Plan for Infections) policy (Revised May 2022) read in part: The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions. -The Purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAIs, to guide appropriate interventions, and to prevent future infections. -The Criteria for such infections are based on the current standard CDC definitions of infections. -Infections that will be included in routine surveillance include those with: evidence of transmissibility in a health care environment; available processes and procedures that prevent of reduce the spread of infection; clinically significant morbidity or mortality associated with infection (e.g., pneumonia, urinary tract infections, C. difficile); and pathogens associated with serious outbreaks. (e.g., invasive streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza.) -The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. -For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: infection site (be as specific as possible, e.g., cutaneous infections should be listed as pressure ulcer, left foot, pneumonia as right upper lobe, etc.); pathogens; pertinent remarks (additional relevant information, i.e., temperatures, other symptoms of specific infection, white blood cell count, etc.);Treatment measures and precautions. The infection surveillance monthly report for October 2024 was reviewed. The section of the line listing surveillance report labeled symptoms was blank for all the listed infections. There were no diagnostic or laboratory results for any of the listed infections. An interview was conducted with the Infection Preventionist (IP) on 11/20/24 at 10:13 AM. The IP explained she had started the IP role in February 2024 and had attended the North Carolina State Program for Infection Control and Epidemiology (NCSPICE) in April 2024. The IP discussed how she tracked the facility infections. The IP explained she used the electronic computer systems infection control program to track infections. She stated when a resident was started on an antibiotic or a medication for treating an infection the electronic computer systems infection control program added the resident as an infection case. The IP said she did not track infections that were not treated with an antibiotic or anti-infective medication because they were not triggered as a new case in electronic computer systems infection program. She explained a new infection case was triggered in the electronic computer systems infection program when an order was entered for an antibiotic or other anti-infective medication. The IP said infections that were not treated with a medication were not triggered by the electronic computer systems infection program and were not included in the surveillance report. The IP explained she did not have a way she tracked those type of infections. The IP said viral infections, gastrointestinal illnesses such as norovirus, or respiratory illnesses that did not require an antibiotic/ medication for treatment were not tracked. The IP said if an influenza case was not treated with an antiviral medication, it would not be tracked. The IP opened the electronic computer systems infection program and after reviewing the program, she thought she could generate and add a new case manually for an infection that was not treated with an antibiotic/ medication. The IP said, I may start doing that, it would give me a way to track those type infections. The IP agreed those type of infections should be tracked to identify infection trends or outbreaks. The IP said there had not been any outbreaks of GI illness, influenza, or respiratory illnesses that she was aware of. During the interview the IP was unfamiliar with standardized infection definitions and was unable to say what standardized definitions the facility's infection program used. The IP explained if a provider ordered an antibiotic for an infection, she included it as a health care associated infection (HAI) if the antibiotic had not been present on admission. The IP said there was not an infection definition criterion she used to review infections that determined if the infection met the criteria to be counted as a HAI. The IP explained she did not collect data related to infection symptoms to include in the infection surveillance report. The IP said infection symptoms were documented by the provider when they saw the resident and were documented by the floor nurses. The IP said she did review diagnostic and laboratory results but did not include the data on the infection surveillance tracking report. An interview was conducted with the Director of Nursing (DON) on 11/20/24 at 2:15 PM. The DON said the IP should track all infections not just infections that were treated with antibiotics. The DON said all infections needed to be tracked to monitor for trends or a potential outbreak. The DON said she was familiar standardized definition of infections and that the facility used the McGreer Criteria for urinary tract infections. The DON explained she knew there were standardized definitions for other types of infections, but the facility currently did not use them. She said the facility went by what the provider said and the diagnosis the provider gave. The DON stated infection symptoms, diagnostics, and laboratory data results should be included in the surveillance report. The DON had not been aware the IP was only tracking infections that were treated with an antibiotic/medication. An interview was conducted with the Administrator on 11/21/24 at 10:15 AM. The Administrator said the IP should track all infections not just infections that required a medication for treatment. The Administrator agreed all infections should be tracked to monitor for trends or an outbreak. The Administrator said it was important to monitor so interventions could be put into place if trends or an outbreak occurred.

Based on record review and staff interviews, the facility failed to protect residents' rights to be free from misappropriation of controlled medications for 2 of 2 residents (Resident # 348 & Resident #147) reviewed for misappropriation of residents' property. Findings included: The facility has a policy against abuse, neglect, exploitation and misappropriation with a revised date of 3/3/2017. The policy states that any suspected incident of abuse, neglect, exploitation, or misappropriation of resident property is to be reported immediately to a supervisor or a member of administration. The facility will subsequently report any and all suspected incidences of abuse, neglect, exploitation, and/or misappropriation of resident property to the required State and Federal agencies. Any staff member who witnesses abuse, neglect, exploitation, or misappropriation should immediately intervene to protest the resident involved. The witnessing staff member should then report the abuse to their immediate supervisor and/or administrative personnel. All staff members reporting abuse will be protected from reprisal. Any staff member suspected of abuse, neglect, exploitation, or misappropriation will be suspended without pay pending the outcome of the investigation and reported to the proper agencies. The facility will also comply with any instructions or requests that are given or made by any agencies while investigating a situation of abuse, neglect, exploitation, or misappropriation. 1. Resident #348 was admitted to the facility on [DATE]. The significant change Minimum Data Set, dated dated dated [DATE] revealed Resident #348 had severe cognitive impairment. He was coded for a scheduled pain medication regimen, answered yes to the presence of occasional pain, and rated his pain intensity as a 5 on a 0-10 pain scale. He was coded as taking opioid medication. The Physician's order dated 1/23/24 revealed Resident #348 had an order for Hydromorphone (pain medication) 2 milligram (mg) 1/2 tablet by mouth every 8 hours for pain. Review of the Medication Administration Record (MAR) for February 2024 revealed Resident #348 received Hydromorphone three times per day scheduled for 6:00 AM, 2:00 PM, and 10:00 PM. It was signed as administered as scheduled except for being held on 2/06/24 at 10:00 PM for the resident's condition. The controlled substance count sheet for Resident #348's Hydromorphone was requested from the Director of Nursing during interview on 11/20/24 at 8:22 AM. She stated it was probably in a box somewhere in storage. As of the survey exit, the controlled substance count sheet was not provided. The initial allegation report completed by the Administrator dated 2/09/24 revealed the facility became aware of the misappropriation of Resident #348's property on 2/09/24 at 7:20 AM. There were 4 Hydromorphone pills unaccounted for and two nurses (Nurse #6 & Nurse #7) were suspended pending the outcome of the investigation. The 5-day investigation report completed by the Administrator dated 2/14/24 revealed the allegation of misappropriation of resident's property was substantiated as the pills were unaccounted for. Nurse #7 discovered some pills were missing and notified the Director of Nursing (DON). It was discovered that a narcotic medication card containing Resident #348's Hydromorphone tablets were missing from the medication cart. The narcotic count sheet was still in the narcotic count book and showed that the missing card should have had 4 tablets. Review of the facility security camera revealed that Nurse #6 and Medication Aide (MA) #1 had completed the narcotic change of shift count on 2/08/24 at 10:46PM. At 11:03 PM Nurse #6 was observed on the security camera to access the narcotic drawer and take out a narcotic medication card. She removed a pill from the package and placed the medication card on top of the medication cart. She crushed the pill and walked into Resident #348's room. At 1:51 AM on 2/09/24, Nurse #6 was observed to pick up the narcotic medication card and walk into the nurses' station. On exiting the nurses' station at 1:52 AM she had the top portion of the medication card in her hand. She was observed to walk down the hall and throw the top portion of the medication card into the trash can at the end of the hall at 1:53 AM. The trash cans and dumpster were searched but the missing medication card or pills were not located. Nurse #6 and #7 completed urine drug screens which were negative on 2/13/24. Nurse #6 was terminated on 2/14/24. Law enforcement was notified on 2/09/24 at 2:45 PM. A telephone interview on 11/21/24 at 10:50 AM with MA #1 revealed she and Nurse #6 completed the narcotic medication count at the change of shift on 2/08/24, and it was correct when she turned the narcotic keys over to Nurse #6. A telephone interview on 11/19/24 at 7:14 PM with Nurse #6 revealed she denied taking any narcotic medication. She stated the medication count was correct when she and Nurse #7 verified the count at shift change. She stated she had no idea what happened to the missing narcotics. Attempts to interview Nurse #7 by phone were unsuccessful. An interview on 11/20/24 at 8:22 AM with the Director of Nursing (DON) revealed she believed Nurse #6 had either taken the missing pills or thrown them away. The narcotic count sheet showed the missing medication card should have had 4 tablets. She stated she had completed an audit of all narcotic medications in the facility and found no other discrepancies. She stated that based on her observations from the security camera, Nurses #6 and #7 had not counted the narcotic medication cards correctly and miscounted the number of narcotic cards that were in the drawer and the card was not in the drawer at the change of shift. She stated Nurse #7 completed a pain assessment as scheduled on 2/09/24 at 7:00 AM on Resident #348 which was negative. She stated that Resident #348 did not miss any scheduled pain medication. An additional interview on 11/21/24 at 8:24 AM with the DON revealed they completed a corrective action plan for Resident #348's missing narcotic medication. She stated she completed a weekly audit of all narcotic medications in the facility for 6 months and staff in services for misappropriation were conducted on 2/12/24. An interview on 11/21/24 at 9:00 AM with the Administrator revealed she had no idea what happened to the missing narcotic medication but expected the staff to properly count and safeguard the residents' property. She stated the corrective action plan included staff education on misappropriation on how to properly count narcotic medications during shift change and weekly narcotic medication audits for 6 months and these items were completed. 49000 2. Resident #147 was admitted to the facility on [DATE]. There was a physician's order dated 12/21/23 stating that Resident #147 could receive 1 tablet of Oxycodone (controlled narcotic pain medication) 5 milligrams (mg) every 4 hours as needed for pain. An Initial Allegation Report completed by the Administrator on 03/29/24 revealed the facility became aware of a possible narcotic diversion on 3/29/24 at 9:00 pm involving Resident #147. The report stated that Nurse #2 called the Director of Nursing (DON) and informed her that she believed there was a possible narcotic diversion involving Nurse #1. Nurse #2 believed that Nurse #1 signed her name on a narcotic count sheet and that Nurse #1 signed off narcotics with a future date. On 3/30/24 at 7:35PM the local police department was notified, and a telephone message was left for the Department of Social Services. Nurse #1 was terminated from her position on 3/30/24 and the allegation was substantiated. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #147 was cognitively intact. He had a diagnosis of diabetic foot ulcer and currently prescribed an opioid. On 11/19/24 at 3:30 PM a telephone call was made to Nurse #1 and was unsuccessful in reaching her. On 11/19/24 at 5:30 PM a telephone interview was completed with Nurse #2. She stated that she worked the evening shift from 6:30 pm till 6:30 am and knew Resident #147 very well. Nurse #2 stated that when assigned to Resident #147 he had never asked for more than 1 of his (as needed) PRN narcotic pain pills (oxycodone) during her 12 hour shift. Nurse #2 stated that Resident #147 was alert and oriented times 4. Nurse #2 stated on 3/28/24 she started her shift at 6:30 PM. She remembers giving Resident #147 a oxycodone medication at 2:00 AM on 3/29/24 and remembers signing the narcotic record sheet. Nurse #2 remembered that after giving out the 2:00 AM oxycodone pill there was at least 4 pills left maybe more she could not remember for sure. Nurse #2 did not give out any more oxycodone during her shift and left around 6:30 AM on 3/29/24. Nurse #2 came back on shift around 6:30 PM on 3/29/24 and was given report from Nurse #1 who was leaving her shift. During report Nurse #1 told Nurse #2 that if Resident #147 needed any oxycodone that Nurse #2 would need to get more of the medication from the automated medication dispersing unit. Nurse #2 was surprised to hear this since when she left 12 hours ago there were at least 4 oxycodone pills left. Nurse #2 went to find the narcotic record sheet and noticed that Nurse #2's signature was on the sheet showing she (Nurse #2) gave Resident #147 a oxycodone at 6:00 AM on 3/29/24. Nurse #2 knew that she did not give out this pill and that it appeared that Nurse #1 had forged her signature. Nurse #2 called the Director of Nursing (DON) about this. Then Nurse #2 looked at the sheet more closely and noticed that Nurse #1 had signed out oxycodone for a date of 3/30/24. Nurse #2 called the DON again and informed her that pills had been signed out for a future date. On 11/20/24 at 9:30 AM an interview was conducted with the DON. She stated that she got a call from Nurse #2 around 7:30 PM on 3/29/24 regarding the narcotic sheet for Resident #147. The DON stated that Nurse #2 explained to her that she gave Resident #147 a oxycodone at 2:00 AM but the sheet was showing that she signed out a pill for him at 6:00 AM on 3/29/24 and Nurse #2 let the DON know she did not administer the pill. The DON started reviewing the medication administrative record from home. The DON stated she could not remember if it was her or Nurse #2 that noticed that oxycodone pills were signed out for 3/30/24 and it was the evening of 3/29/24. On 3/30/24 Nurse #1 came to the facility to start her 6:30 AM shift and the DON and the Assistant Director of Nursing (ADON) questioned Nurse #1 about the narcotic sheet and Nurse #1 admitted to taking 4 oxycodone pills from Resident #147. The DON stated that Nurse #1 was terminated on the spot and Nurse #1 told them that she would be giving up her license voluntarily. The DON had already informed the Administrator by this time. The local police department was called as well. The DON stated medication costs for Resident #147 were being paid by the facility, so it was no cost to him. On 11/20/24 at 2:35 PM an interview was conducted with the ADON. The ADON stated she got a call from the DON the evening of 3/29/24 about a possible drug diversion and asked her to meet her at the facility. She came to the facility the morning of 3/30/24 and met Nurse #1 along with the DON. They went into an office and spoke to Nurse #1 regarding Resident #147's narcotic sheet. Nurse #1 admitted to taking 4 oxycodone pills from Resident #147. The ADON stated that when she was first notified of this incident she and the DON called the local police and the police came to the facility to start their investigation. The ADON and DON also called the Administrator, Medical Director and the Resident #147's family. On 11/21/24 at 10:35 AM an interview was conducted with the Administrator. She stated that she received a call from the DON regarding a possible drug diversion involving Nurse #1 and Resident #147. The Administrator met with the Nurse #1 on 3/30/24 and she was terminated. The Administrator stated she and the DON started a plan of correction involving monitoring the narcotic drug sheets, in service on signing the sheets and reviewing the cards to make sure they are correct. The Administrator stated they have not had any other drug diversion since March 2024. The facility provided the following Corrective Action Plan with a correction date of 3/31/24. Corrective action for resident(s) affected by the alleged deficient practice. - Employee was immediately terminated after her own admission to protect residents. The facility reported the nurse to the Local Police Department, Adult Protective Services, NC Healthcare Personal registry, and NC Board of Nursing. Completed on 3/30/24. - The DON will complete a misappropriation in-service with nurses including agency staff and medication aides about Diversion of Narcotics, the severity of diverting medications, and the ramifications of taking part in diverting narcotics. Completed on 3/30/24 - Resident's medication administration records (MARs) were audited on the nurse's assignment on March 29, 2024, to identify if the nurse may have diverted any other narcotics from any other residents. There was no evidence that any other medication had been diverted from any other residents. Measures/Systemic changes to prevent reoccurrence of alleged deficient practice: - They had previously educated the employee on the facility misappropriation policy upon hire in November 2023, and during the quarterly abuse in-service on February 21, 2024. The nurse would have received extensive training to obtain her license in not diverting medications. - The facility followed pre-employment procedures, which include background check, references checked, orientation, and all other in-services. - The facility immediately reported the incident, investigated, and took action. Monitoring Procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements. - The DON or designee will audit the narcotic sign out books for suspicious entries every week for 3 months, every two weeks for 1 month, and then monthly thereafter for six months, unless deficient practice is found, and the time will be extended until total compliance is achieved. - This audit will be documented and turned into the Administrator to be reviewed with the IDT in the monthly QAPI meeting to assure complete compliance. - Nurses and medication aides were in-serviced prior to the start of their next shift. Date of Compliance : 3/31/24 On 11/21/24, the facility's corrective action plan effective 3/31/24 was validated by the following: On 3/29/24 the DON started in-service training for all nurse and medication aides. The in-service was to ensure nurse/medication aides visualized both the medication card and the narcotic count sheets together at the medication cart. The nurse coming on and the nurse signing off would be doing the narcotic medication count together at the cart seeing both the medication card and the narcotic sheet. If the nurse/medication aide notice anything suspicious with the count, the number of medications given or missing medication they were to call the DON immediately. They were also in-serviced on the fact that drug diversion was a criminal offense and will result in termination and could result in license suspension, criminal charges and or jail time. There was an in-service attendance sign in sheet dated 3/30/24 that had 32 signatures and 4 attendees that were in-serviced by telephone. Interviews were conducted with licensed nurses, and they were able to verbalize going over the narcotic sheet and count book when ending or beginning a shift. They were able to verbalize if they see something wrong they would call the DON immediately and report what they saw. Starting on week 3/30/24 the DON started doing a narcotic sheet audit every week for each hall. This audit started on 3/30/24 and shows audit being done weekly for all halls in the facility. It was confirmed through the Board of Nursing that Nurse #1's license had been suspended on 4/22/24 for a minimum of 12 months. The completion date of 3/31/24 was validated.

Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for 1 of 2 residents (Resident #74) reviewed for PASRR. The findings included: Resident #74 was admitted to the facility on [DATE]. A review of Resident #74's medical record indicated post-traumatic stress disorder (PTSD) was added to his diagnoses list effective 4/22/24. Resident #74's medical record indicated he currently had a PASRR Level I. An interview with the Social Services Director (SSD) on 11/20/24 at 1:29 PM revealed she was responsible for PASRR, and she confirmed that Resident #74 currently had a PASRR Level I. The SSD stated she did not know about Resident #74's PTSD diagnosis and if she had, she would have applied for a PASRR Level II. The SSD further stated that she wasn't sure when Resident #74 was diagnosed with PTSD, but the nurses would need to notify her if the residents had a new mental health diagnosis. An interview with the Minimum Data Set (MDS) Coordinator on 11/20/24 at 1:36 PM revealed she added PTSD to Resident #74's diagnoses list on 4/22/24 based on a note from the psychiatric provider for the same date. The MDS Coordinator stated that Resident #74 was diagnosed with PTSD on 4/22/24. She stated that she didn't have anything to do with PASRR and this was handled by the SSD. The MDS Coordinator further stated that the SSD worked closely with the psychiatric provider, and they should be giving her information about any new mental health diagnoses. During a follow-up interview with the SSD on 11/20/24 at 2:03 PM, the SSD stated that the previous psychiatric provider worked closely with her. She stated that they have had a new psychiatric provider before April 2024, and he did not always notify her of any new mental health diagnosis. She added that she would not apply for a PASRR Level II for Resident #74 because PTSD was not included in the list of approved diagnoses for designation as serious mental illness or serious and persistent mental illness. During the interview, the SSD shared a list entitled, Pre-Admission Screening and Resident Review for Adult Care Homes. The SSD stated that she was told during a seminar about MDS and PASRR that this list also applied to nursing home residents. An interview with the Administrator on 11/20/24 at 2:03 PM revealed they would not necessarily apply for a PASRR Level II for a new diagnosis of PTSD, and it would depend on the circumstances when Resident #74 was diagnosed with PTSD. The Administrator stated that she agreed that PTSD was not included in the list of mental health diagnoses that the SSD used.

Based on record review, review of surveillance video, and interviews with staff, Nurse Practitioner (NP) and Medical Director (MD), the facility failed to assess Resident #287 immediately after a fall from the contracted transportation van. On 12/12/22 Resident #287 was rolled out of the back of the contracted transportation van in her wheelchair and fell to the ground landing on her left side and hitting the back of her head. The Contracted Transporter lifted Resident #287 back into her wheelchair and wheeled her into the facility without being assessed by a licensed professional. The Resident complained of mid back pain at 7 out of 10 (10 being the worst pain) and bruising was noted on her right forearm. Resident #287 was sent to the emergency department for evaluation and diagnosed with a compression fracture of the L1 vertebrae. There is the high likelihood of further injury when a resident is moved after a fall before being assessed by a licensed professional. This deficient practice occurred for 1 of 3 residents review for accidents (Resident #287). Immediate Jeopardy began on 12/12/22 when the Contracted Transporter lifted Resident #287 from the ground back into her wheelchair even after being instructed by a staff member not to move the Resident. Immediate Jeopardy was removed on 6/28/23 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Findings Included: Resident #287 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease with dialysis dependency and diabetes mellitus type 2. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #287 was cognitively intact and required extensive assistance with transfers and was receiving dialysis during the assessment lookback period. A review of a transportation contractor document titled North Carolina Department of Transportation (NCDOT) integrated Mobility Division: Minimum Training Standards dated January 2022 read in part training must be conducted with new hires and annually thereafter as refreshers training with re-certification. Training topics included wheelchair/mobility device training, securement, emergency procedures for medical emergencies, accident or incident reporting procedures, and lift/ramp inspection and operation. The contracted van driver completed these trainings upon hiring. Review of an incident report dated 12/12/22 at 11:36 AM completed by Nurse #3 read in part, Nurse #3 was called to the front of the building and informed that a resident had fallen from her wheelchair onto the lift. Resident #287 stated she had fallen while being escorted from the transport van by the Contracted Transporter. Resident #287 had a small bump to the back of her head. She also had some bruising to her right forearm and complained of mid back pain 7 out of 10. A review of the facility's security video with the Administrator occurred on 6/27/23 at 2:30 PM. The video footage did not contain sound and was partially obscured as Resident #287's wheelchair was seen tumbling from the back of the contracted transportation van without Resident #287 in it. The van's opened back doors partially obstructed the view of the accident and Resident #287 was unable to be viewed falling out of the wheelchair and hitting the grounded gate lift. The video footage showed Resident #287 lying on the grounded lift gate of the van with the Contracted Transporter soon after arriving to Resident #287. Nurse Aide (NA) #3 comes into to view and was seen speaking with the Contracted Transporter and then entering the facility as the Contracted Transporter picked up Resident #287 underneath the arms and placed her into the wheelchair. The Contracted Transporter pushed Resident #287 into the facility. Resident #287 was seen entering the facility without any visible blood and pointing at the back of her head and did not appear to be in distress. A review of the statement signed by the Contracted Transporter dated 12/12/22 read in part, I was unloading Resident #287. While unloading the lift was unfolded without my knowledge, I pushed her out and she fell to the ground. I immediately got down to see if she was okay. Never lost consciousness. She stated she was okay. Got her back in the chair. Again, asked if she was okay, she stated she was still okay. I parked the van and came straight inside. Happened around 11:30. Struck the right side of body. The Contracted Transporter was unable to be interviewed due to no phone contact information. Resident #287 was discharged from the facility 1/7/23 and was unable to be interviewed. The facility's Transportation Supervisor was interviewed on 6/30/23 at 9:10 AM. The Transportation Supervisor reported contracted transporters were not trained or educated by her or the facility. Contracted transporters were trained and certified by the company they worked for, and the Contracted Transporter received his training from the NCDOT as required for hiring. The Contracted Transportation Supervisor was interviewed via telephone on 6/27/23 at 3:30 PM. She confirmed the Contracted Transporter had received his NCDOT training before he was allowed to transport residents. The Contracted Transportation Supervisor stated she could not give any other information. An interview was conducted with NA #3 on 6/26/23 at 1:53 PM. She stated she observed Resident #287 lying on her left side in the fetal position on the ground behind the van as she entered the parking area returning from her break. The resident's wheelchair was located behind and to the side of lift gate. NA #3 explained she spoke to the Contracted Transporter and instructed him to not move Resident #287 as she was going to find assistance from inside the facility. She observed the Contracted Transporter in the process of moving the resident from the ground but did not observe the Contracted Transporter placing the resident back into the wheelchair. Nurse #3 was interview on 6/27/23 at 1:40 PM and stated he was paged overhead by the receptionist to go to the front of the building because a resident had fallen from a transportation van. The Resident was in the front lobby of the facility sitting in her wheelchair when he arrived, and the Contracted Transporter said he was not paying attention to the resident, and she fell out of the van. Nurse #3 stated he assessed Resident #287 in her room who was alert and talking with complaints of intermittent pain in her back and indicated she hit the back of her head. A review of the Nurse Practitioner (NP) assessment note dated 12/12/22 read in part Resident #287 was returning to the facility from dialysis. The driver of the transit van apparently dropped the patient (Resident #287) from the lift. He (van driver) picked the patient up and put her into the wheelchair to bring her back into the facility. The patient is complaining of acute low back pain. Pain is increased with any movement of her legs. She did hit the back of her head and has a small abrasion or contusion with complaints of a headache. Resident to be transferred to the ED for evaluation. An interview with the NP was conducted on 6/28/23 at 9:33 AM. The NP stated had assessed the resident when the resident returned to her unit after the fall from the contracted transportation van. The resident appeared uncomfortable and had told her she had been dropped and the Contracted Transporter picked her up and put her back into the wheelchair. The NP stated that Resident #287 could have had more injury because the Contracted Transporter had moved the resident without being assessed by a licensed staff first. A review of Emergency Department (ED) notes dated 12/12/22 revealed the patient 's chief complaint was a fall. The patient reported sharp shooting pain back of her head and lumbar spine, non-radiating, constant, and worse with motion. The patient denied any neck pain. The ED diagnostic imaging found a 50% compression of L1 (lumbar) vertebral body. The ED plan of care recommended supportive care measures with a primary care physician follow-up. Resident #287 was provided one tablet of oxycodone 325 MG (pain medication) while in the ED. She discharged from the ED on 12/12/22 and sent back to the facility. The Medical Director (MD) was interviewed on 6/30/23 at 10:10 AM. He stated that in general moving a resident without a licensed professional assessing them could result in further injury. The Administrator was interviewed on 6/26/23 at 1:53 PM. She reported she was notified immediately on 12/12/22 when Resident #287 had fallen from a contracted transportation van in the parking lot and went to the front entrance of the building. The Contracted Transporter had picked up the resident and placed her into the wheelchair before licensed staff could assess her. The resident's assigned nurse, Nurse #3, was called to the front to assess and take Resident # 287 to her room. The NP was in the facility, assessed the resident and sent the resident to the ED for evaluation. Resident #287 had a fractured L1 vertebrae from the accident. The Administrator stated the Contracted Transporter was interviewed and the security video footage was reviewed to see the cause of the accident. The Administrator stated the facility initiated an investigation immediately and was able to get a written statement and an interview from the Contracted Transporter before he left. The Contracted Transporter stated he pushed Resident #287 out of the van, and she fell to the ground. The Contracted Transporter immediately got down from the van to check if she was ok. The Contracted Transporter reported Resident #287 reported to him she was ok, and he placed her back into her wheelchair and he pushed her inside the building. The Administrator was notified of Immediate Jeopardy on 6/26/23 at 6:10 PM The facility provided the following Credible Allegation of immediate Jeopardy removal: 1. The facility immediately conducted an action plan to address contract transportation services with post-accident policies to include assessment. Included in this action plan was but not limited to: o On 12/12/2022 - 12/15/2022 we worked with the contracted transportation company to ensure training of all contract drivers that provide services to Skyland Care Center including the individual involved in the accident. I spoke directly with the supervisor about the driver moving the resident before our nurse came to assess. She informed me that she was doing an internal investigation, and this was against their companies' procedures and the driver should have immediately called 911 after the incident. She informed me that the driver was in-serviced on this procedure and if allowed to continue employment, he would be in-serviced again. I also requested training with contracted drivers to notify the facilities front desk staff prior to assisting residents from vehicles to ensure the transfer is completed safely. The driver was not allowed to drive any facility residents if the contracted company allowed his employment going forward. o On 12/15/2022 the administrator in-serviced all front reception employees to locate a CNA/Nurse when transit notified them, they were in the parking lot. They were to go to the transit vehicle and stand beside the lift to assure the residents are unloaded safely. As of March 20, 2023, we no longer use a contracted agency for transportation and all transportation is performed in house unless the resident needs stretcher service and then they are transported per EMS. 2. The facility terminated its transportation contract in March 2023 and no longer has an outside transport company they currently use. 3. On 6/26/2023 the Administrator and Staff Development RN conducted an in-service for all employees on what to do if they witness a resident fall. Staff will not be allowed to complete a shift before completion of the training. In addition, the orientation process was reviewed, and reporting accidents and proper assessing was already part of the orientation process and will continue as part of initial facility education and orientation. The education included: a. Call for a nurse to evaluate for possible injuries (DO NOT MOVE THE RESIDENT UNTIL ASSESSED BY A NURSE). b. Obtain vital signs as soon as safe to do so. c. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. d. Notify residents attending physician and family in an appropriate time frame. e. Report violations of these procedures to the Administrator. 4. Training for all in-house transportation staff was started on 6/27/2023 by the Transportation Director. Transportation staff will not be allowed to drive the van until they have completed the in-service. The in-service included reviewing pictures posted in facility van showing the proper way to load/unload residents and re-reviewed the signage posted in the van citing the steps to take if incident/accident happens in route. These steps include 1. Call 911, 2. DO NOT MOVE RESIDENT UNTIL ASSESSED BY EMERGENCY OFFICIALS, 3. Call Administrator, 4. Call facility to send nurse to the scene, and 5. Wait for further instructions. This was recently in-serviced in our annual October 2022 in-service. 5. The Administrator is responsible for all issues related to immediate jeopardy removal. Alleged IJ removal date: 6/28/23 On 6/30/23 the facility's plan for Immediate Jeopardy removal effective 6/28/23 was validated by the following: Documentation and interviews with staff. Review of the in-service sign in sheets revealed all facility staff received education on what to do if they witness a resident fall. Staff who worked in each department and on all shifts were interviewed. Interviewed facility staff reported they should not move a resident who had fallen before the resident could be assessed by a nurse. Interviewed licensed facility staff reported after the resident had been assessed by a nurse, vitals would be taken, first aid or medical treatment would be administered if appropriate, and the attending physician and family would be notified as soon as possible. Interviewed transportation staff stated if a resident fell during transport, 911 would be called immediately, the resident would not be moved until assessed by emergency officials, the Administrator and facility would be called. The transportation staff stated instructions for actions to take if an accident or incident occurs were posted in the van. The transportation guide instructions were observed accessible in the vans along with posted photographs demonstrating residents facing out of the van when unloading. The facility no longer uses any contracted van services.

Based on observations, record reviews, video surveillance review, and staff and Nurse Practitioner interviews the facility contracted van driver failed to ensure the lift gate was in the elevated position before unloading a resident from the back of a facility contracted van. On 12/12/22 Resident #287 was rolled out of the back of the contracted transportation van in her wheelchair and fell to the ground landing on her left side and hitting the back of her head. The Resident complained of mid back pain at 7 out of 10 (10 being the worst pain) and bruising was noted on her right forearm. Resident #287 was sent to the emergency department for evaluation and diagnosed with a compression fracture of the L1 vertebrae. This occurred for 1 of 3 residents sampled for accidents (Resident #287). Immediate Jeopardy began on 12/12/22 when Resident #287 was rolled out of the back of the contracted transportation van in her wheelchair and fell to the ground. Immediate Jeopardy was removed as of 6/28/23 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: Resident #287 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease with dialysis dependency and diabetes mellitus type 2. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #287 was cognitively intact and required extensive assistance with transfers and was receiving dialysis during the assessment lookback period. She used a wheelchair and a walker for mobility. Review of a facility document titled Transportation Service Agreement for the transit contractor dated July 1, 2022, through June 30, 2023, read in part that the contractor agrees to comply with all applicable federal and state regulations concerning human services. Furthermore, the contractor is responsible for ensuring the drivers are trained in defensive driving and in wheelchair securement. A review of a transportation contractor document titled North Carolina Department of Transportation (NCDOT) integrated Mobility Division: Minimum Training Standards) dated January 2022 read in part training must be conducted with new hires and annually thereafter as refreshers training with re-certification. Training topics included wheelchair/mobility device training, securement, and lift/ramp inspection and operation. The contracted van driver completed these trainings upon hiring. Review of an incident report dated 12/12/22 at 11:36 AM completed by Nurse #3 read in part, Nurse #3 was called to the front of the building and informed that a resident had fallen from her wheelchair onto the lift. Resident #287 stated she had fallen while being escorted from the contracted van by the Contracted Transporter Resident #287 had a small bump to the back of her head. She also had some bruising to her right forearm and complained of mid back pain 7 out of 10. A review of the facility's security video with the Administrator occurred on 6/27/23 at 2:30 PM. The video footage did not contain sound and was partially obscured as Resident #287's wheelchair was seen tumbling from the back of the contracted transportation van without Resident #287 in it. The van's opened back doors partially obstructed the view of the accident and Resident #287 was unable to be viewed falling out of the wheelchair and hitting the grounded gate lift. The video footage showed Resident #287 lying on the grounded lift gate of the van with the Contracted Transporter soon after arriving to Resident #287. Nurse Aide (NA) #3 comes into view and was seen speaking with the Contracted Transporter and then entering the facility as the Contracted Transporter picked up Resident #287 underneath the arms and placed her into the wheelchair. The Contracted Transporter pushed Resident #287 into the facility. Resident #287 was seen entering the facility without any visible blood and pointing at the back of her head and did not appear to be in distress. A review of the statement signed by the Contracted Transporter dated 12/12/22 read in part, I was unloading Resident #287. While unloading the lift was unfolded without my knowledge, I pushed her out and she fell to the ground. I immediately got down to see if she was okay. Never lost consciousness. She stated she was okay. Got her back in the chair. Again, asked if she was okay, she stated she was still okay. I parked the van and came straight inside. Happened around 11:30. Struck the right side of body. The Contracted Transporter was unable to be interviewed due to no phone contact information. Resident #287 was discharged from the facility 1/7/23 and unable to be interviewed. The Contracted Transportation Supervisor was interviewed via telephone on 6/27/23 at 3:30 PM. The Supervisor reported that the Contracted Transporter was no longer employed with the company. The Supervisor stated she was notified by the facility Administrator immediately after the accident occurred on 12/12/22. The Supervisor did not remember the specific day or time the Administrator had called to inform the plan of correction the facility had put into place. The Supervisor confirmed the Administrator had informed her the plan was that the transportation company van drivers would notify the facility upon arrival and wait for a facility staff to be present when unloading a resident. The Supervisor stated and she was unable to share any additional information. The facility's Transportation Supervisor was interviewed on 6/30/23 at 9:10 AM. The Transportation Supervisor reported contracted transporters were not trained or educated by her or the facility. Contracted transporters were trained and certified by the company they worked for, and the contracted van driver received his training from the NCDOT as required for hiring. Furthermore, the Transportation Supervisor stated the facility drivers did not load and unload a resident without additional trained assistant present. The residents were never unloaded facing the front of the van and always had a staff member in direct contact with the wheelchair during the process with a staff in the van and one on the ground. An interview was conducted with NA #3 on 6/26/23 at 1:53 PM. She stated she observed Resident #287 lying on her left side in the fetal position on the ground behind the van as she entered the parking area returning from her break. The resident's wheelchair was located behind and to the side of lift gate. NA #3 explained she spoke to the Contracted Transporter and instructed him to not move Resident #287 as she was going to find assistance from inside the facility. She observed the Contracted Transporter in the process of moving the resident from the ground but did not observe the Contracted Trasporter placing the resident back into the chair. NA #3 said Resident #287 did not appear in distress and was not yelling or crying. Nurse #3 was interview on 6/27/23 at 1:40 PM and stated he was paged overhead by the receptionist to go to the front of the building because a resident had fallen from a transportation van. The Resident was in the front lobby of the facility sitting in her wheelchair when he arrived, and the Contracted Transporter said he was not paying attention to the resident, and she fell out of the van. Nurse #3 stated he assessed Resident #287 in her room who was alert and talking with complaints of intermittent pain in her back and indicated she hit the back of her head. Nurse #3 explained the NP was in the facility and had the resident sent to the emergency department (ED). A review of the Nurse Practitioner (NP) assessment note dated 12/12/22 read in part Resident #287 was returning to the facility from dialysis. The driver of the transit van apparently dropped the patient (Resident #287) from the lift. He (van driver) picked the patient up and put her into the wheelchair to bring her back into the facility. The patient is complaining of acute low back pain. Pain is increased with any movement of her legs. She did hit the back of her head and has a small abrasion or contusion with complaints of a headache. Resident to be transferred to the ED for evaluation. An interview with the NP was conducted on 6/28/23 at 9:33 AM. The NP stated had assessed the resident when the resident returned to her unit after the fall from the contracted transportation van. The resident had low back pain and when moving her legs. The resident was complaining of a headache as she had hit the back of her head and had a bruise to her right arm. The resident did not lose consciousness, was alert and was not bleeding. The resident appeared uncomfortable and had told her she had been dropped and the Contracted Transporter picked her up and put her back into the wheelchair. The NP reported the resident returned to the facility with a diagnoses of a lumbar compression fracture. A review of Emergency Department (ED) notes dated 12/12/22 revealed the patient's chief complaint was a fall. The patient reported sharp shooting pain back of her head and lumbar spine, non-radiating, constant, and worse with motion. The patient denied any neck pain. The ED diagnostic imaging found a 50% compression of L1 (lumbar) vertebral body. The ED plan of care recommended supportive care measures with a primary care physician follow-up. Resident #287 was provided one tablet of oxycodone 325 milligrams (narcotic pain medication) while in the ED. She discharged from the ED on 12/12/22 and sent back to the facility. The Administrator was interviewed on 6/26/23 at 1:53 PM. She reported she was notified immediately on 12/12/22 when Resident #287 had fallen from a contracted transportation van in the parking lot and went to the front entrance of the building. Resident #287 was sitting in her wheelchair inside the front door of the facility. The Administrator indicated no one witnessed the fall but the Contracted Transporter and that NA #3 had seen Resident #287 lying on the ground behind the van as she entered the parking area. The resident's assigned nurse was called to the front to assess and take Resident # 287 to her room. The NP was in the facility, assessed the resident and sent the resident to the ED for evaluation. Resident #287 had a fractured L1 vertebrae from the accident. The Administrator stated the driver of the contracted transportation van was interviewed and the security video footage was reviewed to see the cause of the accident. The Contracted Transporter had reported he did not know the lift gate was on the ground when he was unloading Resident # 287 and he pushed her out the back of the van causing the accident. The Administrator stated the facility initiated an investigation immediately and was able to get a written statement and an interview from the Contracted Transporter before he left. The Contracted Transporter reported to the Administrator while unloading Resident #287, the lift was unfolded without his knowledge. The Contracted Transporter stated he pushed Resident #287 out of the van, and she fell to the ground. The Contracted Transporter immediately got down from the van to check if she was ok. The Contracted Transporter reported Resident #287 reported to him she was ok, and he placed her back into her wheelchair and he pushed her inside the building. The Administrator indicated he spoke with the Contracted Transportation Supervisor and who stated the Contracted Transporter involved with the accident on 12/12/22 would not be allowed to transport any more residents from the facility. The Contracted Transportation Supervisor informed the Administrator all training for contracted transporters was completed, and up to date with Department of Transportation (DOT) standards. The facility put a new process in place on 12/15/22 and the contracted transporters would notify the facility when a resident returned to the facility. A staff member would be present when residents are being unloaded from the van and stand near the van lift to assure the residents are brought down safely. The Administrator concluded with the front door staff (reception) had been in-serviced on the procedure. The Administrator was notified of Immediate Jeopardy on 6/26/23 at 6:10 PM The facility provided the following Credible Allegation of immediate Jeopardy removal: 1. Review of the incident and accident and completion of root cause analysis to identify if the facility could have prevented the fall. In review of this incident, the facility felt the facility could not have done anything else to prevent the fall from occurring as the facility was using an outside contractor service and the driver involved had been properly trained on proper transfer of residents on and off the van. The facility was provided with training that was conducted by the outside company for their drivers and proper use of lifts is part of that training. In this incident, the van driver simply forgot the position of where he had left the lift and made a mistake. 2. The facility immediately reported the Transportation Driver to his employer and demanded review of the situation and corrective actions. The facility requested all documentation from the transportation company. The transport company refused to release the actual training for the driver. They did send a blank copy of the DOT training that all drivers complete. The supervisor did verify verbally that training was up to date for the driver. 3. The facility immediately conducted an action plan to address contract transportation services with post-accident policies. Included in this action plan was but not limited to: o Working with the Transportation Company to ensure training of all contract drivers that provide services to Skyland Care Center to include the individual involved in the accident. This training includes a request to the transport company alert facility staff prior to assisting residents from the van to stand by and monitor the safety of the transfer. The driver involved in the accident was not allowed to transport any facility residents if he was allowed to continue employment with the transportation company. o Systemic changes were as follows: Facility put in place that a facility CNA/Nurse must be present when a contracted company employee unloads a resident from their transport vehicle. We no longer use outside transport companies as of March 20, 2023. In addition to the steps taken in December 2022 and ongoing to prevent adverse outcomes, and following review that this was an isolated conduct issue of a contracted employee, the Facility has taken and/or modified the necessary steps required by the state operations manual to provide a credible allegation of compliance. 1. The facility terminated its transportation contract in March 2023 and no longer has an outside transport company they currently use. 2. Facility drivers will be in-serviced starting on 6/27/2023 by the Director of Transportation on the facility lift and safety procedures in accordance with the manufacturers' specifications and will demonstrate competency. Transportation drivers will not be allowed to drive the van until they have completed the training. The transportation director is keeping track of the training. The transportation drivers were educated that the staff member and resident should be facing out when taking a resident out of the van onto the lift gate. Pictures are posted in the van indicating this. 3. In the future if contract transportation services, are used by the facility, they will be required to provide the same training for their employees and provide documentation of the training for each driver who provides services for the facility before they can transport residents. If they refuse, we will not contract with this company. 4. The Administrator is responsible for all issues related to immediate jeopardy removal. Alleged IJ removal date: 6/28/23 On 6/30/23 the facility's plan for Immediate Jeopardy removal effective 6/28/23 was validated by the following: Documentation and interviews with staff. Review of the in-service sign in sheets revealed all transportation staff received education and training of the facility van lifts and safety procedures. Interviewed transportation staff reported they follow the guide instructions posted in the transport vans for operating the lift, securing the wheelchairs and what actions to take if an accident or incident occurs. The transportation guide instructions were observed accessible in the vans along with posted photographs demonstrating residents facing out of the van when unloading. The facility no longer uses any contracted van services.

Based on observations, record review, resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications for 1 of 1 sampled resident observed with medications at bedside (Resident #53). Findings included: Resident #53 was admitted to the facility on [DATE]. Her diagnoses included heart failure, hypertension, and chronic obstructive pulmonary disease (difficulty breathing). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #53 had intact cognition and required limited to extensive staff assistance with most activities of daily living. Review of the medical record revealed no documentation in 2022 or 2023 that Resident #53 was assessed for self-administration of medications. Review of the physician's orders for Resident #53 revealed no order for self-administration of medications. During an observation and interview on 06/26/23 at 12:06 PM, Resident #53 was sitting up on the side of her bed with the overbed table pulled directly in front of her and placed on top of the overbed table was a medicine cup containing approximately 8 pills and two inhalers. Resident #53 picked up the medicine cup, put all the pills into her mouth and then took a drink of water to swallow the pills. Resident #53 was not observed to self-administer the inhalers. Resident #53 stated the pills were her morning medications that Nurse #1 had left for her to take. Resident #53 stated she had not requested to self-administer her medications and Nurse #1 usually waited as she took her medications before leaving the room but had not done so today. During an interview on 06/26/23 at 4:13 PM, Nurse #1 revealed when she administered Resident #53's morning medications, she watched Resident #53 lift the medicine cup to her lips, so she left the room thinking Resident #53 had put the pills in her mouth to swallow. Nurse #1 was unaware that Resident #53 had not taken her morning medications until 12:06 PM and stated she normally waited in the room with Resident #53 as she took her medications but did not this morning. Nurse #1 confirmed Resident #53 did not have an order to self-administer medications. During an interview on 06/28/23 at 3:45 PM, the Director of Nursing (DON) stated it was not facility procedure for nurses to leave residents oral medications or inhalers at bedside. The DON stated nurses were expected to wait at bedside for the resident to take their oral medications prior to leaving the room. In addition, nurses were to wait for the resident to use the inhaler as ordered and then place the inhaler back in the medication cart. The DON explained residents could get a physician's order to self-administer medications but had to be assessed first. She did not recall Resident #53 requesting or being assessed to self-administer her medications and confirmed Resident #53 did not have a physician's order to self-administer medications. During an interview on 06/30/23 at 12:17 PM, the Administrator stated nursing staff were expected to stay in the room to ensure residents took and swallowed their oral medications. The Administrator further stated in order for a resident to self-administer medications, there needed to be a self-administration assessment completed and a physician's order.

Based on record review and staff interviews the facility failed to develop a baseline care plan within 48 hours of admission that addressed a resident's immediate needs for 1 of 4 sampled residents reviewed for baseline care plans (Resident #82). The findings included: Resident #82 was admitted to the facility on [DATE] with diagnoses including diabetes, pneumonia, and respiratory failure. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had moderate impairment in cognition. He required limited assistance with activities of daily living and used a walker and wheelchair for mobility. Further review revealed Resident #82 received insulin injections 7 of 7 days, anticoagulant (blood thinner) medication 7 of 7 days and antibiotic medication 5 of 7 days during the MDS 7-day look-back period. Review of Resident #82's medical record on 06/28/23 at 2:27 PM revealed no evidence a baseline care plan was completed. During an interview on 06/28/23 at 4:00 PM, Nurse #3 revealed the admitting nurse was responsible for initiating baseline care plans. Nurse #3 could not recall if he was the admitting nurse when Resident #82 was admitted to the facility on [DATE]. Nurse #3 confirmed no baseline care plan was initiated or completed for Resident #82 and stated it was likely just an oversight. During an interview on 06/29/23 at 10:23 AM, the Director of Nursing (DON) revealed the admitting nurse was responsible for initiating and completing baseline care plans. The DON verified Nurse #3 was the admitting nurse when Resident #82 was admitted to the facility. The DON stated a baseline care plan should have been completed for Resident #82 and might have been overlooked. During an interview on 06/30/23 at 12:17 PM, the Administrator explained baseline care plans should be completed by the admitting nurse as part of the admission process.

Based on observations, record review, and interviews with staff the facility failed to assure a nurse assessed a new skin tear and determined treatment for 1 of 4 residents reviewed for skin conditions (Resident #13). The findings included: Resident #13 was admitted to the facility on [DATE]. Resident #13's diagnoses included Alzheimer's disease, dementia, and anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #13 as having severely impaired cognition and extensive assistance was required for bed mobility and transfers and total assistance with toilet use. Review of the physician's standing orders for the treatment of skin tears read in part, The nurse was responsible for documentation in the nurse notes, writing the order for treatment and filling out an incident report and notifying the Medical Doctor (MD) or Nurse Practitioner (NP). Review of the medical records for Resident #13 revealed no documentation of an incident for a skin tear to the right forearm dated 06/24/23, 06/25/23, or 06/26/23. An observation made on 06/26/23 at 11:45 AM revealed a skin tear injury to the anterior middle right forearm of Resident #13. The skin tear was covered with two adhesive skin closures and measured approximately 3 to 4 centimeters in length. Resident #13 was unable to state the cause of the injury to the arm. A phone interview was conducted on 06/29/23 at 10:14 AM with Nurse Aide (NA) #2. NA #2 stated on 06/24/23 when assisting Resident #13 to bed, the resident started swinging her arm towards her trying to hit her. NA #2 stated she saw it coming and moved back out of the way and when she did Resident #13's body tilted when she was swinging her arms and Resident #13's left hand hit her right forearm causing the skin to peel back. NA #2 revealed she did not see the nurse and placed adhesive skin closures on the resident's right forearm. NA #2 revealed another resident's call light was sounding and she went to answer it and forgot to tell the nurse about the skin tear. NA #2 revealed she typically informed the nurse when a resident obtained a skin tear during her care and apologized stating she got busy and forgot. An interview was conducted on 06/29/23 at 10:36 AM with Nurse #2. Nurse #2 confirmed she the assigned nurse for Resident #13 on 06/24/23 at the time the skin tear injury occurred. Nurse #2 stated she was not notified Resident #13 obtained a skin tear during care provided by NA #2 on 06/24/23. During an interview on 06/28/23 at 12:48 PM the Director of Nursing (DON) revealed she could not find an incident report to explain how the skin tear injury occurred to Resident #13's right forearm. The DON revealed typically an incident report was completed and both her and the Wound Care Nurse were informed when a resident obtained a skin tear injury. The DON confirmed neither her nor the Wound Care Nurse were notified of the skin tear injury for Resident #13. During a follow-up interview on 06/28/23 at 3:17 PM the DON revealed Resident #13's right forearm skin tear injury occurred on 06/24/23 during care when NA #2 was assisting the resident into bed. The DON revealed NA #2 could not find the nurse and placed the adhesive skin closures on the arm. The DON stated NA #2 forgot to inform the nurse about the incident.

Based on observations, record review, and interviews with the Speech/Language Pathologist and staff the facility failed to provide a therapeutic diet as ordered by the physician for 1 of 3 residents reviewed for nutrition (Resident #38). The findings included: Resident #38 was admitted to the facility on [DATE]. Resident #38's diagnoses included Alzheimer's disease, abnormal weight loss, and severe dementia. Review of the current physician's diet order dated 11/08/21 revealed Resident #38 was to receive a mechanical soft diet with instructions for ground meats with extra gravy or sauce on the side for the meat. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was rarely understood or understands and was unable to complete the cognitive assessment, therefore a staff assessment was completed and indicated severe impairment. The MDS revealed the amount of assistance Resident #38 required for eating from staff was supervision with setup help and indicated there had been no known weight loss or gain. An observation of meal service in the main dining was conducted on 06/28/23 at 12:28 PM. The meal tray for Resident #38 included a diet card with instructions for a bowl of gravy. Resident #38 was served fried chicken of a ground like texture with no bowl of gravy. Nurse Aide (NA) #1 was observed feeding Resident #38 bites of fried chicken with no gravy or sauce on the meat. Gravy was observed to be available on a steam table also located in the main dining room. During an interview on 06/28/23 at 12:28 PM NA #1 revealed she had read the diet card for Resident #38 that included instructions to have a bowl of gravy. NA #1 stated the kitchen did not have gravy available and she had not asked for it. An interview was conducted on 6/28/23 at 1:12 PM with the Speech/Language Pathologist (SLP). The SLP revealed the physician's diet order for gravy on the side was to help moisten mechanically altered meat as those might be to dry and hard for Resident #38 to swallow. The SLP stated if the diet order provided instructions to include gravy for meats it should be served with the meal. An interview was conducted on 06/28/23 at 3:28 PM with the Director of Nursing (DON). The DON revealed she was made aware Resident #38 was not served gravy with the fried chicken and after she spoke with NA staff, they indicated the gravy was only served with breakfast. The DON revealed the gravy was served with meats to make it easier for Resident #38 swallow and she would expect NA#1 to ensure it was provided after reading the instructions on the diet card. An interview was conducted on 06/30/23 at 12:17 PM with the Administrator. The Administrator stated gravy should be served on the meal tray as ordered by the physician for Resident #38.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following a recertification survey completed on 08/26/21. This failure was for a deficiency originally cited in the area of Quality of Care (F684) on 08/26/21. This continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QAA Program. The findings included: This tag is cross referenced to: F684: Based on record review, review of surveillance video, and interviews with staff, the Nurse Practitioner (NP) and Medical Director (MD), the facility failed to assess Resident #287 immediately after a fall from the contracted transportation van. On 12/12/22 Resident #287 was rolled out of the back of the contracted transportation van in her wheelchair and fell to the ground landing on her left side and hitting the back of her head. The Contracted Transporter lifted Resident #287 back into her wheelchair and wheeled her into the facility without being assessed by a licensed professional. The Resident complained of mid back pain at 7 out of 10 (10 being the worst pain) and bruising was noted on her right forearm. Resident #287 was sent to the emergency department for evaluation and diagnosed with a compression fracture of the L1 vertebrae. There was the high likelihood of further injury when a resident was moved after a fall before being assessed by a licensed professional. This deficient practice occurred for 1 of 3 residents review for accidents (Resident #287). During the recertification survey of 08/26/21, the facility failed to initiate their bowel protocol when a resident went 6 days with no bowel movement. During an interview on 06/30/23 at 12:17 PM, the Administrator revealed the QA committee met monthly which included all administrative staff and Medical Director. During the monthly QA meetings, they discussed a variety of topics, including quality improvement indicators such as readmissions, and she felt the measures they had put into place were successful. The Administrator revealed the QA committee would be reviewing the areas of concern identified during the current survey and discussing what needed to be done to address and how to improve.

Based on record review and staff interviews, the facility failed to notify a resident's legal representative of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #1 was admitted to the facility on [DATE]with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview, conducted with the Assistant Director of Nursing (ADON) on 10/22/21 at 10:00am, revealed on 9/24/21, she was entering new orders into the computer. The Director of Nursing (DON) was notifying the responsible parties of the new orders. The ADON stated the DON told her that the order for Trazadone 50mg one half tab at bedtime needed to be discontinued since Resident #1's responsible party did not want her to be on Trazadone. The ADON was under the impression the DON would contact the physician and get the Trazadone order discontinued. An interview, conducted with the Director of Nursing (DON) on 10/22/21 at 10:30am revealed on 9/24/21, she was responsible for notifying the responsible party of Resident #1 of the new medication order. She stated she knew that the responsible party would not want Resident #1 on the Trazadone. She stated she told the ADON to discontinue the order. She thought the ADON had discontinued the order for the Trazadone. The order failed to get discontinued on 9/24/21. The order was active and Trazadone 25mg was given on 9/24/21 in the evening. On 9/27/21, the DON notified the responsible party that Trazadone 25mg was ordered for agitation and was given one time only on 9/24/21 at 10:44pm. The DON stated there was a communication gap between her and the ADON and she failed to discontinue the order and she failed to notify the responsible party when the Trazadone was ordered on 9/24/21. Attempts to contact the responsible party by telephone were made on 10/19/21 at 2:00pm, 10/20/21 at 9:30am and on 10/20/21 at 3:20pm. Messages were left with no return calls. A telephone interview, conducted with the Administrator on 10/22/21 at 1:38pm, revealed the responsible party should have been notified of the new order for Trazadone.

Based on record review and staff interviews, the facility failed to initiate the bowel protocol when a resident went 6 days with no bowel movement for 1 of 6 residents reviewed for unnecessary medication use. (Resident #10). The findings included: Review of the facility standing orders for bowel protocol revealed: if no bowel movement in 3 days give milk of magnesium (MOM) or [MEDICATION(S)] tabs, if not effective by 6:00 AM the next morning give [MEDICATION(S)] suppository, and if not effective in 4 hours give fleets enema. The doctor should be notified if entire bowel protocol was exhausted without results. Resident #10 was admitted to the facility 5/24/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was severely cognitively impaired and required extensive assistance by 2+ staff persons with toileting. She had an indwelling catheter and was frequently incontinent of bowel. Resident #10's care plan dated 5/30/21 revealed there was no focus to address constipation issues. Review of the facility bowel records from 8/1/21 through 8/23/21 revealed Resident #10 had no bowel movements documented on 8/6/21, 8/7/21, 8/8/21, 8/9/21, 8/10/21, and 8/11/21 for a total of 6 days without a bowel movement. The bowel warnings report dated 8/12/21 was reviewed and revealed Resident #10 was on Day 5 without a bowel movement (BM). Nurse Aide #1 and Nurse #1 recorded that Resident #10 had an extra-large BM on 8/11/21. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She had not received any milk of magnesium, [MEDICATION(S)] suppository, or a fleets enema. During an interview with Nurse Aide (NA) #1 on 8/25/21 at 1:22 PM, she stated Resident #10 was often on the bowel warnings report, which was printed daily. NA #1 did not recall documenting that Resident #10 had an extra-large BM on the bowel warning list dated 8/11/21. An interview was attempted with Nurse #1, but he was not available during the investigation. The Assistant Director of Nursing (ADON) was interviewed on 08/26/21 at 8:44 AM. She revealed the Administrative Assistant (AA) normally processed the bowel warnings report daily, but she was on vacation from 8/9/21 through 8/13/21. The ADON stated she took over this task beginning on 8/9/21 and was provided written instructions by the AA. The report was already programmed to look back at a 3-day period, and the ADON stated she added 3 more days to the report by mistake. Resident #10 did not show up on the bowel warnings report until 8/12/21 when it was corrected by the ADON. The bowel warnings report dated 8/12/21 showed Resident #10 had an extra-large BM on 8/11/21 documented by NA #1 and Nurse #1. The ADON reported anti-diarrheal medication was given to Resident #10 on 8/13/21, but no other bowel regimen was provided from 8/6/12 through 8/12/21. The ADON confirmed the bowel care standing orders located at the bottom of the bowel warnings report: If no BM in 3 days, give MOM or [MEDICATION(S)] tabs. If no results by 6am the next morning, give [MEDICATION(S)] Suppository. An interview on 8/26/21 at 10:17 AM with the Director of Nursing (DON) revealed her expectation was that the bowel warnings report would have been pulled correctly, and the bowel care protocol should have been followed since Resident #10 did not have a BM for more than 3 days. An interview was conducted on 8/26/21 at 10:30 AM with the Administrator. During the interview she stated it was her expectation that for nurses to start the bowel protocol for any resident that did not have a bowel movement in three days.

Based on observations, record review, and staff interviews, the facility failed to obtain a physician's order for oxygen therapy for 1 of 10 residents reviewed for oxygen. (Resident #85) The findings included: Resident #85 was originally admitted to the facility on [DATE]. Resident #85 went to the hospital 7/21/21 and was readmitted [DATE]. Review of the medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85's 5 Day Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and was coded for oxygen use while a resident and while not a resident. Review of the care plan dated 6/27/21 revealed Resident #85 was care planned for CHF with a goal he would make staff aware of any shortness of breath as it occurred. Interventions included to monitor oxygen saturation as ordered and as needed, ensure oxygen tubing had ear protectors on, and encourage rest periods as needed due to fatigue. Observations of Resident #85 receiving oxygen therapy in his room with an oxygen concentrator set at 4.5 liters wearing a nasal cannula occurred on 8/23/21 at 12:39 PM. Observations of Resident #85 receiving oxygen therapy in his room with an oxygen concentrator set at 4 liters wearing a nasal cannula occurred on 8/24/21 at 11:08 AM and 8/24/21 at 11:14 AM. Review of the medical record for Resident #85 revealed oxygen saturations were checked once a shift and all oxygen saturations were 90% or above. Interview with Nurse #2 on 8/24/21 at 4:07 PM revealed Resident #85 was on oxygen and had his oxygen saturation checked every shift. Nurse #2 stated there should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Respiratory Therapist on 8/24/21 at 4:16 PM revealed he had just examined Resident #85 and stated Resident #85 was using 4 liters of oxygen therapy and that he required 4 liters of oxygen therapy at all times. Interview with the Director of Nursing on 8/24/21 at 4:47 PM revealed she expected Resident #85 to have an oxygen therapy order for his current oxygen use. Interview with Nurse #3 on 8/25/21 at 12:46 PM revealed she had been the nurse when Resident #85 had returned from the hospital. Nurse #3 stated Resident #85 did have a previous order for oxygen therapy and thought the order would carry over when he got readmitted . Nurse #3 revealed she had missed the order to reinstate Resident #85's oxygen therapy. Interview with the Administrator on 8/26/21 at 11:58 AM revealed the nurse that readmitted Resident #85 from the hospital had missed the oxygen therapy order. The Administrator expected that Resident #85 would have had an order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, record review, resident, family, and staff interviews the facility failed to maintain a hazard free environment by not properly storing the chemical substance [MEDICATION NAME] alcohol for 1 of 1 residents reviewed for accidents/hazards (Resident #5). Findings included: Resident #5 was admitted to the facility 01/20/18 and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum (MDS) data set [DATE] assessed Resident #5 to be cognitively intact, needing extensive assistance with bed mobility, transfers, and toilet use. During an observation on 05/29/18 at 2:49 PM, a 16-ounce bottle of 50% [MEDICATION NAME] alcohol was observed on a nightstand located at the foot of the bed of Resident #5. During an interview on 05/29/18 at 2:49 PM, a family member explained she had provided the bottle of alcohol for the resident to use. During an interview on 05/29/18 at 2:49 PM, Resident #5 explained she used the alcohol to clean under her breast and underarms, or when she gets a small cut. An observation on 05/29/18 at 4:49 PM revealed the alcohol bottle remained on the nightstand at foot of the resident's bed. An observation on 05/30/18 at 9:08 AM, revealed the alcohol bottle remained on the nightstand at foot of the resident's bed. During an interview on 05/30/18 at 11:01 AM, Nurse #1 explained she provided the resident her morning medications, but didn't notice the alcohol bottle on the nightstand. Nurse #1 revealed the resident shouldn't have alcohol in the room sitting out where other residents could reach and she removed the bottle. The nurse opened the lid and revealed the foil had been punctured and the alcohol had been used. During an interview on 05/30/18 at 11:06 AM, the Director of Nursing (DON) explained cognitively intact residents were informed of the risk of keeping possible hazardous chemicals in their room and the facility would properly store those chemicals. She revealed a physician order [REDACTED].#5 to use the alcohol. The DON revealed it was her expectation the nurse would explain to the resident why alcohol could not be kept in the room were other residents might wander. She expected the nurse would have removed the alcohol and confirmed there were wandering residents that might enter the room.

Based on observations and staff interviews the facility failed to ensure perishable foods were dated, labeled, and stored appropriately in 1 of 1 reach-in freezer, 1 of 1 walk-in freezer and in 2 of 3 nourishment refrigerators. The findings included: 1. Observations of the kitchen's reach-in freezer and walk-in freezer revealed the following problems with food storage: 1a. On 03/27/17 at 8:57 AM an observation of the kitchen's reach in freezer was conducted with the Dietary Manager (DM). Observations of food stored in this reach in freezer revealed an undated and unlabeled clear plastic bag that had been opened which contained 8 three inch in diameter beef patties, 6 hot dogs in a clear plastic bag that was ¾ full of ice crystals, an undated and unlabeled 1 pound bag of diced green peppers, a 1 pound bag of a breaded food which had been opened and was not labeled with the bags contents which the DM identified as breaded okra and an opened 5 pound box which contained exposed and loose chocolate chips. The DM immediately removed the beef patties, hotdogs, diced green peppers, breaded okra, and chocolate chips and disposed of them in the trash. On 03/27/17 at 9:27 AM an interview was conducted with the DM who stated the reach in freezer was to be checked on a daily basis to assure food was appropriately dated, labeled, and stored. The DM stated food was required to be dated and labeled when opened and/or when removed from its original packaging when stored in the reach in freezer. The DM verified the beef patties had not been dated and labeled, the hot dogs had not been labeled and the clear plastic bag contained ice crystals, the diced green peppers had been removed from the original packaging and had not been dated and labeled, the breaded okra had been removed from the original packaging, had been opened and had not been labeled, and the chocolate chips should have not been stored exposed and loose in the opened box. On 03/27/17 at 3:08 PM an interview was conducted with the Administrator who stated the undated, unlabeled, and opened food should not have been in the kitchen's reach in freezer as per facility policy. 1b. On 03/27/17 at 2:49 PM an observation of the kitchen's walk in freezer was conducted with the Dietary Manager (DM). Observations revealed an undated and unlabeled 1 pound bag of breaded sticks which the DM identified as breaded vegetable sticks and one undated and unlabeled 2 pound bag of breaded nuggets which the DM identified as hush puppies. The DM immediately removed these items from the walk in freezer. On 03/27/17 at 2:55 PM an interview was conducted with the DM who stated the 1 pound bag of breaded vegetable sticks and 2 pound bag of breaded hush puppies were out of their original packaging and they should have been dated and labeled by dietary staff when stored in the walk in freezer. The DM stated it was her responsibility that food stored in the walk in freezer was appropriately dated and labeled. On 03/27/17 at 3:08 PM an interview was conducted with the Administrator who stated it was the responsibility of the DM or her designee to check the walk in freezer daily to assure foods were appropriately dated and labeled. 2. Observations of the facility's nourishment rooms revealed the following problems with food storage: 2a. On 03/27/17 at 9:35 AM an observation of the East Hall nourishment refrigerator was conducted with the Dietary Manager (DM) and Housekeeping Manager (HM). Observations of foods stored in this refrigerator revealed one unopened 4 ounce strawberry nutritional shake that was undated and 2 undated and unlabeled plastic bowls which contained an unidentified food. The DM identified the contents in each bowl as fruit cocktail. The HM immediately removed the strawberry mighty shake and the 2 bowls of fruit cocktail from the East Hall nourishment refrigerator. On 03/27/17 at 9:40 AM an interview was conducted with the DM who stated the 4 ounce strawberry nutritional shake per manufacturers' recommendations was good for 14 days once removed from the freezer. The DM stated the strawberry shake should have been dated by the dietary staff with an expiration date prior to being stored in the East Hall nourishment refrigerator because there was no way to determine when the mighty shake would have expired. The DM stated the 2 bowls of fruit cocktail should have been dated and labeled when placed in the East Hall nourishment refrigerator. The DM stated the HM was responsible to check the East Hall nourishment refrigerator daily to assure food was appropriately dated and labeled and was responsible to discard outdated and unlabeled food. On 03/27/17 at 11:52 AM an interview was conducted with the HM who stated food placed in the East Hall nourishment refrigerator was required to be dated and labeled. The HM manager stated she was responsible to check the East Hall nourishment refrigerator daily to assure food was appropriately labeled and dated and was responsible to remove outdated and unlabeled food and discard. The HM stated she had been busy performing other duties and had not checked the East Hall nourishment refrigerator and missed the undated strawberry nutritional shake and 2 bowls of undated and unlabeled fruit cocktail. On 03/27/17 at 3:08 PM an interview was conducted with the Administrator who stated it was the responsibility of the HM or her designee to have checked the East Hall nourishment refrigerator daily to assure foods were appropriately dated and labeled. 2b. On 03/27/17 at 9:45 AM an observation of the West Hall nourishment refrigerator was conducted with the Dietary Manager (DM) and the Housekeeping Manager (HM). Observations revealed 1 pint of melted chocolate ice cream that was undated when opened and was stored in the refrigerator and not in the freezer, one unopened 4 ounce grape juice that was undated, and 1 bunch of undated and unlabeled green grapes. The HM removed the melted chocolate ice cream, grape juice, and the grapes from the West Hall nourishment refrigerator. On 03/27/17 at 9:50 AM an interview was conducted with the DM who stated the melted chocolate ice cream should have been dated when opened and stored in the freezer. The DM stated the 4 ounce grape juice per manufacturers' recommendations was good for 14 days once removed from the freezer. The DM stated the dietary staff should have placed an expiration date on the grape juice prior to placing in the West Hall nourishment refrigerator because there was no way to tell when the grape juice had expired. The DM stated the bunch of grapes should have been dated and labeled when placed in the nourishment refrigerator. The DM stated the HM was responsible to check the West Hall nourishment refrigerator daily to assure food was appropriately dated and labeled and outdated and unlabeled food was discarded. On 03/27/17 at 11:52 AM an interview was conducted with the HM who stated food placed in the West Hall nourishment refrigerator was required to be dated and labeled. The HM manager stated she was responsible to check the West Hall nourishment refrigerator daily to assure food was appropriately labeled and dated and was responsible to remove outdated and unlabeled food and discard. The HM stated she had been busy performing other duties and had not checked the West Hall nourishment refrigerator and missed the undated grape juice, undated and unlabeled grapes, and melted undated chocolate ice cream that was not stored in the freezer. On 03/27/17 at 3:08 PM an interview was conducted with the Administrator who stated it was the responsibility of the HM or her designee to have checked the West Hall nourishment refrigerator daily to assure foods were appropriately dated, labeled, and stored.

Based on observations, record reviews and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place in February 2016. This was for one recited deficiency which was cited in February of 2016 on a Recertification survey and subsequently recited on the current recertification survey. The deficiency was in the area of food storage. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: F371 Based on observations and staff interviews the facility failed to ensure perishable foods were dated, labeled, and stored appropriately in 1 of 1 reach-in freezer, 1 of 1 walk-in freezer and in 2 of 3 nourishment refrigerators. During a recertification survey of 02/04/16 the facility was cited for F371 for failure to dispose of spoiled food and properly store foods together in refrigerator #1, label and date previously cooked food items in refrigerator #2, and label and date an item in the freezer. F371 was cited again on the current recertification survey for failing to date, label and appropriately store perishable foods in 1 of 1 reach-in freezer, 1 of 1 walk-in freezer and in 2 of 3 nourishment refrigerators. During an interview on 03/30/17 at 11:51 AM with the Administrator about the recurrence of problems identified with food storage that were similar to those identified on the facility's last recertification survey, the Administrator stated she felt like the problem in the kitchen had occurred in the past few weeks due to having 3 or 4 newly hired employees in the kitchen that were still in training. She stated the facility had a new Registered Dietician that the Dietary Manager (DM) had been spending a lot of time with and was providing training for on the electronic record and facility policies/practices. The Administrator stated she had talked to the DM about the concerns and stated she thought the breakdown occurred when food deliveries were made and staff got in a hurry when the container was first opened and didn't label the container.

Based on observations and staff interviews, the facility failed to dispose of spoiled food and properly store foods together in refrigerator #1, label and date previously cooked food items in refrigerator #2, and label and date an item in the freezer. The findings included: During the initial tour with the Director of Food Services (DFS) beginning at 10:32 AM on 02/01/16, the following was revealed: 1. Refrigerator #1 had a rectangular shaped metal container with 8 oranges, celery with 3 wilted stalks and a brownish-black fuzzy substance on the exterior of the stalks, and a plastic, see through container with what the DFS stated was tartar sauce with no label or use by date. 2. Refrigerator #2 had a gallon sized storage bag with multiple cooked sausage patties and a second gallon sized storage bag with cooked scrambled eggs. Neither storage bag was labeled or dated. 3. The Freezer had a gallon sized storage bag with an opened bag of chocolate chip pieces inside. The storage bag was not labeled or dated. All contents in the metal container, and the storage bags with unlabeled and undated food items were disposed of in the kitchen waste receptacle immediately after these items were discovered during the initial tour. During an interview with Cook #1 on 02/03/16 at 3:57 PM, it was discovered that the sausage patties and scrambled eggs were leftovers from breakfast put in individual bags to be cooled by sitting them on ice before refrigeration. Cook #1 stated the sausage patties and scrambled eggs storage bags should have been labeled and dated but he had forgotten to do so. During an interview with DFS on 02/03/16 at 4:12 PM it was acknowledged that all food that had been cooked and would be used for another meal needed to be labeled with what was inside and dated. DFS also acknowledged that the celery should have been thrown out and the celery, oranges, and plastic container of tartar sauce should not have been stored together in the same container. DFS also indicated that the chocolate bits in the freezer should also have been labeled and dated. DFS stated re-education of the dietary staff had taken place since these issues had been discovered.

Based on record review and staff interviews the facility failed to complete a significant change assessment for 1 of 15 sampled residents who experienced a significant change (Resident #70) reviewed for activities of daily living and weight loss. Findings included: Resident #70 was admitted to the facility on [DATE]. A review of the admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #70 required extensive assistance with eating and had a weight of 130 pounds. The 14 day MDS assessment dated [DATE] indicated Resident #70 was coded as supervision for eating and coded has having a weight of 121 pounds. Resident #70 had a weight loss of greater than 5 percent in less than 2 weeks. On 02/04/16 at 11:43 an interview was conducted with the MDS Nurse who stated Resident #70 had a change in ADL with eating from admission MDS dated [DATE] to 14 day assessment MDS dated [DATE] and went from extensive assistance with eating to supervision. The MDS Nurse stated Resident #70 had a significant weight loss from admission MDS assessment to 14 day MDS assessment and went from 130 pounds to 121 pounds in 14 days. The MDS Nurse stated she missed coding a significant change MDS assessment for Resident #70. On 02/04/15 at 1:07 PM an interview with the Director of Nursing (DON) was conducted who stated her expectation was that the MDS Nurse would have coded Resident #70's MDS assessment to reflect a significant change had occurred. The DON stated her expectation was for the MDS nurse to have followed the MDS manual and guidelines for coding Resident #70's MDS assessment. On 02/04/15 at 1:13 PM an interview was conducted with the Administrator who stated her expectation was that the MDS Nurse would have coded Resident #70's MDS assessment per Resident Assessment Instrument manual and guidelines. The Administrator stated her expectations was that MDS Nurse would have coded Resident #70's MDS assessment to reflect a significant change had occurred.

Based on observation, medical record review and staff interview, the facility failed to ensure medications were accurately transcribed to the Medication Administration Record and available for administration as ordered for two (2) of ten (10) residents reviewed for unnecessary medication. (Residents # 11 and # 99). The findings are: 1. Resident #11 was admitted to the facility 10/18/10 with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the July and August 2012 Medication Administration Record (MAR) revealed [MEDICATION NAME] 5mg one tablet after breakfast and lunch was listed and documented as administered from 7/16/12 at 2:00 PM through 8/29/12 at 2:00 PM. Review of physician progress notes [REDACTED]. The note indicated the [MEDICATION NAME] was being increased to 10mg after breakfast and lunch. Observation on 8/29/12 at 2:30 PM revealed (Licensed Nurse)LN #1 administering [MEDICATION NAME] 5mg one tablet by mouth to Resident # 11. On 8/29/12 at 3:12 PM LN #1 reviewed the physician's orders [REDACTED]. ON 8/29/12 at 4:21 PM the Director of Nursing (DON) reviewed the physician's orders [REDACTED]. She also reviewed the July and August MARs and confirmed the dosage change had not been transcribed to the July 2012 or August 2012 MAR. On 8/30/12 at 2:50 PM the DON stated mid-July 2012 the facility transitioned from a paper MAR to an electronic MAR. Review of the July 2012 electronic MAR for Resident #11 revealed the transition to the electronic MAR started on 7/16/12. On 8/30/12 at 5:48 PM the DON stated there is a triple check system for every new medication order that is received. The LN receiving the order removes the order from the chart and faxes it to the pharmacy. The LN working the 11 - 7 shift checks the new orders against the (electronic) E-MAR. The next day after the order is received, the DON checks the orders against the E-MAR. If the order is not in the E-MAR, she calls the pharmacy to inquire as to why the E-MAR hasn't been updated. The DON stated she thinks perhaps the pharmacy didn't get the fax with the new order and she and the LN working the 11 - 7 shift missed that it hadn't been entered in the E-MAR. The DON could not explain why it had been missed. 2. Resident #99 was admitted to the facility 3/22/12 with [DIAGNOSES REDACTED]. Review of physician progress notes [REDACTED]. Resident #99 was discharged to the hospital 6/3/12 and readmitted to the facility 6/6/12. Readmission orders [REDACTED]. Review of physician orders [REDACTED]. Review of the June 2012 Medication Administration Record (MAR) and controlled drug record revealed Resident #99 took 24 doses of the [MEDICATION NAME] from 6/14/12 to 6/30/12. Review of the July 2012 MAR and controlled drug record revealed Resident #99 took six doses of [MEDICATION NAME] from 7/1/12 to 7/14/12. On 8/30/12 at 2:50 PM the Director of Nursing (DON) stated mid-July 2012 the facility transitioned from a paper MAR to an electronic MAR. Review of the July 2012 electronic MAR for Resident #99 revealed the transition to the electronic MAR started on 7/17/12. Review of July 2012 MAR for Resident #99 revealed the [MEDICATION NAME] was not listed as a medication available for use. Review of physician orders [REDACTED].#99 since it was ordered on [DATE]. Review of the August 2012 MAR for Resident #99 revealed the [MEDICATION NAME] was not listed as a medication available for use. On 8/30/12 at 3:00 PM the DON reviewed physician orders [REDACTED].#99 and confirmed the [MEDICATION NAME] had been omitted from the MAR. On 8/30/12 at 3:30 PM the DON stated when the facility transitioned from paper MARs to electronic MARs licensed nursing staff reviewed the electronic MARs against the paper MARs for each resident. The DON stated she did not have a record to indicate which licensed nurse reviewed the electronic MAR for Resident #99. The DON stated the omission of the [MEDICATION NAME] should have been identified and could not explain why it had been missed.

Based on observations, staff interviews, resident interview, electrician interview, review of fire department reports and facility reports the facility failed to operate room air conditioners on single outlet circuits per the manufacturer recommendations to prevent overloading the electrical circuit to prevent a potential fire hazard, to ensure rooms were free of electrical extension cords and keep resident beds and bedding an acceptable distance away from baseboard heating units in nineteen (19) of thirty-nine (39) resident rooms and in one (1) of two (2) therapy rooms.(Rooms #1, #2, #5, #9, #10, #12, #14, #17, #18, #19, #20, #24, #27, #28, #30, #31, #32, #34, #35 and #41) Immediate jeopardy began on 7/24/11 when a fire occurred in one (1) resident room (Room #19) after a circuit was overloaded and sparks from the air conditioner wiring ignited the bedding in the room. Immediate jeopardy was removed on 8/09/11 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of E (a pattern of deficient practice, no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put into place and completion of employee training. The findings are: 1. During the initial tour of the facility on 7/25/11 at 1:34 PM, Room #19 (a room that was occupied by Residents #18 and #93) was observed cleared of furniture and in the midst of being painted. The wall outlet under the window had a solid silver plate cover with blackened area surrounding the outlet. The white painted window sill just above the outlet was also blackened but not charred. In addition, the electric baseboard heater running along the wall under the outlet had the cover removed. The wall just above the baseboard was observed slightly blackened. Review of the nurse's notes for Resident #93 revealed an entry dated 07/24/11 at 3:15 a.m. which specified that at approximately 2:00 a.m. the fire alarm sounded. A fire was noted in Room #19 which was Resident #93's room. The residents in this room were immediately evacuated. The fire was extinguished with fire extinguishers and no injuries were noted. An interview with Resident #93, who is considered alert and oriented by the facility, was conducted on 07/25/11 at 2:11 p.m. The resident stated on 07/24/11 she was awake and watching television when she noticed the oxygen concentrator she was using had a "red" light on. She used her call light to summon facility staff. At that time she noticed sparks on the opposite side of her roommate's bed. She began yelling for help. As the room door opened, she stated she saw flames where the sparks had been. Resident #93 stated facility staff quickly pulled her and her roommate from the room and moved them to safety. A review of an incident report from the city fire department revealed that on 07/24/11 an alarm was received at 2:20 a.m. from the facility. The report described the ignition factor as electrical. The form of ignition was electrical short. Equipment involved in ignition was electrical wiring. The type of material ignited was fabric. The area of fire origin was patient room (bedroom). A review of the facility's investigation of the 07/24/11 fire which occurred in Room #19 revealed the County Fire Marshall reported that an air conditioner plugged into the receptacle in Room #19 caused the fire. The report continued the residents remained off the affected wing until the wiring was checked by a licensed electrician. The electrician's examination was in progress by 8:00 a.m. on 07/24/11. Further review of the facility's investigation revealed the electrician "noted a multi-plug surge protector had been used in this room (Room #19). and that with the recent hot weather and the room air conditioner running constantly that it probably over heated the sure (sic)-protector." The electrician recommended a higher capacity surge protector for this room. Further review of the investigation report revealed rounds were conducted by the maintenance director, housekeeping director, and administrator to assure beds were pulled away from walls that have electrical outlets. The report specified multi-plug surge protectors utilized throughout the building were identified by the maintenance director and replaced with a higher capacity surge protector by 07/25/11. Review of a letter, dated 07/26/11, that was written by the licensed electrician who performed the electrical check described the fire of Sunday, 07/24/11, in Room #19 specified that the fire was due to an "electrical incident". The electrician specified that "A multi-device splitter was installed in the duplex (two outlet) receptacle located under the exterior window. The combination of devices plugged into the splitter, the amount of current consumed by these devices, and the arrangement of the cords attached to the individual devices collectively led me to believe excessive heat and eventual fire took place due to a loose connection and/or an overloaded splitter." On 07/25/11 at 5:21 p.m. the Licensed Electrician, who declared the building's wiring was undamaged by the fire, was interviewed. The Electrician stated that he found a six (6) way adapter plugged into a duplex receptacle with multiple cords plugged into the adapter in Room #19. The electrical items plugged into the receptacle included an air conditioner and television. He stated the electrical adapter was melted when he examined it. The Electrician specified that the electrical receptacle that the adapter was plugged into was rated to allow fifteen (15) amps (measurement of electrical current). The air conditioner plugged into the adapter was rated to need 15 amps without adding the other devices plugged into the adapter. He added that too many items were plugged into that receptacle and that air conditioners should never be plugged into electrical adapters. An interview with the Maintenance Director on 07/25/11 at 3:07 p.m. revealed the fire was caused by a six (6) plug adapter plugged into a two (2) plug wall outlet. He stated the multi-port adapter was not like a surge protector with a reset button. The multi port plug had the air conditioner unit, radio, television, and telephone charger plugged into it. The heat generated in the plug melted the covers of the wires and the wires were next to the bed covers. The Maintenance Director stated he was not aware the six (6) plug adapter was in use in Room #19. Review of the Owner's Manual of the window air conditioner that was involved in the fire in Room #19 on 07/24/11 revealed it was to be operated on a dedicated circuit. The manual also specified that overloading the line could create a fire hazard. During an interview with the facility's Maintenance Director and Administrator on 08/08/11 at 3:25 p.m., the air conditioner that was involved in the fire which occurred in Room #19 was observed. Observations of the air conditioner revealed information written on the side of the air conditioner specified; "Use on Single Outlet Circuit Only". Inspection of the air conditioner revealed that its electrical cord was melted. The Maintenance Director stated he had not read the information that was on the side of the air conditioner and was unaware of when the unit was purchased or put into use. 2. Observations on 08/08/11 of window air condition units being utilized in the facility revealed the following units were not operating on single outlet circuits as specified by their manufacturer's: a. Observations on 08/08/11 at 10:28 a.m. of Room #18 revealed a window air conditioner was in operation and plugged into a duplex (two outlet) electrical wall outlet along with a rechargeable phone. Review of information printed on the air conditioner specified; "Use on Single Outlet Circuit Only". b. Observations on 08/08/11 at 10:31 a.m. of Room #34 revealed a window air conditioner was plugged into a duplex electrical outlet. A white plug was noted in second outlet attached to a white cord that went into the resident's closet. A television was observed on a shelf above the closet and was turned on. Review of information printed on the side of the air conditioner specified; "Use on Single Outlet Circuit Only". c. Observations on 08/08/11 at 10:35 a.m. of Room #17 revealed a window air conditioner was in operation and plugged into a duplex electrical wall outlet which had a surge protector plugged into its second port. A television was observed plugged directly into the surge protector. Review of information printed on the air conditioner specified; "Use on Single Outlet Circuit Only". d. Observations on 08/08/11 at 11:30 a.m. of Room #41 revealed a window air conditioner was plugged into a duplex outlet with a television plugged into the outlet's second port. Review of information printed on the side of the air conditioner specified; "Use On Single Outlet Circuit Only". e. Observations on 08/08/11 at 11:37 a.m. of Room #14 revealed a window air conditioner was in operation and plugged into a duplex electrical wall outlet along with a television. Review of information printed on the air conditioner specified; "Use on Single Outlet Circuit Only". f. Observations on 08/08/11 at 11:45 a.m. of Room #10 revealed a surge protector was plugged into a duplex electrical wall outlet. A window air conditioner, an oxygen concentrator and an extension cord were observed plugged into this surge protector. The other end of the extension cord was observed to be plugged into a another duplex electrical wall outlet in this room. Review of information printed on the air conditioner specified; "Use on Single Outlet Circuit Only". g. Observations on 08/08/11 at 11:45 a.m. of Room #28 revealed a window air conditioner was plugged into a surge protector along with a television and telephone charger. The surge protector was plugged into a duplex electrical outlet. Review of information printed on the side of the air conditioner specified; "Use on Single Outlet Circuit Only". h. Observations on 08/08/11 at 12:00 p.m. of Room #31 (Therapy Room) revealed a window air conditioner was plugged into a surge protector along with an office printer and an exercise machine. The surge protector was plugged into a duplex outlet that had a television plugged into the outlet's second port. Review of information printed on the side of the air conditioner specified; "Use on Single Outlet Circuit Only". i. Observations on 08/08/11 at 2:01 p.m. of Room #24 revealed a window air conditioner was plugged into a surge protector along with a television and an oxygen concentrator. The surge protector was plugged into a duplex outlet with an electric bed plugged into the outlet's second port. Review of information printed on the side of the air conditioner specified; "Use on Single Outlet Circuit Only". Interviews with the Administrator and Maintenance Director on 08/08/11 at 3:10 p.m. revealed there was no written manufacturer's instructions or safety precautions available for any of the window air conditioning units that were being utilized in the facility to reference regarding proper installation or safe use. Both the Administrator and Maintenance director stated that they were unsure which in room window air conditioning units required dedicated electrical circuits in order to operate in a safe manner per their manufacturer's specifications. The Administrator stated that the facility was in the process having dedicated electrical outlets installed, so that all window air conditioners requiring dedicated outlets would be able to operate in a safe manner per their manufacturer's specifications. The Administrator further stated that she was unsure how long it would take to have this electrical work performed. The Administrator was notified of the Immediate Jeopardy on 08/08/11 at 9:55 a.m. The facility provided a credible allegation of compliance on 08/09/11 at 5:10 p.m. The following interventions were put into place by the facility to remove the Jeopardy: 1) On 07/24/11 a fire occurred in Room #19. Both residents (Resident #18 and Resident #93) who resided in this room were immediately removed from the room by staff without injury on July 24, 2011 and were placed in another room. On 07/24/11 Room #19 was inspected by staff (administrator, maintenance director, DON), licensed electrician and the fire department to ensure that the room was safe and did not pose any potential fire hazards. 2) a. On 07/24/11 all residents who resided on the same wing (East) as Room #19, where the fire occurred were relocated in vacant beds within the facility until staff (administrator, maintenance director, DON) fire marshal, and licensed electrician could thoroughly investigate the origin of the fire. Based on the facility's investigation of this fire, staff determined that residents were safe and secure and no harm to any resident occurred. Residents, other than the two residents who resided in Room #19, (which needed repair) were moved back into their original beds on July 24, 2011 after the facility was declared safe by the County Fire Marshall and the licensed electrician who inspected the facility ' s wiring and determined that the facility was safe and the facility wiring was never penetrated by the fire. b. On 7/24/2011 at approximately 8:30AM a licensed electrician inspected the electrical wiring in the facility including air conditioners (A/C) to ensure the electrical wiring was safe. The licensed electrician acknowledged the building's electrical supply was safe. The licensed electrician also wrote a conclusion to his investigation which stated a multi device splitter was installed in the duplex receptacle located under the exterior window. The combination of devices plugged into the splitter, the amount of current consumed by these devices and the arrangement of the cords attached to the individual devices collectively led me to believe that excessive heat and eventual fire took place due to a loose connection and/or an overloaded splitter. c. On 07/24/11 at approximately 8:30AM the administrator and the facility's maintenance supervisor made rounds throughout the entire facility to identify any potential non-compliant forms of energy; including multi plug electrical outlet adaptors/splitters and extension cords. Through these rounds it was identified that multi device splitters, electrical outlet adaptors/splitters, and individual extension cords were being utilized in resident rooms. The electrical outlet adaptors/splitters and extension cords were immediately removed from resident rooms and were replaced with UL rated surge protectors on 07/24/11. During these rounds beds were moved away from the electric base board heaters, this is an ongoing process checked daily department manager rounds and each housekeeper signs off when they clean the room. These QA rounds also include checking for extension cords being brought into the building by family members. d. On 7/25/2011 the administrator wrote a letter to all family members and/or responsible parties requesting that they do not bring extension cords into the facility and that they get approval by the administrator if they had a request for additional electrical outlets to be placed in a resident ' s room. e. On August 3-4, 2011 the facility completed an in-service (completed by Administrator, DON, Maintenance Director, and Carolina Fire Protections) of all facility staff regarding the no extension cord policy and also for staff to check to ensure that all beds are at least 12 inches from wall mounted heaters. Any staff who did not attend this inservice, training will be in-serviced via phone by Administrator/DON before their next scheduled day to work. f. On 8/5/2011 the administrator and president (of the managing company) made the decision to install dedicated receptacles throughout the facility for air conditioner (A/C) units to ensure that receptacles are not overloaded and these receptacles will be brought up to current life safety code. On 7/27/2011 the Administrator and Maintenance Director conducted an audit of the whole facility to determine which a/c units in house require dedicated receptacles. g. On 8/8/2011 the licensed electrician, who assisted with the initial investigation of the fire, met with the administrator and will begin 8/9/2011 to install dedicated receptacles for all air conditioner units that require them. Installation of these dedicated electrical receptacles is estimated to be completed in 5 to 7 days. h. On 08/08/11 at approximately 6:00PM the facility began requiring an employee who is dedicated to be on "fire watch" each shift to ensure the safety of all residents until all dedicated receptacles are installed in the facility. This employee is responsible for conducting continuous facility rounds on at least an hourly basis, to monitor and identify a potential fire or fire hazard in the facility. This employee is responsible for monitoring if they smell anything burning, if any equipment is hot to touch, if beds are 12 inches off base board heater, and assures there are no extension cords used in the rooms and recording this on a log. On 08/08/11 each employee, who will be functioning in this capacity, was in serviced by the Administrator/DON on the job's duties and responsibilities. These employees were instructed on how they are to monitor the facility, how they are to document on the fire watch log, and that they are to immediately report any problems involving resident safety to their supervisor and the administrator. Hourly Rounds will be documented on QA checklist by the fire watch safeguard and forwarded to administrator at the conclusion of their shift to ensure compliance. During the hours that the Administrator is not in the building the charge nurse will need to sign off that the rounds have been completed. On 08/08/11 and 08/09/11 all staff were in serviced by the administrator/DON that electrical extension cords are not to be utilized in the facility and on the responsibilities of the "fire watch safeguard" and the fact that this individual is assigned to only do fire watch monitoring during their scheduled time. Any staff who was unable to attend this inservice training will be inserviced before being allowed to return to work. 3) On 07/26/2011 the facility began adding a form to its admission packet instructing family not to bring in their own extension cords, outlet adapters and such without facility approval. 4) a. On 08/08/11 daily monitoring of the facility was restarted by the administrator and all department managers to ensure that the facility is free of extension cords and non-approved surge protectors and electrical outlet adaptors/splitters. This monitoring will include daily rounds of the entire facility performed by the administrator and or her designees (maintenance director, other department staff, and administrative personnel) for 3 weeks, then on a monthly basis and then at least quarterly thereafter to ensure compliance. b. Once the dedicated receptacle outlets are installed in resident rooms the facility's maintenance director will perform monthly inspections to ensure that all air conditioners that require a dedicated receptacle are safely operating with a dedicated receptacle in place. Findings from these inspections will be reported at the facility ' s monthly safety meeting. Immediate Jeopardy was removed on 08/09/11 at 6:50 p.m. Observations of the facility confirmed no electrical adaptors/splitters or extension cords were being utilized in the facility. Observations revealed a staff member designated with "fire watch" duties was conducting continuous facility rounds on at least an hourly basis, to monitor and identify a potential fire or fire hazards in the facility. Staff interviews revealed they had received inservice training on prohibiting the use of electrical adaptors/splitters and extension cords in the facility and on the responsibilities of the staff member who was assigned to be on "Fire watch". 3. Review of the facility's undated policy "Safety Guidelines" revealed the purpose of the policy was "to ensure a safe and comfortable living environment for the residents." Included in the guidelines was "12. Do not allow the use of extension cords in the building." Observations of the facility on 07/25/11 and 07/26/11 revealed electrical extension cords were being used by the facility in resident rooms due to inadequate accessible wall outlets as follows: *Room #9 on 7/25/11 at 4:40 p.m.: a television, located on a shelf above a closet, was plugged into a household extension cord which ran inside the closet and plugged into a large grey extension cord which plugged into a wall outlet. The Director of Nursing (DON) who accompanied the surveyor during this observations stated "I don't like it." *Room #10 on 7/25/11 at 4:44 p.m.: a window air conditioner was plugged into a surge protector which was plugged into a heavy extension cord which was plugged into the wall outlet. *Room #12 on 7/25/11 at 4:50 p.m.: an electric lounge chair was plugged into an orange extension cord which was plugged into a surge protector which plugged into a wall outlet. The Maintenance Director stated "I know it is safe." *Room #5 on 7/25/11 at 5:00 p.m.: a television and window air conditioner unit was plugged into a surge protector which was plugged into a thick extension cord which was plugged into the wall outlet. *Room #34 on 7/25/11 at 5:23 p.m.: a television located above a closet was plugged into an extension cord which ran through the closet and into a wall outlet. *Room #2 on 7/26/11 at 9:11 a.m.: a television was plugged into a surge protector strip that was plugged into another surge protector strip which was plugged into the wall outlet. *Room #1 on 7/26/11 at 9:48 a.m.: an air conditioner was plugged into a household extension cord which was plugged into the wall outlet. On 7/26/11 at 8:25 a.m. a telephone interview with the fire marshal revealed extension cords should not be used in resident rooms. Further interview with the fire marshal on 7/26/11 at 11:20 a.m. revealed that connecting two surge protectors together, referred to as a daisy chain, was also not safe. Interview with the Maintenance Director on 7/25/11 at 4:49 p.m. revealed that there were not enough plugs in the rooms and extension cords had to be used sometimes so residents could have television, air conditioning, etc. He stated he was comfortable with using the extension cords and connecting surge protector cords together. He stated this was what he did in place of making any structural changes to the facility. On 7/26/11 at 12:20 p.m., the Administrator stated that on Sunday, 7/25/11 after the fire, she instructed the maintenance staff to remove all extension cords. She stated that she was told by Maintenance staff yesterday 7/25/11 there were still some extension cords used due to televisions. On 7/26/11 at 2:29 p.m., Nurse Aide (NA) #4 stated she was unaware of instructions related to the use of extension cords. On 7/26/11 at 2:31 p.m., housekeeper #1 stated that extension cords were alright to use as long as they were not frayed and not on the floor in a place that created a fall hazard. On 7/26/11 at 2:40 p.m., NA #6 stated that extension cords were alright to use but should not be in the way of people who could trip or fall over them. On 7/26/11 at 4:01 p.m. an interview with the maintenance staff and administrator was conducted. The maintenance staff conducted weekly safety checks which he turned into the quality assurance committee monthly. Maintenance stated that surge protector strips connected to each other was alright. Maintenance staff further stated he tried not to use extension cords but that it could not be helped sometimes. The Administrator stated that during the quality assurance monthly meetings nothing was reported regarding extension cords because they did not know their use was unsafe. Further observations of the facility on 08/08/11 revealed that electrical extension cords were still being utilized in the following resident rooms: * Observations of Room #34 on 08/08/11 at 10:31 a.m. revealed a white extension cord plugged into a wall outlet that went into the resident's closet and was attached to a television set positioned on an upper shelf of the closet that was turned on. * Observations of Room #10 on 08/08/11 at 11:45 a.m. revealed an extension cord was plugged into an electric wall outlet and a surge protector that was plugged into an electrical wall outlet. A window air conditioner was plugged into the surge protector. Interview with the Administrator on 08/08/11 at 4:08 p.m. revealed that after the 07/24/11 fire she directed staff to remove all of electrical extension cords from the building because they were a safety hazard. The administrator stated that she thought all extension cords had been removed from the facility. 4. A review of a report of an Inspection conducted by the county Fire Marshal on 07/26/11 revealed the facility failed to provide a twelve (12) inch clearance between heating units and combustibles (bedding). An interview was conducted with the county Fire Marshall on 07/26/11 at 11:20 a.m. The Fire Marshall stated there should be a twelve (12) inch clearance between bed material and the heater per state regulation. The Fire Marshall added that bedding near the heater baseboards was a fire hazard even when the heaters were off. He stated that he had instructed this facility on a previous inspection that beds were to be kept twelve (12) inches from the heater baseboards. Observations on 07/26/11 and on 07/27/11 revealed beds and/or bedding were positioned in close proximity or directly on board heaters in the following resident rooms: On 07/26/11 at 9:06 a.m. the B bed in Room #9 was positioned against the baseboard heater with bed's covers lying on the heater panel. On 07/27/11 at 8:57 a.m. a bed in Room #2 was positioned in close proximity (less than twelve inches away) to a baseboard heater. Resident #32, who was lying in this bed, stated that he had been in this bed for over a year and it was always positioned close to the wall. On 07/27/11 at 9:29 a.m. both beds in Room #30 were positioned against baseboard heaters. The blanket on the room's B bed was observed touching the heating panel. On 07/27/11 at 9:35 a.m. the B bed in Room #32 was positioned against the baseboard heater with bedding touching the heating panel. On 07/27/11 at 9:38 a.m. the B bed in Room #27 was positioned against the baseboard heater. On 07/27/11 at 9:42 a.m. the B bed in Room #20 was positioned against the baseboard heater. On 07/27/11 at 10:25 a.m. the B bed in Room #5 was positioned against the baseboard heater. A plastic bag was observed between the bed and the heater panel touching both. On 07/27/11at 4:04 p.m. the B bed in Room #35 was positioned against the heater baseboard. All baseboard heating units were turned off during the above observations. An interview with NA #2 on 07/28/11 at 10:50 a.m. revealed housekeeping staff was responsible to move the beds to the appropriate position away from baseboard heaters. She stated she was aware of this procedure and that staff were reminded every winter when heat is required. NA #2 demonstrated how the baseboard heaters in resident rooms were turned on by easily rotating a dial at the base of a switch. The switches to turn the room heaters on and off were observed positioned on the walls next to the doorway in resident rooms approximately in the same area where overhead light switches are usually located. NA #2 stated the heater control switch is readily accessible to ambulatory residents, family, and facility staff. At this time, NA #2 verified that both beds in Room #30 remained positioned against baseboard heaters as observed on 07/27/11 at 9:29 a.m. An interview with the Administrator on 07/27/11 at 11:20 a.m. revealed that she was aware resident beds should not be positioned against baseboard heaters at any time. She acknowledged that a bed against a baseboard heater was a safety hazard even when the heat was turned off. The Administrator added it was her expectation that beds remain at least twelve (12) inches away from baseboard heaters at all times.