Every finding on record at The Carrolton of Fayetteville

Based on observation, record review, and interviews with staff, Consultant Pharmacist, and Physician, the facility failed to ensure documentation of administered doses of Resident # 1's seizure medication could be accurately reconciled with the number of tablets dispensed from the pharmacy and removed from Resident # 1's supply of seizure medication, which could indicate the possibility that the seizure medication may not have been given as ordered or that staff were borrowing the medication from other residents' supplies. This was for 1 of 2 residents whose medications were reviewed (Resident # 1). The findings included:Record review revealed Resident # 1 was admitted to the facility on [DATE]. The resident's diagnoses included a history of subarachnoid hemorrhage with shunt placement and epilepsy. Medications listed on the 5/6/26 hospital discharge summary included two medications for Resident # 1's epilepsy. One of these two medications was Levetiracetam 750 mg (milligrams) two tablets two times per day.Review of facility admission orders, dated 5/6/26, revealed Resident # 1 was ordered to receive the Levetiracetam 750 mg (milligrams) two tablets two times per day along with the other ordered seizure medication.Review of Resident # 1's May 2026 MAR revealed the Levetiracetam 750 mg two tablets was scheduled to be given at 9:00 AM and 9:00 PM. Between the dates and times of 5/7/26 at 9:00 AM and 5/24/26 at 9:00 AM, there were 35 times the Levetiracetam was documented as administered. This documentation indicated the Levetiracetam had been administered as ordered. Given that two tablets were ordered to be given with each administration time, this indicated there should have been 70 tablets total administered between these dates and times.A facility pharmacist was interviewed on 6/2/26 at 2:01 PM and reported the following information. The pharmacy's records showed the pharmacy first sent Resident # 1's supply of Levetiracetam 750 mg on the night of 5/7/26. On 5/7/26 the pharmacy dispensed 56 tablets, and this was the only supply dispensed prior to the night of 5/24/26 when the pharmacy dispensed 56 more tablets. According to the pharmacist, if given correctly, Resident # 1 would have run out of medication prior to 5/24/26. The pharmacist did not stipulate when the facility had reordered the medication for it to be sent on the night of 5/24/26. The pharmacy records showed that the facility staff only removed Levetiracetam from the facility's back up supply one time from 5/7/26 to 5/24/26 for Resident # 1. This was on 5/24/26 when they signed out two 500 mg tablets and two 250 mg tablets at 9:45 AM. The pharmacist reported the staff should not be borrowing from other residents' supply of medications. According to the pharmacist, the new supply of 56 tablets of Levetiracetam 750 mg was sent to the facility on the night of 5/24/26.Review of nursing notes revealed an entry on 5/24/26 at 3:32 PM that Resident # 1 was transferred to the hospital when her whole body was observed to be twitching. Review of a hospital Discharge summary, dated [DATE], revealed Resident # 1 was hospitalized from [DATE] through 5/28/26 due to having a seizure. Review of the 5/28/26 discharge summary revealed upon discharge Resident # 1's Levetiracetam dosage was changed. The new Levetiracetam dosage was 500 mg two tablets two times per day.Review of facility admission orders revealed an order on 5/28/26 for Levetiracetam 500 mg two tablets two times per day.Review on 6/2/26 of Resident # 1's May and June 2026 MARs revealed since Resident # 1's readmission date of 5/28/26, Resident # 1 had been documented to receive the ordered Levetiracetam 500 mg two tablets 10 times. The ten documented times were between the dates and times of 5/28/26 at 9:00 PM and 6/2/26 at 9:00 AM and which indicated the Levetiracetam 500 mg two tablets two times per day had been given correctly. Given that the 500 mg two tablets had been administered 10 times, this indicated that 20 tablets should have been removed from Resident # 1's supply or from the facility's back up supply.On 6/2/26 at 5:25 PM Resident # 1's Levetiracetam supply of 750 mg tablets, which had been filled on 5/24/26 by the pharmacy, was observed with the DON (Director of Nursing.) There were eight tablets punched out of the bubble card from Resident # 1's supply of 750 mg Levetiracetam tablets which had been dispensed after the resident was transferred to the hospital on 5/24/26. The DON was interviewed at this time as to why any doses would have been punched out from this Levetiracetam supply given that this 5/24/26 Levetiracetam supply was dispensed after the resident was discharged and upon readmission her dosage was no longer 750 mg. The DON reported she did not have an answer to that.Resident # 1's new supply of Levetiracetam 500 mg was also observed with the DON on 6/2/26 at 5:25 PM. The card noted the Levetiracetam had been filled on 5/29/26. There were twelve tablets punched out from the Levetiracetam 500 mg card. The DON was interviewed regarding the discrepancy between the MAR reflecting that 20 tablets of Levetiracetam 500 mg had been administered since 5/28/26 while the Levetiracetam supply cards showed that 8 tablets of 750 mg were punched after 5/24/26 and 12 tablets of 500 mg had been punched out from the 500 mg supply. The DON reported she had talked to some of the nurses who had been documenting the administration and they had reported that there was more on the cart from where the nurses could have obtained the correct dosage, but she was not sure at that time where the doses had specifically been taken from. According to the DON, the nurses were not supposed to borrow, and the MAR documentation should be able to be reconciled with the medication that was dispensed for Resident # 1.During an interview with the facility's Consultant Pharmacist on 6/3/26 at 11:42 AM, the Consultant Pharmacist reported that nursing staff should not be borrowing medications. The facility staff should order medications to get them in stock for administration availability. If staff were totally out of a resident's medication before a medication could be dispensed, then they should acquire the medication from the facility's back up medication supply or order it to be delivered from the pharmacy stat (right away).During an interview with Medication Aide (MA) # 1 on 6/3/26 at 11:10 AM (who had been responsible for the first documented dose of Levetiracetam on 5/7/26 at 9:00 AM), MA # 1 reported there were other residents on Levetiracetam, and she had borrowed medication for Resident # 1 from another resident on that specific date.During an interview with the DON on 6/3/26 at 9:05 AM the DON confirmed that other residents in the facility were receiving Levetiracetam which would indicate the possibility that some doses may have been borrowed.Resident # 1's Physician was interviewed on 6/3/26 at 12:45 PM and reported that when Resident # 1 seized on 5/24/26, Resident # 1 was on an antibiotic (Levaquin) which could lower the threshold for seizure activity.

Based on observation and staff interviews, the facility failed to ensure debris was removed from in front of the dumpsters for 2 of 3 dumpsters observed. The facility also failed to ensure that the doors to the dumpsters were closed for 1 of 3 dumpsters. This practice had the potential to attract pests and rodents.The findings included:An observation of the dumpster area and interview with the Dietary Manager was conducted on 9/8/25 at 7:22 AM. Three dumpsters were observed lined up in a row. The middle dumpster door was open on the right side and debris was in front of the middle dumpster and right dumpster. The debris included used gloves, used napkins, and a large pile of lint from a washing machine. The Dietary Manager stated that his department was responsible for the dumpster area, but all departments used the dumpsters. He further stated that his staff were supposed to clean up the dumpster area daily. The Administrator was interviewed on 9/12/25 at 9:34 AM. He revealed that trash was picked up three days each week and often, debris would be left on the ground afterward and the doors would slide open. There was a reacher available near the dumpsters, so anyone could pick up the loose items or close the dumpster doors as well. The Administrator stated that there was not a cleaning schedule for the dumpster area, but rather staff were expected to pick up any items if seen.

Based on record review and staff interviews, the facility failed to obtain and document consent from a resident's Responsible Party (RP) for the use of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #55).The findings included:Resident #55 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, depression and cerebral infarction (stroke).A physician order dated 8/6/25 indicated mirtazapine (antidepressant) tablet 15 milligram (mg). Give 0.5 tablet by mouth at bedtime for depression.A physician order dated 8/6/25 indicated quetiapine fumarate (antipsychotic) tablet 25 mg. Give 1 tablet by mouth at bedtime for dementia with behavior disturbances.An admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #55 as severely cognitively impaired. She was coded for having received an antidepressant and antipsychotic in the last 7 days or since admission or reentry if less than 7 days. A review of Resident #55's medical records on 9/9/25 revealed no documentation of consent, a discussion of risk verses benefits, or alternate treatment options with Resident #55's RP for use of psychotropic medications. During an interview with the facility Director of Nursing (DON) on 9/10/25 at 2:00 PM, she indicated that Resident #55 was admitted on [DATE] with psychotropic medications and consent should have been obtained at that time to continue administering the psychotropic medications, but it was missed. The DON stated that it was the responsibility of the admitting nurse, unit manager and all licensed nurses entering the orders to ensure consent was obtained prior to administering psychotropic medications. An interview was conducted with the Unit Manager (UM) on 9/12/25 at 8:53 AM. The UM explained that she would normally obtain consent for psychotropic medications use from the resident or RP when the resident was admitted , or a new psychotropic medication was ordered and that consent for Resident #55 was probably missed because it was an evening admission.During an interview on 9/12/25 at 11:45 AM with the facility Administrator, he stated that consent should have been obtained from the RP prior to administration of psychotropic medications, when Resident #55 was admitted to the facility.

Based on record review and staff interviews, the facility failed to inform a resident and/or Responsible Party (RP) of their right to accept or refuse medical or surgical treatment or to formulate an advance directive for 1 of 24 residents reviewed for advance directives (Resident #2).The findings included:Resident #2 was admitted to the facility on [DATE]. The medical record indicated Resident #2's RP was her legal guardian. A physician order for Resident #2 dated 4/30/25 indicated full code status. A social service history and initial assessment form completed by the Social Worker (SW) with an effective date of 5/1/25 included an advanced care planning section that had not been completed. Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #2 as moderately cognitively impaired.A review of the medical record revealed no documentation that Resident #2 or her RP was informed of the right to refuse medical or surgical treatment or to formulate an advance directive. An interview was conducted on 9/12/25 at 8:34 AM with the SW. She indicated she normally discussed advance directives with the resident or resident's RP during admission. She stated that she had been trying to get in touch with Resident #2's RP via telephone to discuss advance directives and that she should have sent a certified letter to the RP informing her to contact the facility after 3 phone call attempts. The SW stated she was able to get in touch with Resident #2's RP on 9/9/25 and discussed the advanced care planning information with RP to include the right to formulate an advance directive and updated Resident #2's medical records to include the information discussed with RP on 9/9/25.During an interview on 9/12/25 at 8:44 AM with the Director of Nursing (DON) she indicated the SW should have followed up with Resident #2's RP to discuss advance directives. During an interview on 9/12/25 at 11:43 AM with the Administrator, he indicated advance directives were normally discussed with resident or RP during admission and that the SW should have followed up and ensured advance directives were discussed and documented in Resident #2's medical records.

Based on record review and staff interviews, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident with newly evident mental health diagnoses for 1 of 2 sampled resident reviewed for PASRR (Resident #10).The findings included:Resident #10 was readmitted to the facility on [DATE] with diagnoses including unspecified psychosis not due to a substance or known physiological condition and psychotic disorder with hallucinations due to known physiological condition.The admission Minimum Data Set (MDS) dated [DATE] had Resident #10 coded as severely cognitively impaired and was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #10 had listed diagnosis of psychotic disorder (other than schizophrenia) and vascular dementia, unspecified severity, with mood disturbance.An interview with the Social Worker (SW) was conducted on 09/10/2025 at 9:40 AM. The SW stated she was not an employee in 2024 and was currently responsible for completing PASRR screenings for residents. The SW also stated a PASSR level II screening should have been completed and submitted for Resident #10 when she was readmitted to the facility on [DATE] with new mental health diagnoses of unspecified psychosis not due to a substance or known physiological condition and psychotic disorder with hallucinations due to known physiological condition. An interview with the Director of Nursing (DON) was conducted on 09/12/2025 at 10:28 AM. The DON indicated the SW was expected to complete a PASRR level II screening for all residents with a mental health diagnosis.

Based on record review and staff interviews, the facility failed to apply for a Preadmission Screening and Resident Review (PASRR) Level II screening for 1 of 5 residents reviewed for PASRR Level II screenings (Resident #4). The findings included: A review of the PASRR level I determination letter dated 11/04/2023 revealed a PASRR number already existed for Resident #4. Resident #4 was admitted to the facility on [DATE] with diagnoses including bipolar disorder 12/13/2023. A physician's order dated 12/13/2023 revealed an order for risperidone (antipsychotic medication) extended-release subcutaneous injection (used to administer medications between skin and muscle) 120 milligrams (mg) one time a day every 28 days for psychosis. The admission Minimum Data Set (MDS) dated [DATE] had Resident #4 coded as cognitively intact and was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #4 used psychotropic medication related to bipolar disorder. The care plan dated 02/07/2024 had focus of the resident at risk for adverse reaction related to psychotropics. An interview with the Social Worker (SW) was conducted on 06/12/2024 at 10:07 AM. The SW explained that if a newly admitted resident had a PASRR level I at admission and had a psych diagnosis or psych medications, that was her cue to apply for a PASRR level II screening. The SW also stated Resident #4 was admitted on [DATE] with a diagnosis of bipolar disorder and a PASRR level II was not submitted and she did not know why it was not completed. It must have been an oversite. An interview with the Administrator was conducted on 06/12/2024 at 10:35 AM. The Administrator explained that Resident #4 came in with a completed PASRR level I and she should have been screened for a PASRR level II when she was admitted due to her diagnosis of bipolar disorder. The Administrator also stated the SW was the person responsible for this task and in the future, they will have training and a 2nd SW so an issue like this will not happen again.

Based on record review, Responsible Party (RP) and staff interviews, the facility failed to inform the RP of skin tears and bruises for one (1) out of four (4) sampled residents reviewed. (Resident #150) Findings include: Resident #150 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, hypothyroidism and hypertension. The resident was discharged from the facility on 05/25/2024. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #150 had short-term and long-term memory problems and cognitive skills for daily decision making was severely impaired. A review of Resident# 150 Skin Observation Tool dated 12/26/2023 by Nurse #1 revealed the resident was observed with a skin tear on left hand 1st digit. A review of Resident #150 Skin Observation Tool dated 03/05/2024 by Nurse #2 revealed the resident was observed with a skin tear on the right cheek. During an interview on 06/13/2024 at 1:29 PM, Nurse #2 indicated that she did not notify the RP on 03/05/2024 about a skin tear on Resident #150's right check. She indicated the facility protocol was to notify the RP about a skin tear and complete an incident report. She also indicated for the future she will make sure she notifies the RP of a skin tear A review of Resident #150 Skin Observation Tool dated 04/29/2024 by Nurse #3 revealed the resident was observed with a skin tear on the face. During an interview on 06/13/2024 at 12:45 PM, Nurse #3 indicated she observed the skin tear on Resident # 150 on 04/29/2024 but did not notify the RP. She indicated she did not know the reason why she did not notify the RP of the skin tear. She indicated she had been trained to complete an incident report and notify the RP of any skin tear or bruise on a resident at the facility. She reported moving forward she will make sure the RP is notified of a skin tear and bruise on a resident at the facility A review of Resident #150 Skin Observation Tool dated 05/20/2024 by Nurse # 4 revealed the resident was observed with a bruise on the left knee. Review of the nursing progress notes between December 2023 and May 2024 revealed no documentation of the RP being made aware of the discovered injuries. During an interview on 06/13/2024 at 11:00 AM, Resident#150's RP stated she was not notified of the resident's skin tear on left hand 1st digit, right cheek, right face, and a bruise on the resident's knee. During an interview on 06/13/2024 at 11:42 AM, Assistant Director of Nursing (ADON) indicated she was not aware of the reason the staff failed to notify the RP about the Resident #150's skin tears and a bruise. She indicated the staff at the facility was expected to notify the RP about a change in the condition of a resident and document in the progress notes that the RP was notified. She indicated moving forward the staff will call the RP and document that the RP had been notified of the skin tear or a bruise on a resident. An attempt to contact Nurse#1 was unsuccessful. An attempt to contact Nurse #4 was unsuccessful. During an interview on 06/13/2024 at 2:14 PM, the Director of Nursing reported it was his expectation that residents or their RP be notified of skin tears and bruises. He reported the staff at the facility had been trained to notify the RP of any skin tear or bruises. During an interview on 06/13/2024 at 3:00 PM, Administrator reported he did not know the reason for the staff not notifying the RP of the skin tears and a bruise on Resident #150. He indicated his expectation was that RP be notified of skin tears and bruises. He reported the staff would be in serviced in reference to notifying RP of a skin tear or bruise.

Based on record review, and staff interviews, the facility failed to ensure the facility was free of medication errors due to an incorrectly transcribed admission order to stop Lovenox (A medication that helps prevent the formation of blood clots.) when the International Normalized Ratio (INR) (a blood test that indicates how well the blood can clot.) was less than 2.0. The Physician's order was to stop Lovenox when INR was greater than 2.0. The deficient practice was for 1 of 3 residents reviewed for medication errors (Resident #1). The findings included: A review of the hospital summary dated 04/08/2024 revealed the chief complaint was recurrent acute respiratory failure. Resident #1 was readmitted to the facility on [DATE] with diagnoses including acute respiratory failure. The care plan dated 04/09/2024 had focus of at risk of impaired air exchange related to chronic respiratory failure. A review of a physician's note dated 04/09/2024 revealed Resident #1 was currently on Lovenox treatment dose being bridged until INR is greater than 2. A review of the Resident #1's lab result dated 04/09/2024 revealed INR was 1.4. (In healthy people an INR of 1.1 or below is considered normal. An INR range of 2.0 to 3.0 is generally an effective therapeutic range for people on Warfarin.) A review of Physician's readmission orders dated 04/09/2024 revealed Warfarin Sodium Oral Tablet (A medication that helps prevent the formation of blood clots) 10 milligrams (mg) tablet one time a day for deep vein thrombosis (DVT) (blood clot) and 04/10/2024, Enoxaparin Sodium Injection Solution Prefilled Syringe (Lovenox) 80 mg/0.8 milliliter (ml). Inject 0.8 ml subcutaneously one time a day for DVT. Stop Lovenox when INR is greater than 2.0. The April Medication Administration Record (MAR) revealed the following orders: 04/09/2024: Warfarin Sodium Oral Tablet 10 mg tablet one time a day for deep vein thrombosis (DVT). The medication was administered as ordered. 04/10/2024: Lovenox, 80 mg/0.8 ml. Inject 0.8 ml subcutaneously one time a day for deep vein thrombosis (DVT). The medication was held on 04/10/2024, 04/11/2024 and 04/12/2024. It was administered on 04/13/2024 and 04/14/2024. 04/10/2024: Stop Lovenox when INR is less than 2.0. The 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was coded as moderately cognitively impaired. An interview with Nurse #2 was conducted on 06/04/2024 at 11:14 AM. Her chart was reviewed, and the order for Lovenox 0.8 ml once daily was transcribed incorrectly. The order should have read to stop the Lovenox if the INR was greater than 2.0 and not when it was less than 2.0. The nurse also stated she was removed as admissions nurse to floor nurse. They also educated her and the staff to have two nurses do a second check on all physician orders. An interview with the Physician was conducted on 06/04/2024 at 12:21 PM. Resident #1 had comorbidities including chronic respiratory failure, and a replaced heart valve. The order for Lovenox was transcribed incorrectly. The Lovenox was supposed to be held when the INR was greater than 2.0 but the Nurse put the order to stop the medication when it was less than 2.0. Resident #1 did miss three doses of Lovenox, but she was still receiving Warfarin as directed. The Physician also stated missed doses did not contribute any harm to Resident #1's well-being. An interview with the Administrator was conducted on 06/04/2024 at 1:19 PM. The Resident did miss several doses of Lovenox due to a transcription error made by one of their nurses. The nurse was educated and asked to step down as admission nurse. All the nurses were educated on the importance of transcribing the physicians' orders correctly and going forward, the need for two nurses to check all physician orders. A plan of correction was completed on May 30, 2024. Plan of Correction (POC) Problem: 04/10/2024, 04/11/2024 and 04/12/2024, 9:00 AM doses of Lovenox were missed on Resident #1 due to a transcription error. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice include: Lovenox order for resident was transcribed in error, stating to hold Lovenox when the INR was greater than 2. The nurse transcribed the order to say hold when INR is less than 2. All residents who are currently taking Lovenox orders were reviewed with no discrepancies noted. Address how the facility will identify other residents having the potential to be affected by the same deficient practice include: All residents who are currently taking Lovenox orders were reviewed by the Administrator with no discrepancies noted. The facility has determined that all residents with Lovenox orders have the potential to be affected. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur include: May 1, 2024, to May 30, 2024, the Director of Nursing and Administrator provided in-service education programs for all licensed staff regarding managing orders including transcription and submission of Physician orders will require two nurse verification. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting regarding managing orders including transcription and submission of Physician orders was initiated on May 1, 2024. The admission Nurse who made the transcription error was counseled on 05/14/2024 and removed from the admission nurse position. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and include dates when corrective action will be completed: The DON/Designee will monitor all admission orders from 05/01/2024 to 05/30/2024 with audits to ensure transcription of Physician's orders were correct. The nurse consultant will also perform daily chart audits on the previous days admission and report the finding to the DON and ADON. This plan of correction will be monitored at the monthly Quality Assurance meetings until such a consistent substantial compliance has been met. Corrective action completion date: May 30, 2024 On 06/04/2024 the facility's plan of correction was validated by the following: Monitoring using audits started 05/01/2024 when the error was found and was completed on 05/30/2024 with a system in place to review daily chart audits on the previous days admissions to ensure all transcribed Physicians' orders were correct. The audit was found to be completed according to the plan of correction. Staff interviews with nurses verified education was provided on the importance of including 2 nurse verification when transcribing physicians' orders. The staff signed in-service training content included: Provisions of physicians ordered services and Residents admission process. The Administrator stated he and the DON completed training with the nurses at the facility on 05/30/2024 and provided the education via telephone to the nurses that were not in the facility. The training check-off sheets were noted to have DON's and Administrators' signature as the instructors. In-service for all facility staff started 05/01/2024 and was completed on 05/30/2024. The Administrator stated he was responsible for this POC and ensured all new hires will be in-service on needing two nurses to check all physicians' orders. The audit tool revealed the DON completed the audits. The chart audits revealed the corporate Nurse completed the audits. On 06/04/2024 sampled Residents on Lovenox were reviewed and their medications were transcribed and administered as ordered. There were no complaints of medication errors from other sampled residents. The staff Nurses that were interviewed, were able to express understanding of the education. The Risk Management/Quality Assurance Committee form dated 05/01/2024 revealed the issue of following Physician's (admission, Lovenox) orders was addressed in QAPI. An interview with DON was conducted on 06/04/2024 at 1:15 PM. The DON stated he oversaw monitoring by auditing all admission orders from 5/1/2024 to 5/30/2024 and there were no discrepancies found. An interview with the Nurse Consultant was conducted on 06/04/2024 at 1:27 PM. The Nurse Consultant stated she did complete the daily chart audits and there were no discrepancies with the audits. The facility's plan of correction was validated to be completed as of 06/04/2024.

Based on record reviews and resident, staff and physician interviews, the facility failed to thoroughly investigate an allegation of staff to resident physical abuse for 1 of 3 residents reviewed for abuse (Resident #1). The findings included: Review of the facility's Abuse, Neglect and Exploitation policy, last revised 03/20/23, read in part, V. Investigation of Alleged Abuse, Neglect and Exploitation: B4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. B6. Providing complete and thorough documentation of the investigation. Resident #1 was admitted to the facility on [DATE]. A review of the facility's Initial Allegation Report, completed by the Administrator and sent to the State Agency on 04/16/24 revealed that Resident #1 informed the facility that an employee in blue scrubs hit him in the stomach on 04/16/24. The report indicated the facility presented two employees to the resident and Resident #1 identified Nursing Assistant (NA) #1 as the person who hit him in the stomach. The report indicated the facility became aware of the incident on 04/16/23 at 6:45 p.m. and that the facility notified the local police department and Adult Protective Services and suspended NA #1 and began an investigation of the allegation. A review of the facility's Investigation Report, completed by the Administrator on 04/17/24, revealed, during the investigation, resident [Resident #1's] roommate [Resident #2] stated 3 times that nothing ever happened. The report stated that the incident did not result in physical injury or harm to Resident #1, nor did it result in mental anguish for the resident. The report indicated Resident #1 had no emotional response noted. Resident does have manipulative and attention seeking behaviors. The Investigation Report indicated Human Resources reviewed the employee record of NA #1 and there had been no issues noted in it. Corrective actions following the incident included skin assessments and resident interviews as well as an Ad-hoc Quality Assurance Performance Improvement (QAPI) meeting on 04/17/24 was completed to deem compliance and unsubstantiate the allegation. A review of the summary of the incident, written by the Administrator and undated, read as follows: On 4/16/2024 at approximately 6:45 p.m. Chief Clinical Officer was notified that resident [Resident #1] said someone hit him in the stomach. Resident initially described a nurse in blue scrubs with short hair. The nurse that fit that description was presented to the resident and he laughed and stated no. The assigned Certified Nursing Assistant [CNA] was called back to the facility and presented to the resident and he stated yes. CNA did not meet the description provided by resident. Resident had a skin assessment completed with no issues noted. Resident's roommate [Resident #2] (BIMS 15) [brief interview for mental status which scores a resident's cognition] was interviewed and stated he did not hear or see anything occur that day. Nurse interviewed alert and oriented residents on the hall (BIMS 13 or higher) with no issues noted. Nurse completed skin assessments on resident with BIMS less than 13 on hall with no issues noted. [Resident #1] is care planned for manipulative and attention seeking behaviors. Due to inconsistencies of story and other interviews, facility unsubstantiates the allegation of abuse. Review of NA #1's assignments on 04/08/24, 04/09/24, 04/11/24, and 04/14/24 revealed she had cared for residents on the 200 Hall. On 04/15/24, NA #1 cared for residents on the 500 Hall. Resident #1 resided on the 200 Hall and had been assigned to NA #1's care on 04/16/24. An interview was conducted with NA #1 on 04/22/24 at 2:16 p.m. NA #1 confirmed she had worked from 7:00 a.m. until 3:00 p.m. on 04/16/24 and had been assigned to care for Resident #1. She stated after Resident #1 identified her, she left his room, and said that she had been suspended from working during the facility's investigation. She stated she was allowed to return to work after one day of suspension. An interview was conducted with the Director of Nursing (DON) on 04/23/24 at 2:00 p.m. The DON stated she had just begun her job as DON on 04/15/24 and the abuse allegation from Resident #1 related to NA #1 was on 04/16/24. The DON stated she went to Resident #1's room to interview him about the abuse allegation he made on 04/16/24. After interviewing the resident, the DON informed the Chief Clinical Officer of her interview with the resident and then she left. The DON explained the Chief Clinical Officer had been the facility's interim DON prior to her starting at the facility and the Chief Clinical Officer took over the investigation at that point. An interview was conducted with the Chief Clinical Officer on 04/23/24 at 2:21 p.m. The Chief Clinical Officer explained she was informed of the abuse allegation by the DON. She indicated Resident #1 identified NA #1 as the alleged perpetrator. The Chief Clinical Officer explained NA #1 was immediately suspended from work at the facility pending the investigation and then she had a couple of nurses interview alert and oriented residents and perform skin assessments on residents who were not alert and oriented on NA #1's 04/16/24 assignment on the 200 hall as well as other residents who resided in close proximity to NA #1's assignment on the 200 hall. The Chief Clinical Officer explained the interviews and skin assessments did not reveal any positive abuse findings and therefore, the investigation did not expand to other areas of the facility such as the 500 hall where NA #1 had been assigned to work on 04/15/24. An interview was conducted with the Administrator on 04/23/24 at 12:41 p.m. The Administrator explained skin assessments were performed on residents with a BIMS score of less than 13 who resided on the same hall as Resident #1, and they had no signs or symptoms of abuse. He stated interviews were conducted with residents with a BIMS score of 13 or greater who resided on the same hall as Resident #1 which were negative for abuse allegations. When asked to clarify whether he expanded the interviews (of alert and oriented residents) or skin assessments of residents (who were not alert and oriented) in other areas of the facility where NA #1 worked prior to the incident of 04/16/24, the Administrator stated he had not. He explained they had only looked at those residents who had been assigned to her care on 04/16/24 as well as other residents who resided on the 200 hall near the area of her assignment and that they had found no problems or concerns. The Administrator further explained had there been any concerns that alluded to abuse then the investigation would have expanded to other areas of the facility where NA #1 had worked. The Administrator stated by suspending NA #1 immediately after the allegation of abuse was made, he had removed the immediate potential threat. He also stated that the decision to not expand the investigation to other areas in the building was because there had been no positive findings from the resident interviews and skin checks. The Administrator stated after the investigation had been completed, NA #1 had been allowed to return to work.

Based on record reviews, and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of property when a staff member (Floor Technician #1) took money from a Resident's pants pocket while he was in bed without the resident's consent. The deficient practice was for 1 of 3 residents reviewed for misappropriation of resident property (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses including other orthopedic conditions. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact. The Facility Reportable Incident reported dated 02/26/2024 completed by the Administrator was reviewed. On 02/26/2024 staff notified the Social Worker (SW) and Director of Nursing (DON) that Resident #2 was lying in bed with his head covered, when a staff member (Floor Technician #1) came in the room and took money out of his pocket. A review of the police report dated 02/27/2024 revealed there was a theft at the facility, and the victim (Resident #2) requested no police involvement at that time. An interview with the police officer was attempted by phone but was not successful. A review of the written statement from Floor Technician #1 dated 02/26/2024 revealed he was pulling trash from Resident #2s room and seen some money sticking out the Residents pocket. He took $1.00, was startled by Resident as he woke up, so he exited the room. He apologized for his mistake. An interview with Floor Technician #1 was attempted by phone but was not successful. An interview with Resident #2 was conducted on 04/02/2024 at 9:41 AM. The Resident stated he was in bed and felt someone take money out of his pants pocket and run out of the room. He saw the guy and was able to identify him but did not know his name (Floor Technician #1). He was missing around $25.00 dollars. The police came and he did not want to press charges against the guy (Floor Technician #1). The Resident also stated he felt safe in the facility, and this had never happened before. An interview with the Social Worker (SW) on 04/02/2024 at 9:50 AM revealed the Director of Nursing (DON) notified her that someone came into Resident #2's room and took his money out of his pocket while he was in bed with his head covered with his blanket. The Resident did not know the person but had seen him in the facility. He also stated some money was missing. The DON continued the investigation while the SW went and called the resident's mother, and the Administrator called the police. The detective arrived and she escorted him to the resident's room. The resident told the detective the employee stole money out of his pocket while he was in bed and ran. The detective asked if he wanted to press charges and Resident #2 refused. An interview with the Director of Nursing (DON) was conducted on 04/02/2024 at 10:03 AM. The DON stated Resident #2 reported a staff member (Floor Technician #1) came into his room and took about $25.00 dollars out of his pocket while he was in bed. DON and SW began the investigation. The police were called, and they came but the Resident refused to press charges. The DON escorted the staff member out of the facility, and he was terminated. The initial report was filed, and they reimbursed the Resident $25.00. They also educated the staff what misappropriation of Residents' property was and who, when, how to report it. They had alert and oriented Residents and Residents Responsible Parties (RP) fill out a questionnaire concerning misappropriation of property and no other Resident or RP voiced concerns. They audited the grievances and incidents for and there were no other incidents of misappropriation of property found. It was also included in their Quality Assurance and Performance Improvement (QAPI) committee that meets quarterly. The facility provided the following Plan of Correction (POC) with a compliance date of 04/01/2024: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Law enforcement was called on 02/26/2024. A statement received on 02/26/2024 from Resident #2 revealed he did not want to press charges against Floor Technician #1 and felt safe in the facility. Upon interview with the DON on 02/27/2024, Floor Technician #1 confessed to taking a dollar bill from the resident's pocket. Floor Technician #1 was terminated and escorted out of the facility. Interviews with staff conducted by the DON on 02/27/2024 that were assigned to the resident's hall were conducted. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected. On 02/26/2024 through 03/05/24 statements were obtained from all facility employees and questionnaires were obtained from all alert and oriented residents and the Residents Responsible Parties (RPs) for residents who were not alert and oriented. The staff were asked if they were aware of any residents that reporting missing money. The questionnaires asked if they had any money missing at the facility. This was completed by the Social Worker. No concerns were identified. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: 100 % of staff was in serviced from 02/27/2024 and completed on 03/05/2024 by the DON for Misappropriation of Resident Property. All new hires will continue to receive education on misappropriation of property by DON. This education started on 02/27/24 and was completed on 03/05/24. All new staff are educated on Misappropriation of Property on hire and this process will continue. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator or DON will monitor grievance and incidents weekly in March with the Social Worker to ensure no further incidents of misappropriation have occurred. The DON will present to the Quality Assurance Performance Improvement (QAPI) results of the completed monitoring to the senior team via morning meetings, and to the next quarterly QAPI for the next 2 quarters. Corrective action completion date: 04/01/2024 On 04/02/2024 the facility's plan of correction was validated by the following: Audits conducted by the facility were reviewed and were found to be completed according to the plan of correction. Auditing started 02/26/2024 and was completed 03/27/2024. Staff interviews and verified education were provided on misappropriation of property and staff were able to express verbal understanding of education. The training in-service dated 02/26/2024 to 03/05/2024 content titled Misappropriation of property was signed by staff members. The Interim Director of Nursing (DON) stated she conducted the training for misappropriation of property of the staff at the facility on 02/27/2024 and provided the education via telephone to the staff members that were not in the facility. All staff were educated by 03/05/2024. The DON stated she was responsible for this POC and ensured all new hires would be in-serviced on misappropriation of property. They have audited the grievances for the month of March and there were no other incidents of misappropriation of resident's property. The March audit tool revealed the SW completed the audits of the grievances and incidents without any new complaints of any misappropriation of resident's property. On 04/02/2024 sampled residents and family members were interviewed concerning misappropriation of property and there were no concerns voiced. A review of a receipt dated 03/04/2024 revealed $25.00 was given to Resident #2 for missed money. The Risk Management/Quality Assurance Committee revealed the issue was addressed in QAPI. The facility's plan of correction was validated to be completed as of 04/01/2024.

Based on record review, and staff interviews, the facility failed to ensure the facility was free of medication errors due to a missed dose of Intravenous (IV) Therapy. The deficient practice was for 1 of 4 residents reviewed for medication errors (Resident #4). The findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory reaction due to wound infection. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was severely cognitively impaired. The care plan dated 03/26/2024 had focus of IV Antibiotic Medications related to wound infection. Record review of active medications revealed an order dated 03/20/2024 that read Piperacillin-Tazobactam in Dextrose Intravenous (IV) Solution (an antibiotic to clear infections) 3-0.375 grams (GM)/50 milliliters (ML). Use 50 ml intravenously every 8 hours for wound infection for 23 Days. The Medication Administration Record (MAR) for March 2024 revealed Piperacillin-Tazobactam in Dextrose IV had not been documented as administered as ordered for the 2:00 PM scheduled dose on 03/30/2024 by Nurse #1. A telephone interview with Nurse #1 was conducted on 04/02/2024 at 1:33 PM. The Nurse stated she recalled Resident #4, and she was supposed to administer the IV medication on 03/30/2024 because the Medication Aides cannot administer IV medications. It was missed due to an oversite while working with another resident at that time. The Nurse also stated the next day, she had been educated on the importance of administering the medications as ordered and would be more cautious in the future. An interview with the interim Director of Nursing (DON) on 04/02/2024 at 1:40 PM revealed she received a report on 03/31/2024 that stated Resident #4 did not receive her 2:00 PM dose of IV antibiotics on 03/30/2024. The DON stated after the report, she reviewed Resident #4's MAR and the 2:00 PM dose of IV antibiotic was not documented as administered. She spoke with Nurse #1 that worked with Resident #4 on 03/30/2024 during the missed dose and Nurse #1 informed the DON of the missed 2:00 PM dose due to working with another resident at the time and overlooked Resident #4's medication. A Plan of Correction began then with assessing Resident #4 and calling the family and physician. The Resident was not in distress and had received the next doses as ordered. The DON educated all Nurses in person and by phone, of the importance of administering medications as ordered. All Residents that were on IV therapy and had the potential to be affected were audited. The review of the medications did not reveal any other missed doses of medications. All MARs and Treatment Administration Records (TAR) are now audited daily to ensure all medications are being administered. The DON stated their Quality Assurance Committee meets quarterly and this issue was addressed in the last meeting on 04/01/2024. A telephone interview with the Ombudsman was conducted on 04/02/2024 at 2:04 PM. The Ombudsman stated he had meetings with the family of Resident #4 and was told there was a missed dose of IV therapy on 03/30/2024. The facility was informed, and they completed a POC for the staff there. The Ombudsman also stated the family did not voice any concerns about any effects of missing the medication but was concerned that it was missed. The facility provided the following plan of correction (POC): Problem: 03/30/2024, 2:00 PM dose of IV antibiotics missed on Resident #4. Immediate actions taken for the residents found to have been affected include: The MD was contacted about the missing dose of antibiotic. Orders were given to add another dose to the end of the administration time. Family aware of the missing dose and MD recommendations. The next dose was given as ordered. Identification of other residents having the potential to be affected was accomplished by review of the Matrix to identify all other residents on IV antibiotics. The Medication Administration Records (MAR) and Treatment Administration Records (TARS) were reviewed for all residents on IV antibiotics. Actions taken and systems put into place to reduce the risk of future occurrence include: The Interim DON met with nursing staff on 03/31/2024 and discussed the following items: The importance of giving medications as ordered by the physician. The importance of increased communication between the nurse and medication aide. The importance of reporting any missed medications or med errors as soon as identified. How the corrective actions will be monitored to ensure the practice will not recur: The Corporate Facility Nurse Consult review MARs and TARS daily to ensure all medications and treatments are completed as ordered. Unit managers/Charge nurses will review the audit and take appropriate actions for any missed doses. Audit results will be reviewed by the Risk Management/Quality Assurance Committee during the quarterly meetings until such a time consistent substantial compliance has been achieved as determined by the committee. Corrective action completion date: 04/01/2024 On 04/02/24 the facility's plan of correction was validated by the following: Audits conducted by the facility were reviewed and were found to be completed according to the plan of correction. Auditing started 03/31/2024 and is ongoing with a system in place to review all MARs and TARs daily. Staff interviews with nurses verified education was provided on the importance of giving medications as ordered by the physician. The staff signed in-service training content included: Medication Administration/ Medication Errors were verified for the Nurses. The interim Director of Nursing (DON) stated she conducted the training of the nurses at the facility on 03/31/2024 and provided the education via telephone to the nurses that were not in the facility. The training check-off sheets were noted to have DON's signature as the instructor. In-service for all facility staff started 03/31/2024 and was completed on 03/31/2024. The DON stated she was responsible for this POC and ensured all new hires will be in-serviced on medication administration errors. The Medication Administration Records (MAR) and Treatment Administration Records (TAR) were being audited daily by the Corporate Facility Nurse and the unit managers are to review the audit for any missed doses. The audit tool revealed the Corporate Facility Nurse, and the Unit Managers were completing the audits. On 04/02/2024 sampled residents were reviewed, and their medications were documented as administered. There were no complaints of missing medications from other sampled residents. The staff Nurses that were interviewed, were able to express understanding of the education. The Risk Management/Quality Assurance Committee revealed the issue was addressed in QAPI. An interview with the Corporate Facility Nurse was conducted on 04/02/2024 at 1:52 PM. The Nurse stated she oversees auditing the MARs and TARs daily to make sure the nurses are administering all medications as ordered. The Nurses are completing medications administrations as ordered. The Nurse also stated if there are any discrepancies then the charge nurse will be notified, and actions will be taken immediately. The facility's plan of correction was validated to be completed as of 04/01/2024.

Based on record review and staff and Medical Director interviews, the facility failed to complete and document comprehensive weekly skins assessments and nursing notes related to treatment or prevention of pressure ulcers, provide treatments as ordered, and initiate an air mattress and protective heel boots when recommended for a resident with and at risk for pressure ulcers. Resident #1 developed new pressure ulcers and existing pressure ulcers deteriorated. This deficient practice occurred for 1 of 3 residents reviewed for pressure ulcers (Resident #1). The findings included: Resident #1 was admitted into to the facility on [DATE] with diagnoses of dementia, protein malnutrition, muscle wasting/atrophy, paranoid schizophrenia, anxiety, and peripheral vascular disease, protein calorie malnutrition, and muscle weakness. A review of Resident #1's admission skin assessment dated [DATE] noted a pressure wound to his right hip. A review of Resident #1's Braden Scale (a scale composed of six subscales, mobility, activity, sensory perception, skin moisture, nutritional status and friction. Each subscale has its own operational definitions and rate from 1 (least favorable) to 3 or 4 (most favorable) completed on 1/2/24 revealed Resident #1's score was a 13 which meant Resident #1 was at moderate risk for developing pressure areas. A review of Resident #1's admission Minimum Data Set, dated dated dated [DATE] noted he was severely cognitively impaired, had one stage 4 pressure area present on admission and noted no pressure ulcer/injury care, applications of nonsurgical dressings, or applications of ointments or medications. It further noted that he had no behaviors, rejected care 1-3 days, had received both antipsychotic and antianxiety medications, had limited range of motion in his bilateral lower extremities. A review of Resident #1's undated care plan revealed there was no care plan regarding pressure ulcers. A review of Resident #1's Physician orders revealed an order dated 1/2/24 for Resident #1was to been seen, evaluated, and treated by Wound Care. a. Resident #1 was seen by the Wound Care Nurse Practitioner (NP) on 1/3/24 who noted a stage 4 right hip posterior wound (Wound A) measured 0.9 cm (centimeters) x 1cm x 1cm (estimated depth) and ordered Calcium Alginate with silver dressing to be applied daily. She also recommended a low air loss mattress and heel suspension boots be utilized. A review of Resident #1's January 2024 Treatment Administration Record (TAR) did not indicate an order for Calcium Alginate with silver dressing to be applied daily. The Medical Director saw Resident #1 on 1/8/24 and noted that Resident #1 had transferred from another nursing home, had been noncompliant quite often, refused medication often, and had a stage 4 pressure injury to the right hip. Resident #1 was seen by the Wound Care NP on 1/10/24. She also noted Wound A had not improved measurements remained the same and ordered Wound A packed with silver hydro-fiber or alginate (rope or sheet cut into strand) and covered with an absorbent dressing. She noted there was no low air loss mattress on the bed and Resident #1's heels were not suspended, she again recommended both be utilized. A culture and bone biopsy were obtained during this visit of Wound A. She noted laboratory blood work completed on 1/9/24 included Albumin level of 2.9 (normal range 3.4-5.4), Total Protein 6, (6.0-8.3) [NAME] blood cell count 10.7 (normal range 4.5- 11), Hemoglobin 10.3 (normal range 12-16), Hematocrit 32.4 % (normal range 36-48%), and Creatinine 1.4 (normal range 0.7-1.3). She also recommended a low air loss mattress and heel suspension boots be utilized. A review of Resident#1's medical record indicated one weekly skin assessment was completed by the licensed nursing staff on 1/16/24 which noted an area to the left buttock measuring 4.5 cm x 3.0 cm with a red fleshy peri wound. This was the only weekly skin assessment documented in the medical record. A review of Resident #1's medical record revealed bone biopsy results reported on 1/16/24 that indicated medullary space tissue with granulation response comprised predominantly of plasma cells, lymphocytes, and a few scattered neutrophils with adjacent trabeculae compatible with chronic non-specific osteomyelitis (bone infection). On 1/17/24 the Physician wrote an order for the for Levofloxacin (antibiotic) 500 mg given once a day by mouth for 22 days (1/18/24 through 2/9/24) for the diagnosis of osteomyelitis. A review of Resident #1's January 2024 Medication Administration Record (MAR) revealed he refused to take this medication on January 24th through the 28th, his February MAR indicated he took the medication as scheduled. Resident #1 was seen by the Wound Care NP on 1/17/24. She noted Wound A had not improved measurements were 0.9 cm x 1 cm x 1 cm with undermining at 12 o'clock of 3 cm, undermining at 6 o'clock of 1 cm, undermining at 3 o'clock of 2 cm and undermining at 9 o'clock 3.5 cm. She continued with the order of calcium alginate with silver and a dry protective dressing. A review of Resident #1's January 2024 (TAR) noted the order to pack Wound A with silver hydro-fiber or alginate (rope or sheet cut into strand) and cover with an absorbent dressing daily was not documented as completed on January 15th, 18th, 20th, 23rd, or 24th. A review of the Registered Dietician noted dated 1/16/24 included Resident #1 was on a regular dysphasia advanced diet with thin liquids noted a 50-100% intake at majority of meals with maximum assistance. Increased nutrient needs to aid in wound healing and recommended 30 milliliters of an advanced wound care ready to drink concentrated liquid protein providing 17 grams of hydrolyzed collagen protein and 100 calories per fluid ounce twice a day, obtain Resident#1's weight, monitor appetite percentage, and labs as ordered. A review of the Wound Care NP note dated 1/24/24 indicated Wound A was not improving and measured 1 cm x 1 cm x 1.5 (estimated depth). The Wound Care NP ordered to cleanse Wound A with normal saline or a wound cleanser, pack with gauze moistened with a mixture of sodium hypochlorite (0.4% to 0.5%), and boric acid (4%) diluted in water and fill all the dead space then cover with an absorbent dressing. She also recommended a low air loss mattress and heel suspension boots be utilized. A review of Resident #1's medical record indicated the Medical Director saw him on 1/24/24 and noted that he was seeing Resident #1 because of a decline in the past several days. He also noted that Resident #1 was currently on antibiotics for a presumed osteomyelitis of the left hip wound and that Resident #1 had been refusing quite a bit of medications and was not eating. It was also noted that Resident #1 had developed six new wounds in the last few days with deep tissue injuries as well. The Medical Director further indicated that he had spoken with Resident #1's sister and updated regarding the new wounds and that he had developed and that he may be in the dying process and suggested Resident #1 be placed on hospice which the sister refused, the sister also declined Resident #1 to have a feeding tube and wanted the facility staff to feed him. The Medical Director advised Resident #1's sister that the facility could not force feed him and if he declined more that he would be sent to the hospital for evaluation. A review of Resident #1's January 2024 Physician orders revealed the order from the Wound Care NP 1/25/24 to cleanse Wound A with normal saline or a wound cleanser, pack with gauze moistened with a mixture of sodium hypochlorite (0.4% to 0.5%) and boric acid (4%) diluted in water and fill all the dead space then cover with an absorbent dressing daily. A review of Resident #1's January TAR revealed the order to cleanse Wound A with normal saline or a wound cleanser, pack with gauze moistened with a mixture of sodium hypochlorite (0.4% to 0.5%) and boric acid (4%) diluted in water and fill all the dead space then cover with an absorbent dressing daily was documented as completed from 1/25/24 through 1/29/24. Further review revealed the treatment was not documented as completed on 1/30/24. A review of the February 2024 TAR indicated the treatment was documented as completed 2/1/24 through 2/7/24. Attempts to interview the Treatment Nurse employed by the facility for the month of January 2024 were unsuccessful. An interview on 2/28/23 at 2:00 PM with the Chief Clinical Officer indicated that the low air loss mattresses and heel suspension boots were in the building on 1/31/24, however if she was notified of a resident requiring one before 1/31/24 one would have been made available. She further revealed that weekly skin assessments on all the residents should be completed by the nursing staff. She indicated Resident #1 had the low air loss mattress placed on his bed on 2/1/24 and that heel suspension boots were placed on Resident #1 the same day. A review of Resident #1's Wound Care NP notes dated 2/7/24 indicated the wound had not improved measured 2.5 cm x 2.5 cm x 1.8 cm and noted that he had had rapid health decline and malnutrition, healing may not be feasible and skin failure was highly suspected. It further noted that his primary care physician had recommended Resident #1 be sent to the emergency room . b. A review of Resident #1's Wound Care NP notes dated 1/17/24 noted a new stage 2 pressure area on Resident #1's left buttock (Wound B) measured 4.5 cm x 3.5 cm x 0.1 cm with serosanguinous drainage and ordered hydrophile paste dressing covered with a dry dressing daily. A further review of Resident #1's Physician orders indicated an order from the Wound Care NP dated 1/17/24 to cleanse Wound B with wound cleanser or normal saline, apply hydrophilic paste and cover with a dry dressing daily and prn. She also recommended a low air loss mattress and heel suspension boots be utilized. A review of Resident #1's January 2024 TAR indicated the treatment to cleanse Wound B with wound cleanser or normal saline, apply hydrophilic paste and cover with a dry dressing was not documented as completed on January 18th, 20th, and 23rd. A review of the Wound Care NP notes dated 1/24/24 the area was healed. c. A review of Resident #1's Wound Care NP notes dated 1/17/24 noted a new deep tissue pressure injury area (DTPI) had developed on the left foot 1st digit distal (Wound C) measured 0.5 cm x 0.7 cm x 0.2 cm (estimated depth) and ordered skin prep applied daily to the area. She also recommended a low air loss mattress and heel suspension boots be utilized. A review of Resident #1's January physician orders revealed an order dated 1/17/24 for skin prep daily to the left foot 1st digit distal. A review for Resident #1's Wound Care NP notes dated 1/24/24 noted the DTPI (Wound C) was improved, was smaller by volume without fluctuance or open ulceration. She also recommended a low air loss mattress and heel suspension boots be utilized and to continue the order of skin prep to Wound C. A review of Resident #1's January 2024 TAR revealed the skin prep to the left foot 1st digit distal ordered daily was not documented as completed on January 18th, 20th,23rd, and 30th. A review of Resident #1's Wound Care NP notes dated 1/31/24 noted Wound C had not improved but was stable. She also recommended a low air loss mattress and heel suspension boots be utilized. She continued with the order for skin prep Wound C. A review of Resident #1's Wound Care NP notes dated 2/7/24 noted Wound C was stable in appearance and volume with intact purple discolored skin. She also noted that a low air loss mattress and heel suspension boots were being utilized. d. A review of Resident #1's Wound Care NP notes dated 1/17/24 noted a new deep tissue pressure injury area had developed on the left foot 1st digit medial (Wound D) and measured 1 cm x 1.4 cm x 0.2 cm (estimated depth), she ordered skin prep applied daily to area. She also recommended a low air loss mattress and heel suspension boots be utilized. A review of Resident #1's physician orders indicated an order dated 1/17/24 to apply skin prep to the left foot 1st digit medial daily. A review of Resident #1's Wound Care NP notes dated 1/24/24 noted Wound D had not improved and measured 1.4 cm x 1 cm x 1.4 cm (estimated depth) was stable by volume and appearance and continued the treatment of skin prep to the area. A review of Resident #1's January TAR revealed the skin prep to the left foot 1st digit medial ordered daily was not documented as completed on January 18th, 20th, 23rd, and 30th. A review of Resident #1's Wound Care NP notes dated 1/31/24 noted Wound D measured 1cm x 1.4 cm x 0.2 cm (estimated depth) and was not improved but was stable and continued the treatment of skin prep. She also recommended a low air loss mattress and heel suspension boots be utilized. A review of Resident #1's February TAR included the order for skin prep to the left foot 1st digit was not documented as completed on February 1st, 2nd, 6th, or 7th. A review of Resident #1's Wound Care NP notes dated 2/7/24 noted Area D measured 0.5 cm x 0.3 cm x 0.2 cm (estimated depth) and the deep tissue area had evolved, was now with full thickness depth, exposed smooth bone. Pale pink subcutaneous tissue with scant serous exudate. The wound stage had been changed from deep tissue pressure injury to stage 4 and treatment changed to betadine moist gauze and dry dressing daily for microbial management and osteomyelitis was suspected at the site. She noted that a low air loss mattress and heel suspension boots were being utilized. Resident #1 was sent to the hospital on this day. e. A review of Resident #1's Wound Care NP notes dated 1/24/24 noted a new area to the coccyx and bilateral buttocks (Wound E) was 10% unstageable, was 50% intact and 40% a deep tissue pressure injury. Wound E measured 6 cm x 6 cm with an estimated depth of 0.5 cm, had 10% granulation tissue which was soft and dusky. Wound E presented with purplish non blanching discoloration on both sides of the coccyx with dusky appearing subcutaneous tissue on the left buttock. There was mild serous exudate and the periwound had blanching erythema. She ordered hydrophilic paste with a dry protective dressing done daily. She recommended a low air loss mattress and heel suspension boots be utilized. A review of Resident #1's January 2024 TAR revealed no treatment order for Wound E. A review of Resident #1's Wound Care NP notes dated 1/31/24 indicated wound E was not improving and measured 8.5 cm x 6 cm x 0.5 cm (estimated depth) she further noted the area was slightly larger by length, had non blanching intact skin and intact tissue extending to both buttocks. There was noted a small area of exposed subcutaneous tissue with scant exudate and dusky/pale base. She recommended a low air loss mattress and heel suspension boots be utilized. A review of Resident #1's February TAR revealed an order to cleanse wound on coccyx/buttocks with wound cleanser or normal saline, apply hydrophilic paste and a dressing daily was completed on 2/7/24 through 2/x/24. A review of Resident #1's Wound Care NP notes dated 2/7/24 indicated Wound E had not improved, measured 11.5 cm x 12 cm x 0.8 cm (estimated depth) was now larger by volume with primarily deep maroon discolored skin extending from the sacrum to the bilateral buttocks. She noted that a low air loss mattress and heel suspension boots were both being utilized. f. A further review of Resident #1's Wound Care NP notes dated 1/24/24 noted a new area to the left medial heel (Wound F) which measured 4 cm x 3 cmx 0.3 cm (estimated depth) stage 4 deep tissue pressure injury and ordered skin prep to the area daily. She also recommended a low air loss mattress and heel suspension boots be utilized. A review of Resident #1's Wound Care NP notes dated 1/31/24 noted Wound F was not improved and measured 4 cm x 4.5 cm x 0.3 cm (estimated depth). She noted the area was slightly larger volume with an irregularly shaped deep tissue pressure injury of the posterior/medial heel with bogginess over posterior aspect. She continued with the treatment of skin prep daily to the area. A review of Resident #1's January TAR revealed no treatment order for Wound F. A review of Resident #1's February 2024 physician orders revealed a treatment for skin prep to the left medial heel daily. A review of Resident #1's February 2024 TAR revealed treatment skin prep daily to the left medial heel was not documented as complete on February 1st, 2nd, or 6th. A review of Resident #1's Wound Care NP notes dated 2/7/24 noted measured 4 cm x 4.5 cm x 0.3 cm (estimated depth) was stable. g. A continued review of Resident #1's Wound Care NP notes dated 1/24/24 noted a new area to the right medial ankle (Wound G) which measured 3 cm x1 cm x 0.3 cm (estimated depth) deep tissue pressure injury and ordered skin prep to the area daily. She also recommended a low air loss mattress and heel suspension boots be utilized. A review of Resident #1's January 2024 TAR revealed no treatment order for Wound G. A review of Resident #1's Wound Care NP notes dated 1/31/24 noted Wound G measured 3 cm x 3 cm x 1 cm (estimated depth) and was improved and there was no change to the treatment. A review of Resident #1's Wound Care NP notes dated 2/7/24 noted Wound G measured 1.5 cm x 1.5 cm x 1cm (estimated depth) and the deep tissue pressure injury had evolved and had smaller volume, but primarily black/yellow nonviable tissue curette debridement was preformed to remove the nonviable tissue. The wound base remained obscured due to dusky/purple discoloration and treatment changed to betadine moist gauze with dry gauze dressing. A review of Resident #1's February 2024 TAR revealed no treatment to the area. h. A continued review of Resident #1's Wound Care NP notes dated 1/24/24 noted a new area to the right lower lateral leg (Wound H) measured 1.5 cm x 2 cm x 0.3 cm (estimated depth) was deep tissue pressure injury and ordered skin prep to the area daily. She also recommended a low air loss mattress and heel suspension boots be utilized. A review of Resident #1's Wound Care NP notes dated 1/31/24 noted Wound H had not improved, measured 10.5 cm x 2 cm x 0.3 cm (estimated depth) and was now 70% deep tissue pressure injury and 10% was now open with soft dusky granulation tissue and order was changed to fine gauze mesh cover with gauze dressing every other day. A review of Resident #1's January 2024 TAR revealed no treatment order for Wound H. A review of Resident #1's February 2024 TAR revealed the order for fine gauze mesh and cover with a gauze dressing every other day was documented as completed on the scheduled days. A continued review of Resident #1's Wound Care NP notes dated 2/7/24 noted area not improved, measured 10 cm x 1 cm x 0.3 cm (estimated depth), and noted smaller overall volume, deep tissue pressure injury continues to evolve with dry black/yellow tissue, intact tissue and scant serous exudate. The wound stage had been changed from a deep tissue pressure injury to unstageable. Treatment remained unchanged. Resident #1 was discharged to the hospital 2/7/24. j. A continued review of Resident #1 Wound Care NP notes dated 1/24/24 noted a new area to the left lower medial leg (Wound J) which was 10% unstageable with a soft dusky granulation tissue and 90% intact deep tissue pressure injury measured and 5.5 cm x 1 cm x 0.4 cm (estimated depth) and ordered autolytic foam dressing changed every 3 days. She also recommended a low air loss mattress and heel suspension boots be utilized. A review of Resident #1's January 2024 TAR did not reflect the treatment order for Wound J. A continued review of Resident #1's Wound Care NP notes dated 1/31/24 noted Wound J had not improved and measured 6.5 cm x 2 cm x 0.2 cm (estimated depth). She further noted that Wound J presented with larger volume mostly yellow nonviable adherent tissue with moderate serous exudate. The periwound with mild edema and blanching erythema. Scalpel debridement was performed as medically indicated to viable muscle tissue. Treatment was changed to calcium alginate with silver and covered with dry gauze. A review of the February TAR indicated this treatment was documented completed from 2/2/24 through 2/7/24. A review of Resident #1's Wound Care NP noted dated 2/7/24 noted Wound J was improving with measurements of 5 cm x 2 cm x 0.5 cm (estimated depth) and was smaller with increased soft, pale pink granular tissue. The treatment was changed to betadine moist gauze with a gauze dressing. She also noted a low air loss mattress and heel suspension boots were being utilized. k. The Wound Care NP noted Wound K on 1/31/24 which was a deep tissue pressure injury to the right lateral heel and measured 2 cm x 3 cm x 0.2 cm (estimated depth) and skin prep to the area daily was ordered. A review of Resident #1's Wound Care NP notes dated 2/7/24 was not improved and measured 2 cm x 3 cm x 0.2 cm (estimated depth) and was noted as stable and the treatment remained unchanged. A review of Resident #1's February 2024 TAR revealed the daily skin prep was documented as completed on 2/2/24 through 2/7/24. l. The Wound Care NP noted a deep tissue pressure injury to the right ischium (Wound L) on 1/31/24 measured 2 cm x 1.5 cm x 0.4 cm (estimated depth) and skin prep to the area daily was ordered. A review of Resident #1's Wound Care NP notes dated 2/7/24 noted Wound L was not improved measured 2 cm x 1.5 cm x 0.4 cm (estimated depth) and was noted as stable with intact purple discoloration. A review of Resident #1's February 2024 TAR revealed the daily skin prep was not documented as complete on 2/2/24 through 2/7/24. m. The Wound Care NP noted Wound M on 1/31/24 which was a deep tissue pressure area to the left lower lateral leg measured 3 cm x 1.7 cm x 0.2 cm (estimated depth) and fine mesh gauze and dry dressing to the area every other day was ordered. A review of Resident #1's February 2024 TAR from 2/1/24 through 2/7/24 revealed the order for fine mesh gauze and a dry dressing every other day was documented as completed on 2/3/24 and 2/5/24. A review of Resident #1's Wound Care NP notes dated 2/7/24 indicated the area was improving and measured 1.5 cm x 1 cm x 0.2 cm (estimated depth) and had a smaller volume and increased intact tissue. The treatment remained unchanged to the area. n. A further review of Resident #1's Wound Care NP notes dated 2/7/24 indicated a new area to right upper/mid back (Wound N) which measured 5 cm x 11 cm x0.5 cm (estimate) and an order for skin prep daily was ordered. The Wound Care NP also noted on her notes dated 2/7/24 laboratory blood work completed for Resident #1 on 2/5/24 included an Albumin of 2.7, Total Protein 6, Creatinine 1.0, [NAME] blood count 14.5, hemoglobin 10.1 and Hematocrit 32.4.The Wound Care NP further noted that she discussed her concerns regarding Resident #1's progressive physical/cognitive decline as well as multiple new wounds with rapid onset and lab results with Resident #1's Primary Care Physician and Director of Nursing. In consideration of his rapid health decline and malnutrition, healing may not be feasible and skin failure is highly suspected. The Primary Care Physician ordered Resident #1 to be sent to the emergency room . The Director of Nursing noted on the transfer sheet dated 2/7/24 Resident #1 was sent to the Emergency Department (ED) related to possible wound infection. Review of the ED Provider Note dated 2/7/24 revealed Resident #1 was transferred there for an evaluation of a sacral wound of unknown duration. It was noted Resident #1 was unable to provide significant history but denied chest pain or abdominal pain. When asked if he was in pain he stated yes and indicated the pain was in his bottom. Resident #1 was tachycardic (rapid heart rate) with a heart rate of 119 and was hypotensive (low blood pressure) with a blood pressure (BP) of 88/52 (hypotension). Laboratory blood work included [NAME] Blood Cell Count was 14.3 (4.5-11.0), Erythrocyte Sedimentation Rate (measures inflammation in the body) was 96 (0-15), C-Reactive Protein (sign of inflammation due to infection or chronic disease) was 132 (0.8-1.0), Blood Urea Nitrogen (test kidney function) was 44 (7-25), Thyroid Stimulating Hormone 15.95 (0.4-4.0) and blood cultures were obtained. A computed tomography scan was completed and showed posteriorly and lateral right hip fluid collection with some gas in the posterior soft tissues, consistent with an inflammatory infectious process and gas forming organism. Lower extremities with scattered wounds, the sacrum had an unstageable wound with slough (yellow/white material in the wound bed that can be wet or dry, thick, thin, or patchy) and a right hip with ulceration and surrounding erythema with eschar (dead dark tissue) present. General surgery was consulted for surgical debridement of the sacral and right hip pressure ulcers. The ED Provider's impression was mixed cardiogenic and septic shock. Resident #1 received a bolus of 1.5 liters intravenous (IV) fluids due to symptoms of dehydration including very concentrated urine, dry mucosa and poor skin turgor. Initially Resident #1's BP improved but a short time later his BP started to trend down. X-ray results indicated a right-sided pleural effusion with suspected mild infiltrate. A right femoral central line (venous catheter in the femoral artery) was placed for the administration of medications to treat low BP (vasopressor) and two broad spectrum IV antibiotics. Resident #1 was transferred to the Intensive Care Unit for continued vasopressor support. A review of Resident #1's nursing progress notes indicated there were no notes related to his pressure areas, deep tissue pressure injuries, or nursing interventions related to skin integrity. An interview with the Wound Care NP on 2/18/24 at 1:39 PM indicated that skin breakdown interventions, such as orders, should have been put into place for Resident #1. She further revealed that in her opinion some of the wounds may have been avoidable if the measures that she had recommended had been put into place. An interview with the Medical Director on 2/17/24 at 10:30 AM revealed that pressure areas were unavoidable for Resident #1, and he did not expect them to heal due to the resident's poor appetite, refusal of medication, low albumin, and comorbidities. An interview with Nurse #1 on 2/18/24 at 11:26 AM revealed she had worked with Resident #1 in the month of January, and she could not recall if there were treatments ordered when Resident #1 entered the facility. She also revealed she could not recall if there were any skin breakdown precautions in place. An interview with Medication Aide on 2/18/24 at 10:27 AM revealed that she needed to coax Resident #1 to take his medications and she remembered he had an open area on his hip but did not remember if there were treatments being completed on it or if there were skin breakdown precautions put into place. An interview on 2/18/24 at 10:10 AM with Nurse Aide (NA) #1 indicated that Resident #1 required assistance with eating but ate good for him, he was turned and repositioned every two hours but would refuse at times and he assisted with putting an air mattress on Resident #1's bed on 2/1/24, he stated there were no heel boots to put on the resident available that he was aware of. An interview on 2/18/24 at 10:37 AM with NA #2 stated that Resident #1 was very nice, and she had to either help him start eating or at times feed him but would drink sweet tea any time it was offered. She stated he was turned and repositioned every two hours but would try and refuse at times. She further stated that a week or two before he was sent to the hospital he started refusing to eat or turn more. An interview with NA #3 on 2/18/24 at 10:48 AM revealed that Resident #1 was total care and would initially refuse care but after she talked to him for a bit would usually allow care to be given. She further revealed that he needed assistance to eat and was turned every 2 hours, she did not remember heel boots being on. An interview with the Director of Nursing on 2/19/24 at 9:27 AM indicated after the Wound Care NP saw a resident her recommendations and orders should be entered into the physician orders by the treatment nurse, and she expected for treatments to be done as ordered. She further indicated that residents were discussed in the morning meetings held Monday through Friday. On 2/28/24 at a telephone interview with the Medical Director indicated that while Resident #1 was in overall decline but if interventions such as a low air loss mattress and heel suspension boots were put into place it would have probably delayed or prevented the formation of additional pressure areas and injuries. He was not aware of the recommendations from Wound Care NP but regardless any recommendations that are given by Wound Care NP should be implemented and followed. He further indicated that he was concerned about facility treatment nurse(s) prior to the current one because he felt wound care was not being done as ordered or at times not at all. He stated that the facility does not need to ask him about any recommendations from Wound Care NP as he felt they are there to assist in healing or preventing skin issues with the residents, unless there was a concern that the recommendation was harmful in some way to the resident.

Based on medical record review and staff interviews the facility failed to complete a comprehensive assessment including Minimum Data Set (MDS) within 14 days of admission for 1 of 3 residents (Resident #2). The Findings included: Resident #2 was admitted into the facility on [DATE] with diagnoses of chronic peripheral venous insufficiency, vascular dementia and chronic kidney disease stage 3. A review of Resident #2's medical record on 2/28/24 revealed an admission Minimum Data Set (MDS) had not been started or completed, An interview was conducted on 2/28/24 11:39 AM with the Minimum Data Set (MDS) Coordinator and she revealed that she was behind on MDS's due to an influx of residents and the prior MDS Coordinator not putting information into the system. She further revealed when she started in January 2024 she had to input some of the current residents information into the system before she was able to start completing the residents MDS's. An interview with the Chief Clinical Officer on 2/28/24 at 11:39 AM indicated that she was not aware of the comprehensive assessments not being completed until the current MDS Coordinator informed her. The facility is currently recruiting MDS Coordinators from sister buildings to get the comprehensive assessments and comprehensive care plans up to date.

Based on interviews with staff and medical record review the facility failed to develop a baseline care plan within 48 hours after admission for 1 of 1 resident reviewed for pressure ulcers (Resident #1). The findings included: Resident #1 was admitted into the facility on [DATE] with diagnoses of protein malnutrition, muscle wasting and atrophy, peripheral vascular disease, and anxiety. He was discharged to the hospital on 2/7/24. A review of the medical records indicated there was no baseline care plan developed. A review of Resident #1's admission Minimum Data Set, dated dated dated [DATE] noted he was sometimes understood, usually understands, was severely cognitively impaired, rejected care 1-3 days, was dependent on staff for his activities of daily living, had a urinary catheter, was incontinent of bowel and had a pressure area. A telephone interview was conducted on 2/18/24 at 2:00 PM with the former Social Service Designee who indicated she had overseen the completion of the baseline care plans however, she got behind on them, resulting in some of the baseline care plans not getting completed. She further indicated that she did not remember setting up a care plan meeting with Resident #1 or his family. An interview was conducted with the Director of Nursing on 2/19/24 at 9:27 AM revealed that a base line care plan should have been developed and an initial family care plan meeting scheduled. An interview was conducted with the Administrator on 2/19/24 at 9:00 AM indicated that a base line care plan should have been developed and an initial family care plan meeting scheduled.

Based on interviews with staff and medical record review the facility failed to develop a person-centered comprehensive care plan for 2 of 3 residents reviewed for care plans (Resident #1 and #2). The findings included: 1) Resident #1 was admitted into the facility on [DATE] with diagnoses of protein malnutrition, muscle wasting, and atrophy, and peripheral vascular disease. He was discharged to the hospital on 2-7-24. An admission skin assessment was completed on 1/2/24 indicating a pressure area to the right hip. A review of Resident #1's admission Minimum Data Set, dated dated dated [DATE] noted 1 stage 4 pressure area present on admission and noted no pressure ulcer/injury care, applications of nonsurgical dressings, or applications of ointments or medications. The Care Area Assessment (CAA) dated 1/15/24 indicated pressure ulcers were triggered and required a care plan. A review of Resident #1's care plan revealed there a comprehensive care plan had not been developed within 7 days after the completion of the comprehensive assessment and did not have a care plan related to pressure ulcers. An interview was conducted on 2/17/24 at 1:00 PM with the MDS Coordinator who revealed that she was behind on care plans due to an influx of residents. She agreed there was not a care plan developed regarding pressure ulcers for Resident #1 and there should have been one. An interview was conducted with the Director of Nursing on 2/19/24 at 9:27 AM revealed that a care plan regarding pressure ulcers should have been developed. An interview was conducted with the Administrator on 2/19/24 at 9:00 AM indicated that a care plan regarding pressure ulcers should have been developed. 2) Resident #2 was admitted into the facility on [DATE] with diagnoses of chronic peripheral venous insufficiency, vascular dementia with moderate anxiety and psychotic disturbance, insomnia due to other mental disorders and chronic kidney disease stage 3. A review of Resident #2's medical record revealed a comprehensive assessment nor comprehensive care plan had been formulated. An interview was conducted on 2/28/24 11:39 AM with the Minimum Data Set (MDS) Coordinator and she revealed that she was behind on MDS's due to an influx of residents and the prior MDS Coordinator not putting information into the system. She further revealed when she started in January 2024 she had to input some of the current residents information into the system before she was able to start completing the residents MDS's. An interview with the Chief Clinical Officer on 2/28/24 at 11:39 AM indicated that she was not aware of the comprehensive assessments and care plans not being completed until after the current MDS Coordinator informed her. The facility was currently recruiting MDS Coordinators from sister buildings to get the comprehensive assessments and comprehensive care plans up to date.

Based on observation, record review and resident and staff interviews, the facility neglected to provide [MEDICAL CONDITION] care as ordered by the medical doctor for 1 of 1 resident reviewed for respiratory care (Resident #25) and the facility neglected to clarify or obtain orders for indwelling urinary catheter changes for 1 of 1 resident reviewed (Resident #25) resulting in a resident's indwelling urinary catheter not being changed for several months and a hospitalization for a urinary tract infection [MEDICAL CONDITION]. Immediate Jeopardy for Resident #25 began on 05/18/18 and was removed on 07/03/18 when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at scope and severity of a G (actual harm that is not Immediate Jeopardy) for example 1b. The Findings Included: Resident #25 was admitted to the facility on [DATE]. Her medical [DIAGNOSES REDACTED]. A review of Resident #25's quarterly Minimum Data Set, dated dated [DATE], revealed Resident #25 had been cognitively intact and required total assistance of staff for her Activities of Daily Living (ADL). The MDS indicated Resident #25 had an indwelling urinary catheter and had [MEDICAL CONDITION]. The MDS indicated the resident received oxygen therapy and [MEDICAL CONDITION] care. A review of Resident #25's Care Plan revealed the following: 1. At risk for recurrent UTIs, urosepsis, or renal damage due to chronic UTIs or history or recurrent UTIs. Interventions included, in part, catheter care per facility protocol (last revised 12/06/17). 2. Altered pattern of urinary elimination with indwelling catheter - at risk for infection related to [MEDICAL CONDITION]. Resident with nephrostomy tube and (indwelling urinary) catheter. Interventions included, in part, catheter care per facility protocol, monitor nephrostomy tube and report any changes, change catheter per physician orders and/or facility protocol, monitor for signs and symptoms of UTI (last revised 12/06/17). 3. Resistive to treatment and care (did not want to shower, comb hair, turn off her back, have nails cut, get out of bed, have bed placed in low position, have facial hair removed, have vital signs or weights taken). Interventions included, in part, to allow for flexibility in ADL routine to accommodate the resident's mood, to document the care being resisted per facility protocol and to notify the physician of patterns in behaviors and to discuss the implications of not complying with the therapeutic regiment with the resident (last revised 06/30/17). 4. Had the potential for or actual ineffective breathing pattern related to her [MEDICAL CONDITION]. Interventions included, in part, to provide [MEDICAL CONDITION] care as ordered by the physician and/or facility protocol and to check dressing to stoma site frequently and replace/change as needed or as ordered (last revised 12/28/17). 1a. A record review of Resident #25's (MONTH) (YEAR) Medication Administration Record (MAR) revealed a physician's order for [MEDICAL CONDITION] site dressing change every day and the dressing change was scheduled to be completed at 4:00 p.m. Prior to Resident #25 leaving the facility on 05/17/18, there had been 8 dates the order had not been signed off by a nurse as having been completed - (MONTH) 1, 2, 4, 6, 7, 9, 10 and 15. Prior to being discharged to the hospital on [DATE], the dressing had been documented as completed on 05/16/18. The MAR indicated the dressing had not been completed on 05/17/18. During an interview with Nurse #7 on 05/25/18 at 2:20 p.m., Nurse #7 stated she had worked the 3 p.m. to 11 p.m. shift on 05/16/18 and had remembered changing the dressing on Resident #25's [MEDICAL CONDITION] and stated it had looked fine. Nurse #7 stated she worked the 3 p.m. to 11 p.m. shift on 5/17/18 and had been one of the nurses who had assessed Resident #25 when her PEG tube had dislodged. When asked if she had checked Resident #25's [MEDICAL CONDITION] site prior to Resident #25 being sent out, Nurse #7 stated she remembered there had been no drainage noted on the sheets. During an interview with Nurse #2 on 05/26/18 at 9:56 a.m., Nurse #2 had been asked why she had not signed her initials on the MAR for Resident #25's [MEDICAL CONDITION] site dressing on (MONTH) 2, 4, 6, 7, 9 and 15, (YEAR). Nurse #2 stated while she remembered changing the dressing a couple of times she stated she was going to be honest. Nurse #2 stated when she came on duty she was responsible for a medication cart and 30 residents in addition to overseeing 2-3 medication aides. Nurse #2 stated she stayed stressed out because when she would come on duty she had always been pulled here and there dealing with resident issues and behaviors. Nurse #2 stated it had been very challenging and stated she felt it could be the reason why she did not always do the dressing change. During an interview with Nurse #6 on 05/26/18 at 10:40 a.m., Nurse #6 stated she recalled changing Resident #25's [MEDICAL CONDITION] site dressing in the past but stated she could not recall whether or not she had changed the dressing on 05/01/18. During an interview with Nurse #7 on 05/26/18 at 12:49 p.m., Nurse #7 stated 5/10/18 had been her first day of employment at the facility. Nurse #7 stated she recalled changing Resident #25's [MEDICAL CONDITION] site dressing on 05/10/18 and stated she had forgotten to sign off on the MAR. During an interview with the hospital ED nurse #2 on 07/03/18 at 9:33 a.m., the hospital ED nurse #2 stated Resident #25 arrived in the ED approximately 15 minutes before the end of her 7 a.m. to 7 p.m. shift on 05/17/18. The hospital ED nurse #2 stated Resident #25 smelled like she needed a bath and her nephrostomy and indwelling urinary catheter were in need of some tender loving care however she had not assessed Resident #25's [MEDICAL CONDITION] because her oxygen saturation had been okay. During an interview with the hospital ED nurse #3 on 07/03/18 at 11:30 a.m., the hospital ED nurse #3 stated she had cared for Resident #25 during her 7 p.m. to 7 a.m. shift on 05/17/18. The hospital ED nurse #3 stated Resident #25 had been in real bad condition and had focused her care to Resident #25's nephrostomy and indwelling urinary catheter secondary to Resident #25 having had really bad smelling urine. During an interview with the hospital ED nurse #1 on 05/23/18 at 4:25 p.m., the ED nurse #1, who worked the 7 a.m. to 7 p.m. shift on 5/18/18, stated when she had entered the holding room Resident #25 had been placed in she could smell the stench coming off of her and noted that her face had dried spittle on it, her hair had been matted with white flakes and it appeared like it had not been washed in a long time. The ED nurse #1 stated she looked at Resident #25's [MEDICAL CONDITION] site and had noted a substance on the [MEDICAL CONDITION] which she compared to melted malt chocolate. The ED nurse stated she called a Respiratory Therapist (RT) for [MEDICAL CONDITION] care and oxygen needs. The ED nurse stated once the RT had begun [MEDICAL CONDITION] care, he had informed her of the presence of maggots on Resident #25's skin surrounding her [MEDICAL CONDITION] site. The ED nurse stated she then observed the presence of maggots around the [MEDICAL CONDITION] site. During an interview with the hospital's RT #1 on 05/25/18 at 11:15 a.m., the RT #1 stated he recalled Resident #25 in the ED on 05/18/18. The RT stated he had been called to the ED to assess the resident, assess oxygen saturation and perform [MEDICAL CONDITION] care. The RT #1 stated upon arrival to Resident #25's ED room, he had noticed a foul odor emanating from the resident. The RT #1 stated when he had assessed the [MEDICAL CONDITION], he noticed the [MEDICAL CONDITION] ties were dirty and there were visible dried secretions on her [MEDICAL CONDITION]. The RT #1 stated he removed the [MEDICAL CONDITION] site sponge (gauze dressing from the facility) and it had been so dirty and had secretions so old the sponge was hard. The RT #1 stated Resident #25's skin underneath the sponge was red and he had noticed maggots under the [MEDICAL CONDITION] ties and the sponge. The RT #1 stated he had noticed Resident #25's odor was more prevalent during the [MEDICAL CONDITION] care but could not state whether the foul odor was coming from the [MEDICAL CONDITION] site or not. The RT #1 stated he cleaned all of the maggots off of Resident #25's skin and cleaned the [MEDICAL CONDITION] however he did not have time to change the inner cannula as Resident #25 had to be transferred to another part of the hospital. During a 2nd interview with the hospital RT #1 on -07/03/18 at 8:57 a.m., the hospital RT #1 stated he and another hospital RT #2 had performed Resident #25's [MEDICAL CONDITION] care together on 05/18/18 and the hospital RT #2 had documented the care. A review of the hospital's records indicated Resident #25 had arrived at the Emergency Department (ED) on 05/17/18 at 5:50 p.m. with a chief complaint of a dislodged PEG tube. Further review of the hospital record ED notes revealed the following: 1. An RT note, dated 5/18/18 8:33 a.m. - oxygen device = [MEDICAL CONDITION] collar (TC), fraction of inspired oxygen (FIO2): 30, breath sounds diminished; note - pt placed on 30% TC at this time, peripheral capillary oxygen saturation (SPO2) 97% 2. An ED nurse note, dated 05/18/18 2:02 p.m. - patient's [MEDICAL CONDITION] with brownish drainage, foul odor .called Respiratory Therapist (RT) to clean. RT notified RN that patient has maggots in [MEDICAL CONDITION]. RN confirmed this by eyesight. 3. Final order results of a chest x-ray performed on 05/17/18 at 9:15 p.m. revealed findings of [MEDICAL CONDITION] is stable in position .no acute process A review of a hospital's [MEDICAL CONDITION] Assessment note, dated 5/18/18 at 2:00 p.m., stated called to patient's room for [MEDICAL CONDITION] assessment, upon more detailed look at [MEDICAL CONDITION] this RT found maggots crawling around [MEDICAL CONDITION] site .all maggots that were seen were wiped off .Once RN called to room she asked patient when was the last time they cleaned it at the nursing facility and patient stated they cleaned it 2 days ago. During an interview with Resident #25 on 05/24/18 at 11:35 a.m., Resident #25 was observed to be lying in her hospital bed, awake and alert. Resident #25's skin appeared clean and there had been a slight odor emanating off of her body, possibly coming from her hair which was visibly dirty with a dried brown substance noted in one part of it and areas full of dry white flakes, possibly skin flakes. Resident #25 was observed to have a [MEDICAL CONDITION] in place. Resident #25 stated [MEDICAL CONDITION] care at the facility hardly ever got done. Resident #25 stated the nurses at the facility were supposed to change it once a week and they did not consistently change it as ordered. Resident #25 stated it made her feel terrible knowing the state her [MEDICAL CONDITION] site was in when she got to the hospital. During an interview with the Administrator on 05/26/18 at 2:42 p.m., the Administrator stated his expectation of nursing staff, in regard to [MEDICAL CONDITION] care, is to follow the residents' plan of care as directed by the physician. The Administrator stated it was his expectation nursing staff document according to facility training. The Assistant Director of Nursing was notified of the Immediate Jeopardy on 06/29/18 at 3:10 p.m. On 07/03/18 the facility provided the following credible allegation of compliance and Immediate Jeopardy removal: A thorough investigation was completed by the administrator on 7/02/18 to ascertain the cause. It was determined by the administrator that the cause was the failure of nurse #7 not completely reading the Medication Administration Record which resulted in not documenting [MEDICAL CONDITION] care provided. During the interview, Nurse #6 and nurse #2 both stated that they did not provide [MEDICAL CONDITION] care to resident #25 related to being busy but could not state the reason why they did not ask for assistance. On 5/17/18, Resident #25 was sent out to the hospital for evaluation due to dislodged [DEVICE]. Resident #25's [MEDICAL CONDITION] was assessed by the Treatment Nurse on 4/30/18, 5/7/18, and 5/14/18 with no documentation of larvae, foul odor, or drainage around the [MEDICAL CONDITION] site. On 5/17/18 per hospital record at 6:50 pm, one hour after resident was in the Emergency Department, the RN documented Patient Conscious Alert and Oriented x 4, respiration rate even and unlabored, patient has [MEDICAL CONDITION] and wears O2 @ 3 liters. No mention of drainage, larvae, or foul-odor in [MEDICAL CONDITION]. On 5/17/18 per hospital record at 9:15 pm, resident had a chest x-ray complete. Findings: [MEDICAL CONDITION] in stable position. On 5/17/18 per hospital record at 10:42 pm, per the documentation of the Registered nurse, [MEDICAL CONDITION] in place. O2 @ 3 Liters via [MEDICAL CONDITION] mask. On 5/18/18 per hospital record at 5:32 am, per the documentation of the Registered nurse, suction at bedside. On 5/18/18 per hospital record at 8:33 am there is documentation of a Respiratory Therapist treatment assessment. On 5/18/18 per the hospital record at 2:24 pm, there is documentation of the registered nurse Patient's [MEDICAL CONDITION] with brownish drainage, foul odor. [DEVICE] site needs cleaning. Called RT to clean [DEVICE] and RT notified RN that patient has maggots in [MEDICAL CONDITION]. RN confirmed this by eye site. RN notified physician via phone and awaiting call back. On 5/18/18, the administrator was made aware by resident #25's friend of an allegation that Resident #25 was observed with maggots in her throat while at the hospital. On 5/18/18, an investigation was started by the administrator to include submission of an Initial Allegation Report to Health Care Personnel Investigation (HCPI). On 5/25/18, the investigation was completed and the allegation was unsubstantiated by the administrator. The Investigation Report was submitted to (HCPI) by the administrator. On 5/26/18, Resident #25 returned to the facility and was assessed by the hall nurse to include assessment of the [MEDICAL CONDITION] site, which was clean, dry, and covered with a dry dressing. On 5/26/18, the assessment for Resident #25 was documented by the hall nurse in the electronic medical record. The care of the trachea was not documented to show we followed doctor's orders consistently. Therefore we proactively educated nursing personnel to include Nurse # 2, #6, and #7 on following doctor's order and providing trachea care. Nurse #2 will be reported to the Board of Nursing on 7/3/18 for not documenting on the Medication Administration Record by the Director of Nursing. Nurse #2 is no longer staffed at the facility through the Agency. Nurse # 6 and #7 will be reported to the board of Nursing on 7/3/18 for not providing [MEDICAL CONDITION] care by the Director Nursing on 7/3/18. Corrective Action A contracted Respiratory Therapist (RT) initiated training on [MEDICAL CONDITION] care with licensed nurses to include Nurse #6 and #7 on 7/1/18. The Director of Nursing, Staff Facilitator and eight other nurses have currently received the training by the RT and will complete all resident's [MEDICAL CONDITION] care until the remaining nurses complete the training. There are ten licensed nurses that are left to be trained by the RT and will not be allowed to work until the training has been completed. A contracted RT is on site as of 2:15 pm on 7/3/18 and has initiated the remaining licensed nurse training. On 5/22/18, all alert and oriented residents were interviewed for neglect by the Social Worker with no negative findings. On 5/30/18, an in-service was initiated with all license nurses to include agency nurse, and Nurse # 2, #6, and #7 by the facility nurse consultant and the Staff Facilitator (SF) on providing [MEDICAL CONDITION] care as ordered by the physician. The in-service also addressed the expectation that documentation must be present on the Medication Administration Record (MAR) after providing [MEDICAL CONDITION] care. The in-service was completed on 6/28/18. On 7/2/18, an in-service was initiated with all licensed nurses to include agency nurses and Nurse #6, and Nurse #7 by the Facility Nursing Consultant on reading each [MEDICAL CONDITION] order on the MAR, following the physician order for [REDACTED]. The in-service also included for licensed nurses to ask for additional assistance from the Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, Staff Facilitator, or another hall nurse when feeling like assistance is needed to provide resident care to include [MEDICAL CONDITION] care and time management. No licensed nurse will be allowed to work until the training has been completed. On 6/12/18, an observation of all residents to include Resident #25 was completed by the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and the Quality Improvement (QI) Nurse to physically identify all residents with tracheostomies. There were no other residents with tracheostomies identified during the audit. On 6/12/18, an audit of all MARs, including MARs for Resident #25, for the past 30 days, was completed by the ADON and the QI Nurse to ensure orders for respiratory care, including [MEDICAL CONDITION] care were provided as evidenced by documentation on the MAR. There were no other identified areas of concern noted during the audit. On 6/12/18, an assessment of all residents with tracheostomies, including Resident #25 was completed by the QI Nurse and the ADON to ensure [MEDICAL CONDITION] care was provided as evidenced by observing a clean insertion site and dressing with no drainage present. There were no identified areas of concern during the audit. On 6/12/18, an audit of all residents' physician orders to include Resident #25 was initiated by the QI nurse, the ADON, and the Staff Facilitator (SF) to identify all residents with orders to receive [MEDICAL CONDITION] care. The audit was completed on 6/13/18. There were no other identified residents with orders to receive [MEDICAL CONDITION] care. On 6/29/18, a 100% return demonstration of [MEDICAL CONDITION] care was initiated with all licensed nurses to include agency nurses to include Nurse #2, Nurse #6, and Nurse #7 by the Assistant Director of Nursing (ADON). Retraining will be completed by the ADON during the time of the audit for any nurse that cannot demonstrate successful performance of [MEDICAL CONDITION] care per policy and procedure. No nurse will be allowed to perform [MEDICAL CONDITION] care on a resident until successful completion of the return demonstration. No licensed nurse will be allowed to work until the return demonstration has been completed. On 6/29/18, an in-service for 100% of all staff was initiated by the SF regarding Neglect to include failure to provide [MEDICAL CONDITION] care, signs of neglect, and reporting neglect. No staff will be allowed to work until the in-service is completed. The Quality Improvement Organization was contacted by the Regional Vice President of Operations on 7/03/18 for assistance in evaluation of specific steps to be taken to address [MEDICAL CONDITION] care and training, staff position/title designated to be responsible for the steps, timeline for accomplishment of the steps, specific methodology to be used to evaluate the plan's success, and frequency of monitoring the effects of the plan initiation. All residents with tracheostomies to include Resident #25 will be physically observed and documentation of the MAR and non-ulcer flow sheet assessment will monitored by the Assistant Director of Nursing (ADON) and/or the Quality Improvement (QI) Nurse 5 days weekly for 4 weeks, 3 days weekly for 4 weeks, then weekly for 4 weeks utilizing [MEDICAL CONDITION] Audit tool. This audit is to ensure that [MEDICAL CONDITION] care is being performed per policy and procedure, with documentation on the MAR and an assessment has been completed with documentation in the electronic health record and that the [MEDICAL CONDITION] site is clean, odor-free, and dressing is dry and intact. A medication pass audit on [MEDICAL CONDITION] care will be completed by the Assistant Director of Nursing (ADON) and/or the Quality Improvement (QI) Nurse on 10% of all licensed nurses to include agency nurses and Nurse #6 and Nurse #7, 5 days weekly for 4 weeks, 3 days weekly for 4 weeks, then weekly for 4 weeks utilizing a Medication Pass [MEDICAL CONDITION] Audit Tool. This audit is to ensure that nurses are reading each [MEDICAL CONDITION] order on the MAR, following the physician order for [REDACTED]. Any areas of concern identified during the audits will be addressed immediately by the ADON, QI Nurse, and/or the DON to include providing additional staff training. The DON will present the findings of [MEDICAL CONDITION] Audit tool and the Medication Pass [MEDICAL CONDITION] Audit Tool to the Executive Quality Assurance (QA) committee monthly for 3 months. The Executive QA Committee will meet monthly for 3 months and review [MEDICAL CONDITION] Audit tool and the Medication Pass [MEDICAL CONDITION] Audit Tool to determine trends and/or issues that may need further interventions put into place and to determine the need for further frequency of monitoring. Final date of compliance 7/03/18. The administrator and DON will be responsible for the implementation of corrective actions to include all 100% audits, in services, and monitoring related to the plan of correction. The Credible Allegation for Immediate Jeopardy removal was validated on 07/03/18, which removed the Immediate Jeopardy on 07/03/18. Interviews were conducted with nursing staff present in the facility on 07/03/18. The staff confirmed the recent in-services and trainings related to [MEDICAL CONDITION] care and documentation of [MEDICAL CONDITION] care. Reviews of the in-service records, audit tools, audits performed and facility assessments were made. An interview with the DON on 07/03/18 at 2:45 p.m. revealed the named nurses had been reported to the North Carolina Board of Nursing. An interview with the Regional Vice President of Operations on 07/03/18 at 2:50 p.m. revealed he had contacted the Quality Improvement Organization for assistance in evaluation of specific steps to be taken to address [MEDICAL CONDITION] care and training. 1b. A record review revealed Resident #25 had a hospitalized from [DATE] through 10/25/17. A review of Resident #25's admission orders [REDACTED]. Further record review of documentation of revealed two instances the indwelling urinary catheter had been changed - 10/11/17 and 12/20/17. A review of Resident #25's physician orders 10/25/17 to 05/17/18 revealed there had been no physician order to change her indwelling urinary catheter. A review of the hospital's Emergency Department's (ED's) notes revealed Resident #25 presented to the Emergency Department on 05/17/18 with a chief complaint of a dislodged percutaneous endoscopic gastrostomy (PEG) tube. A review of the hospital's ED registered nurse (RN) notes revealed, on 05/18/18 at 3:39 a.m., condition of patient's (indwelling urinary) catheter noted with hardened large amounts of crystalized sediment . A review of the hospital's Admission History and Physical (H&P), dated 05/18/18, indicated Resident #25 presents from Skilled Nursing Facility (SNF) complaining of dislodged PEG tube. Patient denied any abdominal pain, nausea, vomiting, fevers, chills. Upon evaluation in the ED, the PEG tube was placed back .upon initial exam by ED provider, it was noted that her right nephrostomy tube was draining purulent material. Abdominal computed tomography (CT) scan was obtained and is suggestive of a right [MEDICAL CONDITION]. Patient denies any symptoms .denies abdominal pain, nausea, vomiting, diarrhea, dysuria . Labs remarkable for grossly positive urine analysis . Patient has been treated in this hospital for Proteus [MEDICAL CONDITION] / UTI / [MEDICAL CONDITION] in (MONTH) (YEAR) . Further review of the H&P revealed an assessment [MEDICAL CONDITION] secondary to complicated UTI and [MEDICAL CONDITION] with planned replacements of the nephrostomy tube and indwelling urinary catheter and Resident #25 being treated with intravenous antibiotics. During an interview with Resident #25's medical doctor (MD) on 05/25/18 at 1:00 p.m., the MD stated it was his expectation for nursing to change residents' indwelling urinary catheters every 30 days. The MD stated the fact Resident #25's indwelling urinary catheter had not been changed 30 days since it had been inserted certainly had been a contributory factor to her current hospital diagnoses. The MD stated residents who have indwelling urinary catheters are at increased risk of UTIs. During an interview with Nurse #4 on 05/26/18 at 12:30 p.m., Nurse #4 stated she thought the order to change the indwelling urinary catheter for Resident #25 had been inadvertently left off the MARs in (MONTH) (YEAR) after Resident #25 returned to the facility from a hospitalization for UTI and [MEDICAL CONDITION]. Nurse #4 stated she knew Resident #25's indwelling urinary catheter had been changed since (MONTH) (YEAR) but she could not prove it. During an interview with Nurse #8 on 05/26/18 at 12:35 p.m., Nurse #8 stated residents with indwelling urinary catheters have their catheters replaced once a month. Nurse #8 stated the date of the month depends on the resident and when the catheter was first inserted. Nurse #8 stated she frequently had Resident #25 on her assignment and did not remember changing Resident #25's catheter in the recent past. Nurse #8 stated seeing the order to change the catheter on the MAR is a visual reminder to the nurse the catheter needs to be changed. During an interview with Resident #25 on 05/26/18 at 1:20 p.m., the resident stated she could not remember exactly when her indwelling urinary catheter had last been changed at the facility. When she was told the medical record indicated 12/20/17, Resident #25 stated she felt sure it had been changed since but not for the last 2 months. During an interview with the Administrator on 05/26/18 at 2:42 p.m., the Administrator stated, in regard to indwelling urinary catheter changes, he would expect the nursing staff to follow the plan of care as directed by the physician. The Administrator stated he would expect the nursing staff to document according to facility training.

Based on observation, record review, resident interview and facility staff and hospital staff interviews, the facility failed to provide [MEDICAL CONDITION] care as ordered by the medical doctor for 1 of 1 resident reviewed for respiratory care (Resident #25). Immediate Jeopardy began on 05/18/18 and was removed on 07/03/18 when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at scope and severity of D (not actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to allow for ongoing in-servicing and monitoring to be accomplished. The findings included: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #25's Minimum Data Set (MDS), dated [DATE], indicated Resident #25 was cognitively intact and required total dependence on staff for her Activities of Daily Living (ADLs). The MDS indicated resident received oxygen therapy and [MEDICAL CONDITION] care. A review of Resident #25's Care Plan indicated Resident #25 had the potential for or actual ineffective breathing pattern related to her [MEDICAL CONDITION]. Interventions included, in part, to provide [MEDICAL CONDITION] care as ordered by the physician and/or facility protocol and to check dressing to stoma site frequently and replace/change as needed or as ordered (last revised 12/28/17). The Care Plan indicated Resident #25 had been resistive to treatment and care (did not want to shower, comb hair, turn off her back, have nails cut, get out of bed, have bed placed in low position, have facial hair removed, have vital signs or weights taken). Interventions included, in part, to allow for flexibility in ADL routine to accommodate the resident's mood, to document the care being resisted per facility protocol and to notify the physician of patterns in behaviors and to discuss the implications of not complying with the therapeutic regiment with the resident (last revised 06/30/17). A record review of Resident #25's (MONTH) (YEAR) Medication Administration Record (MAR) revealed a physician's orders [REDACTED].#25 leaving the facility on 05/17/18, there had been 8 dates the order had not been signed off by a nurse as having been completed - (MONTH) 1, 2, 4, 6, 7, 9, 10 and 15. Prior to being discharged to the hospital on [DATE], the dressing had been documented as completed on 05/16/18. The MAR indicated the dressing had not been completed on 05/17/18. During an interview with Nurse #7 on 05/25/18 at 2:20 p.m., Nurse #7 stated she had worked the 3 p.m. to 11 p.m. shift on 05/16/18 and had remembered changing the dressing on Resident #25's [MEDICAL CONDITION] and stated it had looked fine. Nurse #7 stated she worked the 3 p.m. to 11 p.m. shift on 5/17/18 and had been one of the nurses who had assessed Resident #25 when her PEG tube had dislodged. When asked if she had checked Resident #25's [MEDICAL CONDITION] site prior to Resident #25 being sent out, Nurse #7 stated she remembered there had been no drainage noted on the sheets. During an interview with Nurse #2 on 05/26/18 at 9:56 a.m., Nurse #2 had been asked why she had not signed her initials on the MAR for Resident #25's [MEDICAL CONDITION] site dressing on (MONTH) 2, 4, 6, 7, 9 and 15, (YEAR). Nurse #2 stated while she remembered changing the dressing a couple of times she stated she was going to be honest. Nurse #2 stated when she came on duty she was responsible for a medication cart and 30 residents in addition to overseeing 2-3 medication aides. Nurse #2 stated she stayed stressed out because when she would come on duty she had always been pulled here and there dealing with resident issues and behaviors. Nurse #2 stated it had been very challenging and stated she felt it could be the reason why she did not always do the dressing change. During an interview with Nurse #6 on 05/26/18 at 10:40 a.m., Nurse #6 stated she recalled changing Resident #25's [MEDICAL CONDITION] site dressing in the past but stated she could not recall whether or not she had changed the dressing on 05/01/18. During an interview with Nurse #7 on 05/26/18 at 12:49 p.m., Nurse #7 stated 5/10/18 had been her first day of employment at the facility. Nurse #7 stated she recalled changing Resident #25's [MEDICAL CONDITION] site dressing on 05/10/18 and stated she had forgotten to sign off on the MAR. During an interview with the hospital ED nurse #2 on 07/03/18 at 9:33 a.m., the hospital ED nurse #2 stated Resident #25 arrived in the ED approximately 15 minutes before the end of her 7 a.m. to 7 p.m. shift on 05/17/18. The hospital ED nurse #2 stated Resident #25 smelled like she needed a bath and her nephrostomy and indwelling urinary catheter were in need of some tender loving care however she had not assessed Resident #25's [MEDICAL CONDITION] because her oxygen saturation had been okay. During an interview with the hospital ED nurse #3 on 07/03/18 at 11:30 a.m., the hospital ED nurse #3 stated she had cared for Resident #25 during her 7 p.m. to 7 a.m. shift on 05/17/18. The hospital ED nurse #3 stated Resident #25 had been in real bad condition and had focused her care to Resident #25's nephrostomy and indwelling urinary catheter secondary to Resident #25 having had really bad smelling urine. During an interview with the hospital ED nurse #1 on 05/23/18 at 4:25 p.m., the ED nurse #1, who worked the 7 a.m. to 7 p.m. shift on 5/18/18, stated when she had entered the holding room Resident #25 had been placed in she could smell the stench coming off of her and noted that her face had dried spittle on it, her hair had been matted with white flakes and it appeared like it had not been washed in a long time. The ED nurse #1 stated she looked at Resident #25's [MEDICAL CONDITION] site and had noted a substance on the [MEDICAL CONDITION] which she compared to melted malt chocolate. The ED nurse stated she called a Respiratory Therapist (RT) for [MEDICAL CONDITION] care and oxygen needs. The ED nurse stated once the RT had begun [MEDICAL CONDITION] care, he had informed her of the presence of maggots on Resident #25's skin surrounding her [MEDICAL CONDITION] site. The ED nurse stated she then observed the presence of maggots around the [MEDICAL CONDITION] site. During an interview with the hospital's RT #1 on 05/25/18 at 11:15 a.m., the RT #1 stated he recalled Resident #25 in the ED on 05/18/18. The RT stated he had been called to the ED to assess the resident, assess oxygen saturation and perform [MEDICAL CONDITION] care. The RT #1 stated upon arrival to Resident #25's ED room, he had noticed a foul odor emanating from the resident. The RT #1 stated when he had assessed the [MEDICAL CONDITION], he noticed the [MEDICAL CONDITION] ties were dirty and there were visible dried secretions on her [MEDICAL CONDITION]. The RT #1 stated he removed the [MEDICAL CONDITION] site sponge (gauze dressing from the facility) and it had been so dirty and had secretions so old the sponge was hard. The RT #1 stated Resident #25's skin underneath the sponge was red and he had noticed maggots under the [MEDICAL CONDITION] ties and the sponge. The RT #1 stated he had noticed Resident #25's odor was more prevalent during the [MEDICAL CONDITION] care but could not state whether the foul odor was coming from the [MEDICAL CONDITION] site or not. The RT #1 stated he cleaned all of the maggots off of Resident #25's skin and cleaned the [MEDICAL CONDITION] however he did not have time to change the inner cannula as Resident #25 had to be transferred to another part of the hospital. During a 2nd interview with the hospital RT #1 on -07/03/18 at 8:57 a.m., the hospital RT #1 stated he and another hospital RT #2 had performed Resident #25's [MEDICAL CONDITION] care together on 05/18/18 and the hospital RT #2 had documented the care. A review of the hospital's records indicated Resident #25 had arrived at the Emergency Department (ED) on 05/17/18 at 5:50 p.m. with a chief complaint of a dislodged PEG tube. Further review of the hospital record ED notes revealed the following: 1. An RT note, dated 5/18/18 8:33 a.m. - oxygen device = [MEDICAL CONDITION] collar (TC), fraction of inspired oxygen (FIO2): 30, breath sounds diminished; note - pt placed on 30% TC at this time, peripheral capillary oxygen saturation (SPO2) 97% 2. An ED nurse note, dated 05/18/18 2:02 p.m. - patient's [MEDICAL CONDITION] with brownish drainage, foul odor .called Respiratory Therapist (RT) to clean. RT notified RN that patient has maggots in [MEDICAL CONDITION]. RN confirmed this by eyesight. 3. Final order results of a chest x-ray performed on 05/17/18 at 9:15 p.m. revealed findings of [MEDICAL CONDITION] is stable in position .no acute process A review of a hospital's [MEDICAL CONDITION] Assessment note, dated 5/18/18 at 2:00 p.m., stated called to patient's room for [MEDICAL CONDITION] assessment, upon more detailed look at [MEDICAL CONDITION] this RT found maggots crawling around [MEDICAL CONDITION] site .all maggots that were seen were wiped off .Once RN called to room she asked patient when was the last time they cleaned it at the nursing facility and patient stated they cleaned it 2 days ago. During an interview with Resident #25 on 05/24/18 at 11:35 a.m., Resident #25 was observed to be lying in her hospital bed, awake and alert. Resident #25's skin appeared clean and there had been a slight odor emanating off of her body, possibly coming from her hair which was visibly dirty with a dried brown substance noted in one part of it and areas full of dry white flakes, possibly skin flakes. Resident #25 was observed to have a [MEDICAL CONDITION] in place. Resident #25 stated [MEDICAL CONDITION] care at the facility hardly ever got done. Resident #25 stated the nurses at the facility were supposed to change it once a week and they did not consistently change it as ordered. Resident #25 stated it made her feel terrible knowing the state her [MEDICAL CONDITION] site was in when she got to the hospital. During an interview with the Administrator on 05/26/18 at 2:42 p.m., the Administrator stated his expectation of nursing staff, in regard to [MEDICAL CONDITION] care, is to follow the residents' plan of care as directed by the physician. The Administrator stated it was his expectation nursing staff document according to facility training. The Assistant Director of Nursing was notified of the Immediate Jeopardy on 06/29/18 at 3:10 p.m. On 07/03/18 at 2:46 p.m., the facility provided the following credible allegation of compliance and Immediate Jeopardy removal: A thorough investigation was completed by the administrator on 7/02/18 to ascertain the cause. It was determined by the administrator that the cause was the failure of nurse #7 not completely reading the Medication Administration Record which resulted in not documenting [MEDICAL CONDITION] care provided. During the interview, Nurse #6 and nurse #2 both stated that they did not provide [MEDICAL CONDITION] care to resident #25 related to being busy but could not state the reason why they did not ask for assistance. On 5/17/18, Resident #25 was sent out to the hospital for evaluation due to dislodged [DEVICE]. Resident #25's [MEDICAL CONDITION] was assessed by the Treatment Nurse on 4/30/18, 5/7/18, and 5/14/18 with no documentation of larvae, foul odor, or drainage around the [MEDICAL CONDITION] site. On 5/17/18 per hospital record at 6:50 pm, one hour after resident was in the Emergency Department, the RN documented Patient conscious, alert and oriented x 4, respiratory rate even and unlabored, patient has [MEDICAL CONDITION] and wears O2 @ 3 liters. No mention of drainage, larvae, or foul-odor in [MEDICAL CONDITION]. On 5/17/18 per hospital record at 9:15 pm, resident had a chest x-ray complete. Findings: [MEDICAL CONDITION] in stable position. On 5/17/18 per hospital record at 10:42 pm, per the documentation of the Registered nurse, [MEDICAL CONDITION] in place. O2 @ 3 Liters via [MEDICAL CONDITION] mask. On 5/18/18 per hospital record at 5:32 am, per the documentation of the Registered nurse, suction at bedside. On 5/18/18 per hospital record at 8:33 am there is documentation of a Respiratory Therapist treatment assessment. On 5/18/18 per the hospital record at 2:24 pm there is documentation of the registered nurse Patient's [MEDICAL CONDITION] with brownish drainage, foul odor. [DEVICE] site needs cleaning. Called RT to clean [DEVICE] and RT notified RN that pt has maggots in [MEDICAL CONDITION]. RN confirmed this by eye site. RN notified physician via phone and awaiting call back. On 5/18/18, the administrator was made aware by resident #25 friend of an allegation that Resident #25 was observed with maggots in her throat while at the hospital. On 5/18/18, an investigation was started by the administrator to include submission of an Initial Allegation Report to Health Care Personnel Investigation (HCPI). On 5/25/18, the investigation was completed and the allegation was unsubstantiated by the administrator. The Investigation Report was submitted to (HCPI) by the administrator. On 5/26/18, Resident #25 returned to the facility and was assessed by the hall nurse to include assessment of the [MEDICAL CONDITION] site, which was clean, dry, and covered with a dry dressing. On 5/26/18, the assessment for Resident #25 was documented by the hall nurse in the electronic medical record. The care of the trachea was not documented to show we followed doctor's orders consistently. Therefore we proactively educated nursing personnel to include Nurse # 2, #6, and #7 on following doctor's order and providing trachea care. Nurse #2 will be reported to the Board of Nursing on 7/3/18 for not documenting on the Medication Administration Record by the Director of Nursing. Nurse #2 is no longer staffed at the facility through the Agency. Nurse # 6 and #7 will be reported to the board of Nursing on 7/3/18 for not providing [MEDICAL CONDITION] care by the Director Nursing on 7/3/18. Corrective Action A contracted Respiratory Therapist (RT) initiated training on [MEDICAL CONDITION] care with licensed nurses to include Nurse #6 and #7 on 7/1/18. The Director of Nursing, Staff Facilitator and eight other nurses have currently received the training by the RT and will complete all resident's [MEDICAL CONDITION] care until the remaining nurses complete the training. There are ten licensed nurses that are left to be trained by the RT and will not be allowed to work until the training has been completed. A contracted RT is on site as of 2:15 pm on 7/3/18 and has initiated the remaining licensed nurse training. On 5/30/18, an in-service was initiated with all license nurses to include agency nurse, and Nurse #6, and Nurse #7 by the facility nurse consultant and the Staff Facilitator (SF) on providing [MEDICAL CONDITION] care as ordered by the physician. The in-service also addressed the expectation that documentation must be present on the Medication Administration Record (MAR) after providing [MEDICAL CONDITION] care. The in-service was completed on 6/28/18. On 7/2/18, an in-service was initiated with all licensed nurses to include agency nurses and Nurse #6, and Nurse #7 by the Facility Nursing Consultant on reading each [MEDICAL CONDITION] order on the MAR, following the physician order [REDACTED]. The in-service also included for licensed nurses to ask for additional assistance from the Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, Staff Facilitator, or another hall nurse when feeling like assistance is needed to provide resident care to include [MEDICAL CONDITION] care and time management. No licensed nurse will be allowed to work until the training has been completed. On 6/12/18, an observation of all residents to include Resident #25 was completed by the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and the Quality Improvement (QI) Nurse to physically identify all residents with tracheostomies. One resident was identified with a [MEDICAL CONDITION]. On 6/12/18, an audit of all MARs, including MARs for Resident #25, for the past 30 days, was completed by the ADON and the QI Nurse to ensure orders for respiratory care, including [MEDICAL CONDITION] care were provided as evidenced by documentation on the MAR. There were no other identified areas of concern noted. On 6/12/18, an assessment of all residents with tracheostomies, including Resident #25 was completed by the QI Nurse and the ADON to ensure [MEDICAL CONDITION] care was provided as evidenced by observing a clean insertion site and dressing with no drainage present. There were no identified areas of concern during the audit. On 6/12/18, an audit of all residents' physician orders [REDACTED]. The audit was completed on 6/13/18. There were no other identified residents with orders to receive [MEDICAL CONDITION] care. On 6/29/18, a 100% return demonstration of [MEDICAL CONDITION] care was initiated with all licensed nurses to include agency nurses and Nurse #6, and Nurse #7 by the Assistant Director of Nursing (ADON). Retraining will be completed by the ADON during the time of the audit for any nurse that cannot demonstrate successful performance of [MEDICAL CONDITION] care per policy and procedure. No nurse will be allowed to perform [MEDICAL CONDITION] care on a resident until successful completion of the return demonstration. No licensed nurse will be allowed to work until the return demonstration has been completed. The Quality Improvement Organization was contacted by the Regional Vice President of Operations on 7/03/18 for assistance in evaluation of specific steps to be taken to address [MEDICAL CONDITION] care and training, staff position/title designated to be responsible for the steps, timeline for accomplishment of the steps, specific methodology to be used to evaluate the plan's success, and frequency of monitoring the effects of the plan initiation. All residents with tracheostomies to include Resident #25 will be physically observed and documentation of the MAR and non-ulcer flow sheet assessment will monitored by the Assistant Director of Nursing (ADON) and/or the Quality Improvement (QI) Nurse 5 days weekly for 4 weeks, 3 days weekly for 4 weeks, then weekly for 4 weeks utilizing [MEDICAL CONDITION] Audit tool. This audit is to ensure that [MEDICAL CONDITION] care is being performed per policy and procedure, with documentation on the MAR and an assessment has been completed with documentation in the electronic health record and that the [MEDICAL CONDITION] site is clean, odor-free, and dressing is dry and intact. A medication pass audit on [MEDICAL CONDITION] care will be completed by the Assistant Director of Nursing (ADON) and/or the Quality Improvement (QI) Nurse on 10% of all licensed nurses to include agency nurses and Nurse #6 and Nurse #7, 5 days weekly for 4 weeks, 3 days weekly for 4 weeks, then weekly for 4 weeks utilizing a Medication Pass [MEDICAL CONDITION] Audit Tool. This audit is to ensure that nurses are reading each [MEDICAL CONDITION] order on the MAR, following the physician order [REDACTED]. Any areas of concern identified during the audits will be addressed immediately by the ADON, QI Nurse, and/or the DON to include providing additional staff training. The DON will present the findings of [MEDICAL CONDITION] Audit tools and the Medication Pass [MEDICAL CONDITION] Audit Tools to the Executive Quality Assurance (QA) committee monthly for 3 months. The Executive QA Committee will meet monthly for 3 months and review [MEDICAL CONDITION] Audit tools and the Medication Pass [MEDICAL CONDITION] Audit Tools to determine trends and/or issues that may need further interventions put into place and to determine the need for further frequency of monitoring. Final date of compliance is 7/03/18. The administrator and DON will be responsible for the implementation of corrective actions to include all 100% audits, in-services, and monitoring related to the plan of correction. The Credible Allegation for Immediate Jeopardy removal was validated on 07/03/18, which removed the Immediate Jeopardy on 07/03/18. Interviews were conducted with nursing staff present in the facility on 07/03/18. The staff confirmed the recent in-services and trainings related to [MEDICAL CONDITION] care and documentation of [MEDICAL CONDITION] care. Reviews of the in-service records, audit tools, audits performed and facility assessments were made. An interview with the DON on 07/03/18 at 2:45 p.m. revealed the named nurses had been reported to the North Carolina Board of Nursing. An interview with the Regional Vice President of Operations on 07/03/18 at 2:50 p.m. revealed he had contacted the Quality Improvement Organization for assistance in evaluation of specific steps to be taken to address [MEDICAL CONDITION] care and training.

Based on observation, record review and resident and staff interviews, the facility failed to clarify indwelling urinary catheter orders for 1 of 1 resident reviewed (Resident #25) resulting in a resident's indwelling urinary catheter not being changed for several months and a hospitalization for a urinary tract infection [MEDICAL CONDITION]. The Findings Included: Resident #25 was admitted to the facility on [DATE]. Her medical [DIAGNOSES REDACTED]. A review of Resident #25's quarterly Minimum Data Set, dated dated [DATE], revealed Resident #25 had been cognitively intact and required total assistance of staff for her Activities of Daily Living (ADL). The MDS indicated Resident #25 had an indwelling urinary catheter and had [MEDICAL CONDITION]. A review of Resident #25's Care Plan, last revised 12/06/17, revealed the following: 1. At risk for recurrent UTIs, urosepsis, or renal damage due to chronic UTIs or history or recurrent UTIs. Interventions included, in part, catheter care per facility protocol. 2. Altered pattern of urinary elimination with indwelling catheter - at risk for infection related to [MEDICAL CONDITION]. Resident with nephrostomy tube and (indwelling urinary) catheter. Interventions included, in part, catheter care per facility protocol, monitor nephrostomy tube and report any changes, change catheter per physician orders and/or facility protocol, monitor for signs and symptoms of UTI. 3. Resistive to treatment and care (did not want to shower, comb hair, turn off her back, have nails cut, get out of bed, have bed placed in low position, have facial hair removed, have vital signs or weights taken). Interventions included, in part, to allow for flexibility in ADL routine to accommodate the resident's mood, to document the care being resisted per facility protocol and to notify the physician of patterns in behaviors and to discuss the implications of not complying with the therapeutic regiment with the resident (last revised 06/30/17). A record review revealed the resident had a hospitalized from [DATE] through 10/25/17. A review of Resident #25's admission orders [REDACTED]. Further record review documentation of revealed two instances the indwelling urinary catheter had been changed - 10/11/17 and 12/20/17. A review of Resident #25's physician orders 10/25/17 to 05/17/18 revealed there had been no physician order to change her indwelling urinary catheter. A review of the hospital's Emergency Department's (ED's) notes revealed Resident #25 presented to the Emergency Department on 05/17/18 with a chief complaint of a dislodged percutaneous endoscopic gastrostomy (PEG) tube. A review of the hospital's ED registered nurse (RN) notes revealed, on 05/18/18 at 3:39 a.m., condition of patient's (indwelling urinary) catheter noted with hardened large amounts of crystalized sediment . A review of the hospital's Admission History and Physical (H&P), dated 05/18/18, indicated Resident #25 presents from Skilled Nursing Facility (SNF) complaining of dislodged PEG tube. Patient denied any abdominal pain, nausea, vomiting, fevers, chills. Upon evaluation in the ED, the PEG tube was placed back .upon initial exam by ED provider, it was noted that her right nephrostomy tube was draining purulent material. Abdominal computed tomography (CT) scan was obtained and is suggestive of a right [MEDICAL CONDITION]. Patient denies any symptoms .denies abdominal pain, nausea, vomiting, diarrhea, dysuria . Labs remarkable for grossly positive urine analysis . Patient has been treated in this hospital for Proteus [MEDICAL CONDITION] / UTI / [MEDICAL CONDITION] in (MONTH) (YEAR) . Further review of the H&P revealed an assessment [MEDICAL CONDITION] secondary to complicated UTI and [MEDICAL CONDITION] with planned replacements of the nephrostomy tube and indwelling urinary catheter and Resident #25 being treated with intravenous antibiotics. During an interview with Resident #25's medical doctor (MD) on 05/25/18 at 1:00 p.m., the MD stated it was his expectation for nursing to change residents' indwelling urinary catheters every 30 days. The MD stated the fact Resident #25's indwelling urinary catheter had not been changed 30 days since it had been inserted certainly had been a contributory factor to her current hospital diagnoses. The MD stated residents who have indwelling urinary catheters are at increased risk of UTIs. During an interview with Nurse #4 on 05/26/18 at 12:30 p.m., Nurse #4 stated she thought the order to change the indwelling urinary catheter for Resident #25 had been inadvertently left off the MARs in (MONTH) (YEAR) after Resident #25 returned to the facility from a hospitalization for UTI and [MEDICAL CONDITION]. Nurse #4 stated she knew Resident #25's indwelling urinary catheter had been changed since (MONTH) (YEAR) but she could not prove it. During an interview with Nurse #8 on 05/26/18 at 12:35 p.m., Nurse #8 stated residents with indwelling urinary catheters have their catheters replaced once a month. Nurse #8 stated the date of the month depends on the resident and when the catheter was first inserted. Nurse #8 stated she frequently had Resident #25 on her assignment and did not remember changing Resident #25's catheter in the recent past. Nurse #8 stated seeing the order to change the catheter on the MAR indicated [REDACTED]. During an interview with Resident #25 on 05/26/18 at 1:20 p.m., the resident stated she could not remember exactly when her indwelling urinary catheter had last been changed at the facility. When she was told the medical record indicated 12/20/17, Resident #25 stated she felt sure it had been changed since but not for the last 2 months. During an interview with the Administrator on 05/26/18 at 2:42 p.m., the Administrator stated, in regard to indwelling urinary catheter changes, he would expect the nursing staff to follow the plan of care as directed by the physician. The Administrator stated he would expect the nursing staff to document according to facility training.

Based on observations and interviews, the facility failed to properly label food stored in the reach-in refrigerator, failed to properly store scoops, failed to clean and sanitize food carts, failed to clean and sanitize utility carts, failed to clean open floor area below the steam table and failed to clean a wall in the dishwashing area. The findings included: A. An observation of the reach-in refrigerator on 05/21/18 at 12:20 PM revealed 2 unlabeled clear plastic bags that contained a portion of bulk ham and 2 blocks of sliced cheese covered with clear wrap with no date. During an interview with the Certified Dietary Manager on 05/24/18 at 4:25 PM, he stated it was his expectation that all open food items are dated with open date, expiration date and name of food item if removed from the original container. B. An observation was made on 05/21/18 at 12:25 PM of the flour, sugar and cornmeal bins with the scoops stored directly in the food item. During an interview with the Certified Dietary Manager on 05/24/18 at 4:25 PM, he stated it was his expectation that scoops be stored in plastic bags and labeled with date on top of each bin. C. An observation was made on 05/21/18 at 12:30 PM of 3 dirty metal food delivery carts being used during lunch time to deliver meals to the residents with sticky brown substance and built up food debris. The built up food debris covered approximately 50 percent of metal food cart inside and outside. During an interview with the Certified Dietary Manager (CMD) on 05/24/18 at 4:25 PM, he stated it was his expectation that the food delivery carts were cleaned and sanitized after breakfast, lunch and dinner meals. The CDM further stated that whoever was assigned to unload the food delivery carts was responsible for cleaning and sanitizing the food delivery carts. D. An observation was made on 5/21/18 at 12:35 PM of 4 utility carts with a sticky substance and food crumbs on the surface where clean dinnerware and beverage containers were stored. During an interview with the Certified Dietary Manager on 05/24/18 at 4:25 PM, he stated it was his expectation that the utility carts be cleaned and sanitized before storing clean dinnerware and beverage containers on them. E. An observation was made on 05/21/18 at 12:40 PM of an open floor area covered with a thick metal slotted cover (drain cover) below the steam table containing buildup of food particles and trash debris beneath the drain cover and around the edges of drain cover. Observation was made of a foul odor coming from the drain. The area measured 11 inches wide by 8 feet long. During an interview with the Certified Dietary Manager on 05/24/18 at 4:25 PM, he stated it was his expectation that the floor area with drain cover below the steam table be thoroughly cleaned weekly and as needed. The CDM further stated that floor area was not on the cleaning schedule. F. Observation was made on 05/21/18 at 12:45 PM of the wall behind the clean dish rack in the dishwashing area of a brown substance splashed on the wall and a small area had paint peeling from the wall. During an interview with the Certified Dietary Manager (CDM) on 05/24/18 at 4:25 PM, he stated it was his expectation that the wall in the dishwashing area be cleaned weekly and as needed. The CDM further stated that he would put in a work order to have the wall painted. During an interview with the Administrator on 05/26/18 at 2:40 PM revealed that it was his expectation that the dietary staff follow the sanitation guidelines taught by the facility.

Based on record reviews, observations, and resident and staff interviews the facility Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put in place following the recertification/complaint survey of 07/21/17 and the complaint survey of 09/27/17. This was for 2 deficiencies originally cited in (MONTH) (YEAR) and 1 deficiency cited in (MONTH) (YEAR). These 3 deficiencies were subsequently recited on the current recertification complaint survey of 05/26/18. The continued failure of the facility during 3 federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: 1. This tag is cross referenced to: 483.25: Free of Accident Hazards/Supervision/Devices: Based on observation, record review, and staff interviews, the facility failed to implement interventions to prevent falls which resulted in multiple falls for 1 of 11 sampled resident (Resident #74). During the recertification and complaint survey of 07/21/17 the facility was cited for failure to prevent 1 of 2 cognitively impaired residents with exit seeking behaviors from exiting a locked unit in the facility and then eloping from the facility via an unsecured door. The police found the resident on a busy street. The resident was not injured. 2. This tag is cross referenced to: 483.45: Free of Medication Error Rate of 5% or More: Based on observation, record reviews and staff interviews the facility's medication error rate was greater than 5% as evidenced by 2 medication errors out of 25 opportunities for error during the observation of the medication pass. During the complaint survey of 09/27/17 the facility was cited for failure to assure morning insulin coverage was given per sliding scale order for one of three sampled residents, Resident #97, on five days. 3. This tag is cross referenced to: 483.60: Food and Nutrition Services: Based on observations and staff interviews, the facility failed to properly label food stored in the reach in refrigerator, failed to properly store scoops, failed to clean and sanitize food carts, failed to clean and sanitize utility carts, failed to clean open floor area below the steam table and failed to clean a wall in the dishwashing area. During the recertification and complaint survey of 07/21/17 the facility was cited for failure to ensure staff did not handle food with their bare hands for 1 of 1 meal observed for Resident #52. During an interview conducted on 05/26/18 at 3:33 PM the Administrator stated they had multiple turnovers in key departmental staff positions as well as some of the aspects of the citations were different that the previous citations. He continued by stating it was his expectation that they would re-examine systems to find the root cause of the issues and address it with continuous monitoring and improvements.

Based on record review, staff interviews and observation, the facility failed to prevent 1of 2 cognitively impaired residents with exit seeking behaviors from exiting a locked unit in in the facility and then eloping from the facility via and unsecured door, the police found the resident on a busy street. The resident was not injured (Resident # 168). The Immediate Jeopardy began on 6/4/2017 when Resident # 168 exited the facility unattended by the facility staff, and was found 4 miles away from the facility by the police. The Immediate Jeopardy was removed on 6/13/2017 at 5:00 PM when the facility completed in-servicing the staff on elopement policies and procedures. The facility also completed a review of all the residents who were at risk for elopement on 6/13/2017. The facility provided an acceptable plan of correction completed 6/13/2017. The findings included: Resident # 168 was admitted to the facility on [DATE]. Resident # 168's [DIAGNOSES REDACTED]. Review of the resident's admission Wandering Risk Evaluation dated 5/24/2017 revealed the resident scored a 7(score greater that 5 is at risk for wandering) was at high risk for wandering. The admission Minimum Data Set ((MDS) dated [DATE] indicated Resident # 168's cognitive status was severely impaired. The MDS also indicated the resident was independent with locomotion in the unit. The care plan dated 6/1/2017 indicated Resident # 164's problem of wandering and/or at risk for unsupervised exits from facility related to: cognitive impairment due to worsening of his dementia. The goals included allow resident to ventilate feelings regarding nursing home placement, allow resident to wander on unit, Wander Guard in place and resident to stay in Spark unit (locked unit). A review of the Nurse's Note dated 6/4/2017written by Nurse #2 at 4:25 PM documented the resident returned to facility. He was ambulatory with slow steady gait, alert and pleasantly confused as usual. Resident # 168 stated I had to go to the house check on those people that sneak in at night to steal my little bit of things When asked how he exited the facility the resident stated, I just followed a bunch of them people going out that door. A review of the Nurse's Note dated 6/4/2017 written by Nurse # 1 at 6:48 PM documented Resident left facility unsupervised. Resident found and brought back to facility by police; resident refused to go to hospital to be evaluated; resident stated that he was just going to come back to facility that he just needed to go check on his stuff. Resident in room with no distress noted. Facility incident report dated 6/4/2017 revealed that on 6/4/2017 at approximately 1:20 pm staff were unable to locate Resident #168. Immediately upon recognizing Resident #168 was missing; a code orange (a code for a missing resident) was announced by Nurse #2. Nurse #1 then started the unsupervised exit protocol by delegating all the staff to begin searching for the missing resident. Law enforcement was called by Nurse #1 at approximately 2 pm in regards to elopement of Resident # 168 and police arrived at the facility at 2:10 pm. At 2:10 pm, Nurse #1 notified medical director of Resident #168's elopement and Responsible representative was notified of Resident #168's elopement. The police department notified Nurse #2 resident had been found. Resident # 168 was returned to the facility at approximately 4:20 pm by the police department. Resident # 168 was immediately placed on one on one supervision by Administrator. A head to toe assessment was completed on Resident # 168 with no injuries or S\S (signs) of dehydration noted by Nurse #3. Vital signs stable, BP (blood pressure) 165/74 P(pulse) 55 R(heart rate) 16 T(temperature) 98.9 O(oxygen)@ Sats(saturation) 99% resident denied any pain. Medical Director (MD) gave verbal order to encourage po (by mouth) fluids Review of the resident's Wandering Risk Evaluation dated 6/4/2017 revealed the resident scored a 12 (score greater that 5 is at risk for wandering) the resident was a high risk for wandering. Statement written by Housekeeper manager on 6/4/2017 documented on 6/4/2017, I was stripping and waxing the front entrance to the building, I had detoured all visitors and staff to go through the therapy room outside door because it was right off the main sidewalk. The door was open but closely monitored at all times. The only time I left the front area, was when I had to get something. Each time I left I had my floor technician to monitor the door until I returned. At no point during the day was the door left unattended. After the resident was discussed to be missing, the floor technician said that the resident had been telling everyone he was leaving today. Statement written on 6/4/2017 by Nurse # 1 who was assigned Resident # 168 on 6/4/2017 documented at approximately 9:00 AM she was on 300 hall checking on another resident and she saw Resident # 168 walking down the hall stating he needed to leave because he had a doctor's appointment. She returned to the hall around 1:20 PM to pass some medications and Nurse Aide (NA) # 3 asked if she had seen Resident # 168 and she said no as she had just come on the floor. She notified Director of Nursing (DON) the resident was missing around 1:30 PM. She did an overhead page and notified all staff of the elopement and advised staff to do a search of facility and outside perimeter. Review of the psychiatrist evaluation completed 6/6/2017 documented the staff reported patient left facility over the weekend and requested evaluation to assist patient. Patient was reported to be non- combative and was returned safely. Patient presents as very confused pleasant and engaging; obsessed with home and returning to full fill perceived obligations. Worried about his dogs and his car. Patient shared about being a truck driver and feeling the need to be on the go. Patient very fixated on finding a way to return home Interview with Nurse # 2 on 7/21/2017 at 9:30 AM revealed she was the nurse supervisor on Sunday 6/4/2017 when the resident was found missing from the locked unit. She stated a nurse assistant in the locked unit reported to her that they were not able to locate Resident # 168. She announced the code for missing resident and the staff began searching for the resident on the facility grounds. She reported the police were notified after the staff could not locate the resident. She added they were not sure at what time the resident left the building but there was speculation that the family of another resident might have let the resident off the locked unit. She also indicated the resident had a Wander Guard but no staff in the facility heard the alarm going off. She indicated the resident left the building using an unsecured exit door in the physical therapy room after the housekeeper left the door unlocked while waxing the floor by the front door. Nurse # 2 also indicated the families visiting on Sunday of 6/4/2017 were using the physical therapy exit door because the front door was locked due to the waxing of the floor. Interviews with NA # 1 and NA # 2 on 7/21/2017 at 10:00 AM revealed the resident always stated he wanted to go home and was obsessed with wanting to leave to go home since he was admitted to the facility. During the interview on 7/21/2017 at 10:30 AM, NA # 3 who was assigned to Resident # 168 on Sunday 6/4/2017 she realized the resident was missing from the building when she was getting ready to pass the trays at lunch time. NA # 3 also added she had seen the resident earlier that morning and he (Resident # 168) had indicated he wanted to go home. During the interview on 7/21/2017 at 11:30 AM, the floor technician reported on Sunday morning of 6/4/2017 at 2 separate times at approximately 8:00 AM and 9:30 AM he had seen the resident standing by the locked unit entrance door and redirected the resident to go back to his room. He reported the resident had stated that he was leaving to go to the doctor's appointment. Interview with the DON on 7/21/2017 at 2:00 PM revealed the resident was assessed as a high risk and was placed on the locked unit with a Wander Guard. She added there were no witnesses to state how the resident got off the locked unit and the building. She further added the speculation was that a family member who did not know Resident # 168 was a patient in the locked unit had let the resident off the unit. The DON added they are not sure as to the reason why the locked unit doors did not sound the alarm since the resident had on a Wander Guard. She also indicated the resident got out of the building using the physical therapy exit door. She indicated the only door at the facility that is equipped with a Wander Guard alarm is the front door. Other doors at the facility are not equipped to sound an alarm when a resident with the Wander Guard approaches the door. She added the housekeeper was waxing the front lobby and opened the physical therapy exit door for the families to use. The DON also indicated it was wrong for the Housekeeper Manager to open the therapy exit door because it was not safe for the residents. Interview with Administrator on 7/21/2017 at 2:30 PM indicated her expectation was for staff to monitor the residents in the locked unit closely and for the housekeeper not to have opened the physical therapy exit door because it was not equipped with the door alarm. She added a plan of correction was put into place following the elopement incident. Thirty minute checks were initiated on 6/5/2017 for all residents in the locked unit and Resident # 168 remains on one on one monitoring. The Housekeeper Manager who opened the physical therapy door was not available for interview. The Housekeeper was no longer employed at the facility. Nurse # 1 who was assigned to Resident # 168 on Sunday 6-4-2017 was not available for an interview. The nurse was no longer employed at the facility. Observation of the building on 7/21/2017 at 3:00 PM, revealed the main entrance and the locked unit entrance were equipped with Wander Guard alarm. The alarms were observed to be working and they were checked daily by the Maintenance Director to make sure they were functioning. Further observations of the building revealed there were no alarms by the exit doors and the employees had a code that they had to use in order to exit the building. The facility parking lot was observed to be busy with vehicles coming and leaving, and there was a busy road in front of the facility which the speech limit was 45 miles per hour. The temperature on Sunday 6/4/2017 in the afternoon was 98 degrees. The administrator was notified of the Immediate Jeopardy on 7/21/2017 at 10:30 AM. CORRECTIVE ACTION FOR THE AFFECTED RESIDENT Resident # 168 was found by Fayetteville police department at approximately 3:21 pm, approximately 4 miles from the facility. Per police officer EMS arrived on the scene and assessed Resident # 168. EMS (Emergency services) asked Resident # 168 if he wanted to go to hospital but Resident # 168 stated he wanted to return to the facility. Resident # 168 was returned to the facility at approximately 4:20 pm by the police department. Resident # 168 was immediately placed on one on one supervision by Administrator. A head to toe assessment was completed on Resident # 168 with no injuries or S\S (signs) of dehydration noted by Nurse #3. Vital signs stable. , BP(blood pressure) 165/74 P(pulse) 55 R(heart rate) 16 T (temperature)98.9 O(oxygen)@ Sats(saturation) 99% resident denied any pain. Medical Director gave verbal order to encourage po(by mouth) fluids Administrator and Social worker attempted to send Resident # 168 to hospital for evaluation per MD(medical doctor) order; Resident # 168 refused. Resident's Wander Guard was checked by the Director of Nursing with Administrator present, immediately upon entering facility. Resident # 168's Wander Guard worked appropriately. Wandering Risk assessment for resident #168 reviewed and updated by Director of Nursing. On 6/5/2017 Director of Nursing received order for psych referral to evaluate and treat Resident #168 the resident was seen by Health Network on 6/6/17 for collection of identifying information and 6/7/17 by MD who ordered for the resident to remain on supervision with no other orders. He will continue for monitoring for mood and behaviors. CORRECTIVE ACTION FOR THE RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED A 100% Head Count was completed on 6/4/2017 by staff nurses per the census for accountability of all residents. All residents present and accounted for. A 100 % audit was completed on 6/4/2017 by the Maintenance Supervisor of all entrance/exit doors in the facility to ensure all doors were locked and functioning properly. No negative findings found. A 100% audit was completed on 6/4/2017 by the Director of Nursing on all residents for At Risk for Wandering. Appropriate interventions were implemented as indicated from the review. All identified at risk for wandering care guides and care plans were updated by the Director of Nursing, Assistant Director of Nursing, and MDS Nurse completed on 6/5/2017. Q (Every) 30 min checks were initiated on 6/5/2017 for all SPARK (locked unit) unit residents. Resident # 168 remains on 1-1 monitoring. Resident #1 will remain on 1:1 supervision until the residents condition would deteriorate and no longer be able to ambulate and therefore no longer be assessed as an elopement risk or upon the resident's representative choice to discharge. WHAT MEASURES WERE PUT INTO PLACE OF SYSTEMIC CHANGES MADE An In-service was initiated on 6/4/2017 by the Director of Nursing/Administrator/Staff Facilitator for nursing, administrative, dietary, activities, and contract services (Rehabilitation and Housekeeping and Laundry services) Maintenance, Payroll coordinator, and Accounts payable manager, central supply coordinator and receptionist. The Action Checklist for Unsupervised exits to be completed by 6/13/2017. The In-Service includes appropriate steps to take for a missing resident. First start a missing resident search and delegate other staff to notify Director of Nursing and Administrator, (use Pink Book at the Main Nurses Station which has the Action Checklist for Unsupervised Exits, and notify corporate staff). Notify the attending Medical Director, family, and appropriate Authorities delegated by Administrator. Assessment of residents' condition must be completed and Implementing measures to protect other residents. Reviewing Resident #168 and other residents identified as risk for wandering care plan and updating wandering assessment and making sure wandering board pictures are current by the Director of Nursing and Quality Improvement Nurse on 6/5/17. An In- Service was initiated on 6/4/2017 by the Staff Facilitator/Director of Nursing to all staff on Elopement and wandering residents to be completed by 6/13/2017. Please make sure residents' with alarm are not left to exit the building unassisted. Doors with alarms should not be reset without making sure that all residents are safe and secure. All residents on the locked unit should have on A Wander Guard Alarm. Do not prop open exit/entrance doors for any reason as this will and can be a way for exit for residents. Exit Door Keys will not be used to unlock any exit door unless prior approval is attained by the Administrator. All wandering residents should be redirected. Please refer to the Pink Book at the main nurse's station when residents are missing. An In-Service was initiated on 6/4/2017 by the Administrator to the Maintenance Supervisor and all Department Supervisors in reference to unsupervised exits and checking of the wander guard to be completed by 6/13/2017. Manager on Duty must be sure that all wander guards, door checks are completed. Failure to do so will lead up to disciplinary action or termination of employment. This system is in place to keep our residents safe and free from harm. An In-service for nursing, administrative, dietary, activities, and contract services (Rehabilitation and Housekeeping and Laundry services), Maintenance, Payroll coordinator, and Accounts payable manager, central supply coordinator and receptionist. The in-service was started on 6/4/2017 by the Administrator\Staff Facilitator Assistant in regards to proper steps on how to enter\exit the SPARK unit to was completed by 6/13/2017. An Elopement quiz was initiated by the Administrator on 6/4/2017 with all staff and was completed on 6/13/2017. In the case when a staff member can't locate a resident and the resident is nowhere to be found in the facility is called a code orange. An In-service was initiated on 6/4/2107 on 1-1montoring with licensed nurses, nursing assistants, dietary staff and department heads and was completed on 6/13/2017. 1:1 means for the staff member to be sitting with the resident at all times. Staff member cannot allow resident to be out the supervision. The staff are not allowed to leave the resident unattended unless relieved from another staff member. If this system fails the staff member will be terminated for not ensuring the resident is safe at all times. Resident care audit tools initiated on 6/4/2017 with all staff return demonstration in regards to entering and or exiting the SPARK unit by the Administrator and Staff Facilitator assistant and was completed on 6/13/2017. HOW THE FACILITY PLANS TO MONITOR CHANGES IMPLEMENTED Entrance/exit doors to be monitored by maintenance supervisor daily for 1 week then three times a week for 1 week; twice a week times 1 week; 1 time a week times one week; then monthly times two months beginning on 6/4/17. To ensure the door alarm is sounding when the threshold is approached and the door automatically locks down with a wander guard and if the door is constantly locked then the door remains locked upon approach to exit. Any identified areas of concern identified be either the door not enunciating or locking will result in a guard being placed at the door to assure no exit occurs from a wandering resident until the issue is resolved. 10% of the staff for nursing, administrative, dietary, activities, and contract services (Rehabilitation and Housekeeping and Laundry services), Maintenance, Payroll coordinator, and Accounts payable manager, central supply coordinator and receptionist to be monitored entering and exiting the locked Alzheimer's/Dementia care unit weekly for 8 weeks and monthly X 1 month utilizing the Resident care audit-SPARK door observation tool by the Administrator, DON, RN supervisor, Staff Facilitator. This monitoring tool is to ensure staff take proper precautions prior to entering or exiting sparks unit, checking surroundings for a resident that may be close by the door, and making sure door is closed completely prior to proceeding. This tool is utilized for nursing, administrative, dietary, activities, and all other respective departments. The Quality Improvement Executive Committee will review all audit information monthly x 3 months for any recommendations, take actions as appropriate and to monitor continued compliance in this area. On 6/5/17 the Quality Improvement Committee that included the Administrator, Director of Nursing, Quality Improvement Nurse, Admission, Social Worker, Dietary manager, Activity Director, Therapy Manager, Medical Records, Treatment Nurse, Staff Development Nurse, Staff Development Coordinator, maintenance Supervisor, Medical Director Minimum Data Set Nurse and Housekeeping manager to reviewed the plan of correction on for elopement and ascertain the root cause of the elopement. The committee reviewed the occurrence from 06/05/17 for resident #1. The committee determined that the housekeeping supervisor failure to communicate and to report the disarming of the door caused the resident access to exit the facility due to him overriding the door alarm and that staff were not assuring no one was leaving the unit while the doors were closing on the locked unit. The housekeeping supervisor is no longer employed at the facility due to the occurrence of failed to ensure resident safety and communicate the rerouting of the traffic due to buffing the floors. The supervisor was removed from the facility on 6/5/17 by Health Care Services Group. All staff that were involved on the date of the exit (6/4/17) were interviewed. The investigation was not conclusive because no one witnessed the resident leaving the locked unity that is why the in-service was initiated with return demonstration on ensuring when you leave the locked unit no one leaves the unit or that you do not assist anyone from the unit. The investigation was undetermined only on how the resident left the locked unit, the second part of the investigation was admitted to by the housekeeping supervisor of unarming the front door and failure to communicate with the director of nursing or administrator of the occurrence to place a guard at the door. The housekeeping supervisor was terminated in relation to this lack of communication on 6/5/17. It was speculated the housekeeping aide did not secure the door upon exiting and the resident had walked out behind the employee. The facility implemented the in-servicing to ensure the doors upon entering and exiting are secured prior to walking away from the doors and that no resident has left the unit. A laminated sign was placed on the entry doors to the locked unit stating, Attention Visitors Please make sure the 300 hall doors are closed and locked upon entering and exiting on 6/4/17 by the Administrator. On the main entrance doors of the facility a laminated sign was placed by the Administrator on 6/4/17 stating, Before assisting a resident outside please see a staff member. On the main front entry doors another laminated sign was placed by the administrator on 6/4/17 stating, Please do not allow residents out of the building unless authorized by the nursing department Thank you for your cooperation. As part of the validation process on 7/21/2017 at 4:30 PM, the entire plan of correction was reviewed including interviews of all related to identifying residents at risk for elopement, ensuring placement and function of the Wander Guard. The staff was also aware of whom to report the elopement behaviors. A review of the monitoring tools revealed that the facility had completed 100% of their in- servicing on 6/13/2017.

Based on record reviews and staff interviews, the facility failed to revise the care plan for one(1) of one (1)cognitively impaired resident who was identified as being a high risk falls.(Resident # 1) Findings include: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current MDS (Minimum data Set) dated 8/9/2012 revealed the resident 's cognition as severely impaired, she needed extensive assistance with bed mobility, transfer and walking in corridor. MDS further indicated the resident also as totally dependent on staff for locomotion on unit and toileting use. MDS also indicated the resident as not steady with moving from seated to standing position and walking. MDS further revealed the resident had impairment on one side upper extremity and impairment on one side lower extremity. Review of Resident # 1's current care guide dated 2/29/2012 revealed the resident was non- ambulatory, needed a mechanical lift for transfers, used a diaper for incontinence and used a bed alarm. CAA (Care Area Assessments) worksheet dated 6/7/2012 indicated the resident "flagged for Cognitive loss/ Dementia due to a BIMS (Brief Interview for Mental Status) score of less than 13.The resident presents with noted confusion- she will at time make simple decisions regarding her wants/needs, but for the most part, staff anticipates and provide for her care as needed. Resident displays impaired safety awareness and requires frequent monitoring of staff. "CAA worksheet also indicated the resident "is at increased risk for falls/injury secondary to right sided [MEDICAL CONDITION]." The ADLs (Activity of Daily Living) 'CAA documented resident requires "extensive assistance with bed mobility, locomotion on and off unit, dressing, eating, toileting, personal hygiene, bathing and transfers." The Fall CAA indicated the resident "requires extensive assistance from staff for all mobility needs. Resident does have a history of falls- she demonstrates decreased safety awareness secondary to impaired cognition that increase 's her risk for fall/injury. Staff currently transfer resident via the lift." Review of Resident # 1's fall risk evaluation dated 6/7/2012 documented the resident had a score of 19 which indicated the resident was a high risk for falls. The fall risk evaluation further documented the resident was total assist with transport with a fall in the past 30 days and the resident ' s vision was severely impaired.The fall risk assessment also documented the resident "currently has a bed alarm. Mat on the floor beside her bed and a low bed." Review of the Resident # 1's fall risk evaluation dated 8/15/2012 documented the resident had a score of 15 which indicated the resident was at high risk for falls. The intervention was for Resident # 1 to be on " fall risk precaution. " Resident #1's care plan dated 8/17/2012 documented the resident required assistance with transferring from one position to another related to her physical limitation. The care plan documented the following intervention: "Resident can weight bear, mechanical lift and Monitor for safety awareness." The care plan further documented the "resident was at risk for falls characterized by history of falls/ actual, falls, injury, multiple risk factors related to: Disease process: [MEDICAL CONDITION], incontinence, impaired balance, impaired mobility and pain." The interventions were "assist during transfer and mobility, Ensure environment is free of clutter, fall risk protocol and Mechanical lift." Further review of the care plan dated 6/7/2012 and 8/17/2012 revealed it was not updated to include a bed alarm and floor mat as indicated in the resident 's Fall Risk evaluation dated 6/7/2012. Nurse's note dated 9/22/2012 documented "Patient did yell and scream at 6:45 this morning and was found lying on the floor besides her bed. Resident was brought back to bed with NA (Nurse Assistant), (resident) stated she wanted to walk to get some water. On inspection, left hip slightly swollen, no bruises or bleeding assessed." Review of the incident and accident report dated 9/22/2012 documented "On 9/22/2012 patient was yelling and hollering at 6:50 AM in her room, was found lying on floor besides her bed. Bed was in lowest position. Cable to bed alarm was unplugged. No floor mattress was in place. Patient was brought back to bed and alarm was reapplied." The Incident report further revealed the resident had " Muscle weakness, impaired standing balance, decreased functional status, decreased mobility, fatigue secondary to disease process and reaching for objects, acute episode with altered mental status, Decreased safety awareness, [MEDICAL CONDITION], and decline in mental status, mental illness and diabetes mellitus." Review of the hospital record dated 9/22/2012 documented the resident was admitted due to left femur fracture. The hospital record further documented the resident "apparently climbed out of bed today and had a fall. She presented to the emergency department with deformity of the left lower extremity. She was seen by emergency department physician and found to have a [MEDICAL CONDITION]. Patient has significant dementia and is unable to provide any history." The hospital record further documented "A-9 point review of systems was reviewed with her daughter. It is negative with the exception of musculoskeletal. Which is significant for left femur pain." The hospital record also documented "The x- rays of the left femur reveal a [MEDICAL CONDITION] shaft in the upper one-third. There is displacement and shortening." The hospital record further documented "we will take her this evening for intramedullary nail fixation. I have explained to the daughter the risks and benefits of surgery. The risks include bleeding, infection, damage to nerves or blood vessels, failure of the fracture to heal, need for more surgery, [MEDICAL CONDITION], stroke, and death." During the interview on 10/2/2012 at 12:30 PM, NA#1 reported that she took care of Resident # 1 on the night of 9/22/2012. NA#1 stated that she checked the resident at 11:00 PM, 1:00 AM and 5:00 AM. NA #1 further added that she did not see the bed alarm on the Resident # 1's bed during the times that she checked on her. NA#1 further reported that Resident # 1's Care guide indicated that the resident should have a bed alarm but she did not see one on the day she took care of the resident on 9/22/2012. During the phone interview on 10/2/2012 at 1:45 PM, day Nurse # 1 reported she had a loud voice coming from Resident # 1's room in the morning of 9/22/2012. The resident was yelling and was on the floor.Nurse # 1 added Resident #1 had just fallen from her bed.Nurse # 1further reported the bed alarm did not go off before or after the resident fell on the floor. Nurse # 1 also reported she found out the bed alarm cable was not connected all the way while attached beside the bed. Nurse # 1 further added her normal routine was to check the residents bed alarms at the facility to make sure they were functioning correctly at the beginning of her shift. She added she did not check Resident # 1's bed alarm at the beginning of the shift on the night of 9/22/2012. During the interview on 10/2/2012 at 2:30 PM, MDS nurse #1 reported she was responsible for completing the annual assessments at the facility. She added she completed the annual fall risk assessment for Resident # 1 on 6/7/2012 and the resident scored as high risk on her annual fall risk assessment. MDS nurse #1 also added she could not explain why the annual care plan dated 6/7/2012 for Resident # 1 was not updated to include bed alarm, floor mat and a low bed. MDS nurse #1 further reported that she was not responsible for completing the quarterly updates on the care plans at the facility so she could not explain why the quarterly careplan for Resident # 1 dated 8/17/2012 did not include bed alarm, floor mattress and low bed. During the interview on 10/2/2012 at 3:30 PM, MDS nurse # 2 reported she was responsible for completing the residents quarterly assessmnents at the facility. MDS nurse # 2 was asked why the current careplan for Resident # 1 was not updated with the use of bed alarm and floor matress. MDS nurse # 2 answered it was an oversight.

Based on record reviews and staff interviews, the facility failed to implement fall interventions for one (1) of three (3) cognitively impaired residents, who were assessed as being at risk for falls. (Resident # 1) Findings include: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current MDS (Minimum data Set) dated 8/9/2012 revealed the resident ' s cognition as severely impaired; she needed extensive assistance with bed mobility, transfer and walking in corridor. MDS further indicated the resident also as totally dependent on staff for locomotion on unit and toileting use. MDS also indicated the resident as not steady with moving from seated to standing position and walking. MDS further revealed the resident had impairment on one side upper extremity and impairment on one side lower extremity. The MDS revealed the resident was not coded for side rails restraint. Review of Resident # 1's current care guide dated 2/29/2012 revealed the resident was non- ambulatory, needed a mechanical lift for transfers, and used a bed alarm. CAA (Care Area Assessments) worksheet dated 6/7/2012 indicated the resident "flagged for Cognitive loss/ Dementia due to a BIMS (Brief Interview for Mental Status) score of less than 13.The resident presents with noted confusion- she will at time make simple decisions regarding her wants/needs, but for the most part, staff anticipates and provide for her care as needed. Resident displays impaired safety awareness and requires frequent monitoring of staff. "CAA worksheet also indicated the resident " is at increased risk for falls/injury secondary to right sided blindness." The ADLs (Activity of Daily Living) ' CAA documented resident requires "extensive assistance with bed mobility, locomotion on and off unit, dressing, eating, toileting, personal hygiene, bathing and transfers." The Fall CAA indicated the resident "requires extensive assistance from staff for all mobility needs. Resident does have a history of falls- she demonstrates decreased safety awareness secondary to impaired cognition that increase's her risk for fall/injury. Staff currently transfer resident via the lift." Review of Resident # 1's fall risk evaluation dated 6/7/2012 documented the resident had a score of 19 which indicated the resident was a high risk for falls. The fall risk evaluation further documented the resident was total assist with transport with a fall in the past 30 days and the resident ' s vision was severely impaired. "The fall risk assessment also documented the resident " currently has a bed alarm. Mat on the floor beside her bed and a low bed." Review of the Resident # 1's fall risk evaluation dated 8/15/2012 documented the resident had a score of 15 which indicated the resident was at high risk for falls. The intervention was for Resident # 1 to be on "fall risk precaution." Resident #1's care plan dated 8/17/2012 documented the resident required assistance with transferring from one position to another related to her physical limitation. The care plan documented the following intervention: "Resident can weight bear, mechanical lift and Monitor for safety awareness." The care plan further documented the resident was at risk for falls characterized by history of falls/ actual, falls, injury, multiple risk factors related to: Disease process: Blindness, incontinence, impaired balance, impaired mobility and pain." The interventions were "assist during transfer and mobility, Ensure environment is free of clutter, fall risk protocol and Mechanical lift." Further review of the care plan dated 6/7/2012 and 8/17/2012 revealed it was not updated to include a bed alarm and floor mattress as indicated in the resident's Fall Risk evaluation dated 6/7/2012. Nurse's note dated 9/22/2012 documented "Patient did yell and scream at 6:45 this morning and was found lying on the floor besides her bed. Resident was brought back to bed with NA (Nurse Assistant), (resident) stated she wanted to walk to get some water. On inspection, left hip slightly swollen, no bruises or bleeding assessed." Review of the incident and accident report dated 9/22/2012 documented "On 9/22/2012 patient was yelling and hollering at 6:50 AM in her room, was found lying on floor besides her bed. Bed was in lowest position. Cable to bed alarm was unplugged. No floor mattress was in place. Patient was brought back to bed and alarm was reapplied." The Incident report further revealed the resident had "Muscle weakness, impaired standing balance, decreased functional status, decreased mobility, fatigue secondary to disease process and reaching for objects, acute episode with altered mental status, Decreased safety awareness, psychosis, and decline in mental status, mental illness and diabetes mellitus." Review of the hospital record dated 9/22/2012 documented the resident was admitted due to left femur fracture. The hospital record further documented the resident "apparently climbed out of bed today and had a fall. She presented to the emergency department with deformity of the left lower extremity. She was seen by emergency department physician and found to have a fracture of the femur. Patient has significant dementia and is unable to provide any history." The hospital record further documented "A-9 point review of systems was reviewed with the family member. It is negative with the exception of musculoskeletal. Which is significant for left femur pain." The hospital record also documented "The x- rays of the left femur reveal a fracture of the femoral shaft in the upper one-third. There is displacement and shortening." The hospital record further documented "we will take her this evening for intramedullary nail fixation. I have explained to the family member the risks and benefits of surgery. The risks include bleeding, infection, damage to nerves or blood vessels, failure of the fracture to heal, need for more surgery, heart attack, stroke, and death." Review of the hospital's consultation report dated 9/23/2012 documented the resident was "brought to the emergency department (ED) after she fell . On presentation she was found to have a deformity of her left lower extremity. She was found to have a fracture of the femur. She has since then undergone intramedullary nail fixation of her fracture."Further review of the medical record revealed the resident was admitted at the hospital after the surgery on 9/23/2012. Review of the hospital's Discharge Summary dated 10/1/2012 documented "the resident was admitted to hospital on [DATE], after patient was found to have a left femur fracture. Patient was immediately evaluated by orthopedic services and admitted to their services and had open reduction and internal fixation and had an intramedullary nail placement of the left femur fracture after discussion with family." Further review of the Discharge Summary revealed the resident was discharged from the hospital to another long term care facility on 10/1/2012 Review of Resident #1's medical record revealed the resident had not been readmitted back to the facility. Review of Resident # 1's current care guide dated 2/29/2012 revealed the resident was non- ambulatory, needed a mechanical lift for transfers, and used a bed alarm. Review of the facility 's disciplinary warning dated 9/24/2012 for day Nurse # 1 who was working with Resident # 1 on 9/22/2012 revealed Nurse #1 was disciplined for "failure to notify (DON) Director of Nursing that a resident fell out of bed and sustained an injury. Failure to have resident sent to the hospital in a timely manner. Resident found on floor at 6:45 AM and sent to hospital at 10:00AM due to unable to reach MD (Medical Doctor) per employee. Failure to check alarm and Resident care Guide during rounds. This occurred 9/22/2012." Review of the facility 's disciplinary warning dated 9//25/2012 for night Nurse # 2 revealed Nurse # 2 was disciplined due to Failure to ensure intervention provided for safety in place and functioning properly. Resident fell out of bed and sustained a left femoral fracture. The resident's alarm wasn't connected nor was a floor mat beside the bed. Resident care Guide intervention not implemented." During the interview on 10/2/2012 at 12:30 PM, NA#1 reported that she took care of Resident # 1 on the night of 9/22/2012. NA#1 stated that she checked the resident at 11:00 PM, 1:00 AM and 5:00 AM. NA #1 further added that she did not see the bed alarm on the Resident # 's bed during the times that she checked on her. NA#1 further reported that Resident # 1's Care guide indicated that the resident should have a bed alarm but she did not see one on the day she took care of the resident on 9/22/2012. During a phone interview on 10/2/2012 at 1:00 PM, NA#2 reported she was not assigned to Resident #1 on 9/22/2012 but she was asked by Nurse # 1 to assist in lifting the resident from the floor. NA # 2 added the bed alarm did not go off before or after Resident #1 fell on the floor. She added, the bed alarm cord was disconnected. During the interview on 10/2/2012 at 1:30 PM, NA #3 reported that Resident # 1 was a fall risk per her Care Guide. She added the resident was required to have a bed alarm which she (NA#3) was required to check every day at the beginning of her shift to make sure it was functioning properly. NA#3 was asked whether the resident had a mattress on the floor beside her bed. NA# 3 answered that she had not seen a mattress besides the resident ' s bed. During the phone interview on 10/2/2012 at 1:45 PM, day Nurse # 1 reported she had a loud voice coming from Resident # 1's room in the morning of 9/22/2012. The resident was yelling and was on the floor. Nurse #1 added Resident #1 had just fallen from her bed. Nurse # 1 further reported the bed alarm did not go off before or after the resident fell on the floor. Nurse # 1 also reported she found out the bed alarm cable was not connected all the way while attached beside the bed. Nurse # 1 further added her normal routine was to check the residents ' bed alarms at the facility to make sure they were functioning correctly at the beginning of her shift. She added she did not check Resident # 1's bed alarm at the beginning of the shift on the night of 9/22/2012. Nurse #1 added she did not check Resident #1's bed alarm to make sure it was functioning properly at the beginning of the shift because she was busy with other residents. During the interview on 10/2/2012 at 2:01PM, Nurse # 3 reported that Resident #1 was a fall risk and she had a bed alarm on her bed. Nurse # 3 added at the beginning of the shift her usual practice was to check the Resident # 1's bed alarm to make sure it was functioning properly. Nurse # 3 further reported she did not recall seeing a fall mattress beside Resident # 1's bed. During the interview on 10/2/2012 at 2:30 PM, MDS nurse #1 reported she was responsible for completing the annual assessments at the facility. She added she completed the annual fall risk assessment for Resident # 1 on 6/7/2012 and the resident scored as high risk on her annual fall risk assessment. MDS nurse #1 also added she could not explain why the annual care plan dated 6/7/2012 for Resident # 1 was not updated to include bed alarm, floor mat and a low bed. MDS nurse #1 further reported that she was not responsible for completing the quarterly updates on the care plans at the facility so she could not explain why the quarterly care plan for Resident # 1 dated 8/17/2012 did not include bed alarm, floor mattress and low bed. During the interview on 10/2/2012 at 3:30 PM, MDS nurse # 2 reported she was responsible for completing the residents ' quarterly assessments at the facility. MDS nurse # 2 was asked why the current care plan for Resident # 1 was not updated with the use of bed alarm, low bed and floor mattress. MDS nurse # 2 answered it was an oversight." During a phone interview on 10/2/2012 at 3:45 PM, night Nurse # 2 who was assigned to Resident # 1 on third shift the day the resident fell reported that she did not witness Resident # 1's fall on 9/22/2012. She added the resident had a quiet night. Nurse # 2 added she saw the bed alarm on the resident bed at the beginning of the shift but she did not check to make sure it was functioning properly at the beginning of the shift. Nurse # 2 added the resident had her own private bed which her family member brought from home. She (Nurse # 2) also reported the bed had side rails which did not prevent Resident # 1 from getting out of bed. Nurse # 2 reported the rails were not on the resident's way whenever she tried to get out of bed. She further added the rails were on one side of the bed and the other side of the bed was against the wall. Nurse # 2 further added the resident was normally very confused and she (Resident # 1) thought she could walk. She (Nurse # 4) added she regularly reminded the resident that she could not walk. During the interview with DON on 10/2/2012 at 4:00 PM, she reported her expectation of her staff was to check the residents ' bed alarms at the facility at the beginning of the shift to make sure they were functioning properly. DON further added she expected the third and first shift nurses to have checked Resident #1's bed alarm to make sure it was functioning properly at the beginning of their shifts on the night of 9/22/2012. DON added that disciplinary warning notice was given to the third and first shift nurse for failing to check Resident # 1's bed alarm on 9/22/2012 at the beginning of their shifts to make sure it was functioning properly. DON also reported the resident fell and sustained a left femoral fracture due to the fall on 9/22/2012. The DON further reported that a plan of correction was put in place following Resident # 1 falls on 9/22/2012. She reported the staff at the facility were in serviced on 9/25/2012 in reference to checking bed alarms throughout the facility, audit for bed alarms was completed on 9/25/2012, and order for 15 bed alarms with box and chair alarms with box was made on 9/25/2012. During a phone interview on 10/10/2012 at 9:12AM, the family member reported that she was not made aware by the facility staff that her mother was to have a low bed. Family member stated she was never involved in developing the interventions to prevent falls and injuries. She also added she never saw the mattress on the floor during the times she visited the facility. Family member also reported the bed was positioned against the wall. Report provided by the administrator on 10/10/2012 revealed Resident # 1 utilized her own bed. The report further revealed "the bed remained in a fixed height position- approximately 20 inches from floor. Height was not adjustable. The bed had ? side rails. Bed positioned against the wall (left side rail flush with wall.).She has had her own bed since admission 5/26/11."

Based on resident interview, staff interviews and record review, the facility failed to prevent one (1) of one (1) sampled resident from being abused by a staff. The facility also failed to intervene while witnessing 1 of 1 resident being abused. The resident accused a staff member (NA #1) of shoving, pulling hands and legs, wiping the bottom roughly and removing the catheter. (Resident # 93) Immediate Jeopardy began on 10/30/2011 and was identified on 11/29/2011 at 12:36 PM. Immediate Jeopardy was removed on 11/30/2011 at 6:55 PM, when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) the facility was in the process of full implementation and monitoring their corrective action. Findings include: Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had no short or long term memory problems and had no behavioral problems for the last 3 months. The MDS also documented the resident was completely dependent on staff for all her Activities of Daily Living (ADLs). During the interview on 11/14/2011 at 10:00 AM, Resident #93 stated that Nurse Assistant (NA) #1 was rough with her about 2 weeks ago after requesting to be changed. Resident #93 reported she turned her call light on at around 10:30 PM needing to be changed as a result of a bowel movement She reported that she overheard NA #1 telling Nurse # 1 that she was getting ready to leave so Resident # 93 would have to wait for the next shift (11:00 PM - 7:00 PM) to change her. Nurse #1 who works the second shift (3:00 PM-11:00 PM) told NA # 1 that she still had time to change her ( Resident #93) because it was not 11:00 PM yet. Resident #93 stated NA # 1 came to her room after talking to Nurse #1. The resident further reported NA #1 "shoved" her, pulled her legs and hands. The resident also stated NA#1 was rough when wiping her bottom and caused the catheter to come out. Resident #93 further stated she was very upset about NA #1's behavior, she reported , the incident to Nurse #2 who was also a night shift nurse ( 11:00 PM-7:00 PM). The resident added Nurse # 2 reinserted the catheter. During a telephone interview with Nurse #2 on 11/15/2011 at 9:30 AM, she stated she came to work two weeks ago at 10:40 PM. It was about 10:45 PM when she noticed Resident #93's call light was on. She found out the resident needed to be changed as reported by NA #1. Nurse #2 further reported NA #1 was ready to leave after working her 3:00 PM- 11: 00 PM shift. She (NA#1) was asked by Nurse # 1 who was also at the nurses' station to go and assist Resident #93. NA #1 was upset when she was told by Nurse #1 that she (NA #1) still had time to change Resident #93. Nurse #2 further reported that, from her location at the nurses ' station which is approximately 12 feet from this resident ' s room, she heard Resident #93 calling for assistance hollering "Nurse! Nurse!" as soon as NA #1 had left the room. Nurse #2 stated she went to Resident #93' s room to find out what she needed. Resident #93 reported to her that NA #1 was rough when wiping her bottom and had caused the catheter to come out. Resident #93 also reported that NA#1 "shoved" her, pulled her hands and legs. Nurse #2 further stated she looked at the resident's bottom to see whether the catheter had come out and she discovered that it had come out with the balloon still inflated. She reinserted a new catheter back into Resident #93. She (Nurse #2) added she reported the incident to the Assistant Director of Nursing (ADON) the next morning. During the interview on 11/15/2011 at 4:00 PM, Nurse #1 reported that NA #1 was known to have a bad attitude and there had been a lot of complains about NA#1. Nurse # 1 reported that the night of 11/6/2011, she was getting ready to leave after working the second shift (3: 00 PM- 11:00 PM). NA #1 came to her reporting that she did not have the time to change Resident #93 because the resident asked to be changed when it was almost towards the end of the shift. Nurse#1 reported that she told NA #1 that it was only 10:50 PM; she still had plenty of time to change the resident. Nurse #1 further reported NA#1 slammed the nursing station door as she went to Resident #93' s room. During a follow up interview with Resident #93 on 11/15/2011 at 5: 25 PM, she stated that on the night of the incident, NA #1 was working with NA # 2 .Resident # 93 stated that she turned on her call light at about 10:30 PM, and it was answered at about 10:50 PM. Resident stated that NA# 2 came to her room and made a statement that "why did you wait until it was time for the second shift staff to leave to put on your call light?" The resident added NA #2 made a statement that she (Resident #93) would have to wait for the next (third) shift to come in to change her. Resident # 93 added NA #2 went and told NA#1 that she (Resident #93) needed to be changed. NA #1 went to Nurse # 1 who was the night shift (3: 00 PM- 11:00 PM) to complain that she (Resident #93) needed to be changed but it was almost end of the shift. Nurse #1 told NA # 1 that it was not 11: 00 PM yet, and that she could still change her (Resident # 93). Resident # 93 stated that NA #1 came into the room with NA# 2. She (Resident # 93) added NA#1 shoved her over by pulling and pushing her legs, and was wiping her bottom really rough as if she was scrubbing the floor. Resident # 93 stated she was yelling in pain "Ouch! Ouch! Ouch!" The resident further stated NA #1 was chewing on a straw and did not say anything. She( Resident # 93) added "I felt disgusted, my feelings were hurt. My pain was worse. I was not crying, I was saying Ouch! Ouch! To let them know they were hurting me. My catheter came out." The resident reported that when Nurse # 2 came in on the 11:00 PM-7: 00 PM shift, she found her upset and also found that the catheter had come out. Nurse # 2 reinserted a new catheter. The resident also added she would never allow NA #1 and NA #2 to change her or give her any kind of care after the incident. During the interview with NA #1 on 11/15/2011 at 5:40 PM, she reported she went to change the resident on the night of 10/30/2011 and she did not say anything to the resident. NA # 1added she just changed the resident and left the room. During a follow up interview on 11/16/2011 at 10:30 AM, Nurse #2 reported that NA #1 came in about 10:45 PM and stated to her and Nurse # 1 that Resident #93 wanted to be changed. Nurse #1 looked at her watch and stated to NA #1 that "it was not 11: 00 PM, go and change Resident #93." NA #1 went to Resident # 93's room and after she (NA # 1) left the resident's room, Resident #93 called her (Nurse # 2) and stated that she did not want NA # 1 to touch her again; NA # 1 was very rough with her by shoving her over. Resident # 93 further stated to Nurse #2 that NA#1 was rough when wiping her bottom and caused the catheter to come out. When she (Nurse # 2) looked under the resident ' s bottom; it was true that the catheter was out. Nurse #2 stated that she was able to reinsert the resident' s catheter back. During the interview with NA #2 on 11/16/2011 at 10:00 AM, she reported that she assisted NA #1 to change Resident # 93. She added she did not recall Resident # 93 being upset. The administrator was notified of the immediate jeopardy on 11/30/2011 at 9:15 AM. The facility provided an allegation of compliance on 11/30/2011 at 6:55 PM. The allegation of compliance indicated: What corrective action will be accomplished for those residents affected by the deficient practice? ? Resident #93 assessed and interviewed upon notification of her concern. 11-15-11 ? Resident was interview by the Social Worker on 11-15-11. ? Resident re-interviewed by the Social Worker on 11-16-11. ? 24 hour report initiated. 11-15-11 by the Director of Nursing. ? NA #1, and NA#2 were suspended from employment after urine screens obtained. 11-15-11 by Director of Nursing. ? NA #1 with allegation of physical abuse reported by the facility to the Fayetteville Police Department. 11-15-11 by Facility Administrator. ? 5 day report completed and NA#1, and NA#2 were terminated from employment. 11-18-11 by Director of Nursing. ? Administrator/Director of Nursing re-in serviced on reporting abuse neglect and prevention of abuse neglect. 11-18-11 by Regional Vice President of Operations ? Re-training of Department Heads on Abuse/Neglect- prevention and reporting, Elder Justice Act, and Resident Concern Process. 11-18-11 by Facility Administrator. ? Re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. 11-18-11 by Facility Administrator. ? 2nd re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. Elder Justice Act, Resident Concern Process, 24/5 reporting process and to include new forms. 11-18-11 by Facility Administrator. ? Retraining of all staff on Abuse/Neglect-prevention and reporting process. (to include Nurses, Nurse ' s Aides, Housekeeping, Dietary, Administrative Staff, Maintenance, and Contracted Services) 11-22-11 by Administrator, Director of Nurses, and Staff Development Coordinator. ? Interviewable residents were interviewed for potential resident concerns related to potential abuse. 11-16-11 for that resident and other interviewable residents on that hall by Social Worker. Activities Director assisted with completion of interviews on 11-19-11. What corrective action will be accomplished for those residents having potential to be affected by the same deficient practice? ? Administrator/Director of Nursing Services re-in serviced on Reporting Abuse & Neglect, ? Preventing Abuse & Neglect, Training all facility on Reporting Abuse Neglect, and Prevention of abuse and Neglect. 11-18-11 by Regional Vice President of Operations. ? Re-training of Department Heads on Abuse/Neglect- prevention and reporting. Elder Justice Act, Resident Concern Process. 11-18-11 by Administrator. ? Re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. - ? 11-18-11 by Administrator. ? 2nd re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process ? Elder Justice Act, Resident Concern Process, 24/5 reporting process and to include new forms. 11-18-11 by Administrator. ? All new hires will be in-serviced, during orientation, on abuse/neglect and reporting by Staff Development Coordinator or designee. ? Interviewable residents were interviewed for potential resident concerns- 11-16-11 for that resident and other interviewable residents on that hall. On 11-19-11 all other residents in facility by Social Worker & Activities Director. ? Retraining of all staff on Abuse/Neglect - prevention and reporting process. (to include Nurses, Nurse ' s Aides, Housekeeping, and Dietary. Administrative Staff, Maintenance, and Contracted Services) 11-22-11 by Administrator, Director of Nursing Services, and Staff Development Coordinator. ? Monitor non-interviewable residents for changes that would deviate from their normal behavior ; ( done by using resident census-walking rounds tool) by Social Worker and Activities Director. What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not occur: ? Administrator/Director of Nursing Services re-inserviced on Reporting Abuse & Neglect, Preventing Abuse & Neglect, Training all facility & on Reporting Abuse Neglect, and Prevention of abuse and Neglect. 11-18-11 by Regional Vice President of Operations. ? Re-training of Department Heads on Abuse/Neglect- prevention and reporting, Elder Justice Act, Resident Concern Process. 11-18-11 by Facility Administrator. ? Re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. ? 11-18-11 by Facility Administrator. ? 2nd re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. Elder Justice Act, Resident Concern Process, 24/5 reporting process to include new forms. 11-18-11 by Facility Administrator. ? Department Head Meeting Agenda will include the administrator asking the department heads: " Has anyone made you aware of any reports of abuse/neglect? " ? All new hires will be in-serviced, during orientation, on abuse/neglect and reporting by Staff Development Coordinator or designee by Staff Development Coordinator or Designee. ? All staff, including new hires, will be in-serviced on recognizing " Burn Out " and signs of aggression, seeking assistance, and reporting to supervisor any co-workers who may be showing signs of " Burn Out " by Staff Development Coordinator or designee. ? Re-Training on Abuse/Neglect- prevention and reporting process. (to include Nurses, Nurse ' s Aides, Housekeeping, Dietary, Administrative Staff, Maintenance, and Contracted Services) 11-22-11 by Administrator, Director of Nursing Services, and Staff Development Coordinator) ? Resident Care Audits will be done by Administrative Nurses to observe preservation of resident dignity, and absence of care giver burn out, abuse and neglect. (To include all three shifts, Nurse and Nurse Aides)-3 per week on each shift x4 weeks- then weekly x3 months- and reviewed at the Quarterly QI meeting. ? Monitor non-interviewable residents for changes that would deviate from their normal behavior; (done by using resident census-walking rounds tool) by Administrative Nursing staff or designee. Monitoring: ? Re-inservice on Abuse/Neglect prevention. 100% of staff in all departments(to include all 3 shifts Nurses, Nurse Aides, Housekeeping, Dietary, Maintenance, and Contract Employees) by Designated Administrative Staff. Will be done every two weeks x3, then monthly x3, then quarterly by Administrative Nursing Staff or designee. ? Resident interviews for potential concerns weekly x4 weeks then monthly x3, then quarterly by Social Worker or designee. Results will be reviewed at the Quarterly QI Meeting . ? Random staff interviews ( 5 staff members) weekly x4 weeks, then monthly x3, then quarterly. Interviews will cover questions relating to recognition and reporting of abuse/neglect and " Burn Out " by Administrative Nursing Staff or designee. Results will be reviewed at the Quarterly QI Meeting. ? Daily monitoring of staff to observe for signs of burn-out/aggression utilizing a QI tool.(will include all three shifts, Nurses, Nurse ' s Aides, Dietary, Housekeeping, Administrative Staff, Maintenance, and Contract Employees) by Administrative Nursing staff and or designee. ? Resident Care Audits will be done by Administrative Nurses to observe the preservation of resident dignity, and absence of care giver burn out, abuse and neglect. ( To include all three shifts, Nurses and Nurse Aides)- 3 per week on each shift x4 weeks- then weekly x3 months- and reviewed at the Quartely QI meeting. ? Non-interviewable resident audit tool will be done by Administrative Staff or designee ( all non-interviewable resident weekly x4 weeks, then monthly x3, then quarterly . Results reviewed at the Quarterly QI meeting. 11-30-11 Compliance date: 11/30/2011 All new hires will be in-serviced, during orientation, on abuse/neglect and reporting. On 11/30/2011 at 7:00 PM, verification of the credible allegation was evidenced by interviews of direct care staff related to mandatory reeducation on abuse, review of the new "Abuse Prohibition Training " packet dated 11/22/2011, review of in-service rosters on reeducation of staff on abuse, review of disciplinary actions delivered to all staff involved in the incident on 10/30/2011, that included ADON, NA #1 and NA#2 being terminated from their job positions. All direct care staff reported they received reeducation on abuse, the importance of reporting and protecting the residents at the facility.

Based on Resident interview, staff interview and review of facility records, the facility failed to submit a twenty-four hour report and complete five day report to the state agency for one (1) of one (1) sampled resident who reported an allegation of rough handling by staff. (Resident #93) Immediate Jeopardy began on 10/30/2011 and was identified on 11/29/2011 at 12:36 PM. Immediate Jeopardy was removed on 11/30/2011 at 6:55 PM, when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) the facility was in the process of full implementation and monitoring their corrective action. Findings include: Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had no short or long term memory problems and had no behavioral problems for the last 3 months. The MDS also documented the resident was completely dependent on staff for all her Activities of Daily Living (ADLs). During the interview on 11/14/2011 at 10:00 AM, Resident #93 stated that Nurse Assistant (NA) #1 was rough with her about 2 weeks ago after requesting to be changed. Resident #93 reported she turned her call light on at around 10:30 PM needing to be changed as a result of a bowel movement She reported that she overheard NA #1 telling Nurse #1 that she was getting ready to leave so Resident #93 would have to wait for the next shift (11:00 PM - 7:00 PM) to change her. Nurse # 1 who works the second shift (3:00 PM-11:00 PM) told NA # 1 that she still had time to change her ( Resident #93) because it was not 11:00 PM yet. Resident # 93 stated NA # 1 came to her room after talking to Nurse #1. The resident further reported NA #1 "shoved" her, pulled her legs and hands. The resident also stated NA#1 was rough when wiping her bottom and caused the catheter to come out. Resident #93 further stated she was very upset about NA #1' s behavior, she reported , the incident to Nurse #2 who was also a night shift nurse ( 11:00 PM-7:00 PM). The resident added Nurse #2 reinserted the catheter. And told her she was going to report the incident to Assistant Director of Nursing (ADON), who will come to speak with her about the incident. The resident added the ADON or any other member of the facility had not come to speak with her about the incident by the time of this interview. During the interview with ADON on 11/15/2011 at 8:55 AM, she was asked whether it had been reported to her about Resident #93 being handled roughly by NA#1. ADON stated, "I heard something about verbal confrontation between Resident # 93 and NA #1. I don't remember the specifics. I thought Nurse #2 who works night shift (11: 00 PM- 7:00 PM) had done something about it." The ADON added "I just thought it was hearsay." The ADON was asked about the facility's policy on investigation of allegation of abuse of the residents' at the facility. The ADON reported that any allegation of abuse of a resident was to be reported to her and she was to start the investigation immediately by suspending the staff and then writing a 24 hours report, 5 days report then faxing the report to the state agency. During the interview with the Director of Nursing (DON) on 11/15/2011 at 9:00 AM, she stated no one had reported to her about Resident # 93 being handled roughly by NA #1. She (DON) further stated her expectation was for any allegation of abuse to be investigated immediately. She further added that usually the ADON was notified first about an allegation of abuse and the expectation was for the ADON to begin the investigation immediately. During a telephone interview with Nurse # 2 who works third shift (11:00 PM- 7:00 PM) on 11/15/2011 at 9:30 AM, she stated she came to work on the night of the incident at 10:40 PM. It was about 10:45 PM when she noticed Resident # 93's call light was on. She found out the resident needed to be changed. NA #1 was ready to leave after working her 3:00 PM- 11: 00 PM shift. She(NA#1) was asked by Nurse # 1 who was also at the nurse ' s station to go and assist Resident # 93. NA #1 was upset when she was told by Nurse# 1 that she still had time to change Resident # 93. Nurse #2 further reported that she heard Resident # 93 calling for assistance yelling "Nurse! Nurse!" as soon as NA #1 had left the room. Nurse #2 stated she went to Resident # 93 ' s room to find out what she needed. Resident # 93 reported to her that NA # 1 was rough when wiping her bottom and had caused the catheter to come out. Resident #93 also reported that NA#1 "shoved " her, pulled her hands and legs. Nurse #2 further stated she looked at the resident ' s bottom to see whether the catheter had come out. She reinserted a new catheter back. She (Nurse #2) added she reported the incident to the ADON the next morning. The administrator was notified of the immediate jeopardy on 11/30/2011 at 9:15 AM. The facility provided an allegation of compliance on 11/30/2011 at 6:55 PM. The allegation of compliance indicated: What corrective action will be accomplished for those residents affected by the deficient practice? ? Resident #93 assessed and interviewed upon notification of her concern. 11-15-11 ? Resident was interview by the Social Worker on 11-15-11. ? Resident re-interviewed by the Social Worker on 11-16-11. ? 24 hour report initiated. 11-15-11 by the Director of Nursing. ? NA #1, and NA#2 were suspended from employment after urine screens obtained. 11-15-11 by Director of Nursing. ? NA #1 with allegation of physical abuse reported by the facility to the Fayetteville Police Department. 11-15-11 by Facility Administrator. ? 5 day report completed and NA#1, and NA#2 were terminated from employment. 11-18-11 by Director of Nursing. ? Administrator/Director of Nursing re-in serviced on reporting abuse neglect and prevention of abuse neglect. 11-18-11 by Regional Vice President of Operations ? Re-training of Department Heads on Abuse/Neglect- prevention and reporting, Elder Justice Act, and Resident Concern Process. 11-18-11 by Facility Administrator. ? Re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. 11-18-11 by Facility Administrator. ? 2nd re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. Elder Justice Act, Resident Concern Process, 24/5 reporting process and to include new forms. 11-18-11 by Facility Administrator. ? Retraining of all staff on Abuse/Neglect-prevention and reporting process. (to include Nurses, Nurse ' s Aides, Housekeeping, Dietary, Administrative Staff, Maintenance, and Contracted Services) 11-22-11 by Administrator, Director of Nurses, and Staff Development Coordinator. ? Interviewable residents were interviewed for potential resident concerns related to potential abuse. 11-16-11 for that resident and other interviewable residents on that hall by Social Worker. Activities Director assisted with completion of interviews on 11-19-11. What corrective action will be accomplished for those residents having potential to be affected by the same deficient practice? ? Administrator/Director of Nursing Services re-in serviced on Reporting Abuse & Neglect, ? Preventing Abuse & Neglect, Training all facility on Reporting Abuse Neglect, and Prevention of abuse and Neglect. 11-18-11 by Regional Vice President of Operations. ? Re-training of Department Heads on Abuse/Neglect- prevention and reporting. Elder Justice Act, Resident Concern Process. 11-18-11 by Administrator. ? Re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. - ? 11-18-11 by Administrator. ? 2nd re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process ? Elder Justice Act, Resident Concern Process, 24/5 reporting process and to include new forms. 11-18-11 by Administrator. ? All new hires will be in-serviced, during orientation, on abuse/neglect and reporting by Staff Development Coordinator or designee. ? Interviewable residents were interviewed for potential resident concerns- 11-16-11 for that resident and other interviewable residents on that hall. On 11-19-11 all other residents in facility by Social Worker & Activities Director. ? Retraining of all staff on Abuse/Neglect - prevention and reporting process. (to include Nurses, Nurse ' s Aides, Housekeeping, and Dietary. Administrative Staff, Maintenance, and Contracted Services) 11-22-11 by Administrator, Director of Nursing Services, and Staff Development Coordinator. ? Monitor non-interviewable residents for changes that would deviate from their normal behavior ; ( done by using resident census-walking rounds tool) by Social Worker and Activities Director. What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not occur: ? Administrator/Director of Nursing Services re-inserviced on Reporting Abuse & Neglect, Preventing Abuse & Neglect, Training all facility & on Reporting Abuse Neglect, and Prevention of abuse and Neglect. 11-18-11 by Regional Vice President of Operations. ? Re-training of Department Heads on Abuse/Neglect- prevention and reporting, Elder Justice Act, Resident Concern Process. 11-18-11 by Facility Administrator. ? Re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. ? 11-18-11 by Facility Administrator. ? 2nd re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. Elder Justice Act, Resident Concern Process, 24/5 reporting process to include new forms. 11-18-11 by Facility Administrator. ? Department Head Meeting Agenda will include the administrator asking the department heads: " Has anyone made you aware of any reports of abuse/neglect? " ? All new hires will be in-serviced, during orientation, on abuse/neglect and reporting by Staff Development Coordinator or designee by Staff Development Coordinator or Designee. ? All staff, including new hires, will be in-serviced on recognizing " Burn Out " and signs of aggression, seeking assistance, and reporting to supervisor any co-workers who may be showing signs of " Burn Out " by Staff Development Coordinator or designee. ? Re-Training on Abuse/Neglect- prevention and reporting process. (to include Nurses, Nurse ' s Aides, Housekeeping, Dietary, Administrative Staff, Maintenance, and Contracted Services) 11-22-11 by Administrator, Director of Nursing Services, and Staff Development Coordinator) ? Resident Care Audits will be done by Administrative Nurses to observe preservation of resident dignity, and absence of care giver burn out, abuse and neglect. (To include all three shifts, Nurse and Nurse Aides)-3 per week on each shift x4 weeks- then weekly x3 months- and reviewed at the Quarterly QI meeting. ? Monitor non-interviewable residents for changes that would deviate from their normal behavior; (done by using resident census-walking rounds tool) by Administrative Nursing staff or designee. Monitoring: ? Re-inservice on Abuse/Neglect prevention. 100% of staff in all departments(to include all 3 shifts Nurses, Nurse Aides, Housekeeping, Dietary, Maintenance, and Contract Employees) by Designated Administrative Staff. Will be done every two weeks x3, then monthly x3, then quarterly by Administrative Nursing Staff or designee. ? Resident interviews for potential concerns weekly x4 weeks then monthly x3, then quarterly by Social Worker or designee. Results will be reviewed at the Quarterly QI Meeting . ? Random staff interviews ( 5 staff members) weekly x4 weeks, then monthly x3, then quarterly. Interviews will cover questions relating to recognition and reporting of abuse/neglect and " Burn Out " by Administrative Nursing Staff or designee. Results will be reviewed at the Quarterly QI Meeting. ? Daily monitoring of staff to observe for signs of burn-out/aggression utilizing a QI tool.(will include all three shifts, Nurses, Nurse ' s Aides, Dietary, Housekeeping, Administrative Staff, Maintenance, and Contract Employees) by Administrative Nursing staff and or designee. ? Resident Care Audits will be done by Administrative Nurses to observe the preservation of resident dignity, and absence of care giver burn out, abuse and neglect. ( To include all three shifts, Nurses and Nurse Aides)- 3 per week on each shift x4 weeks- then weekly x3 months- and reviewed at the Quartely QI meeting. ? Non-interviewable resident audit tool will be done by Administrative Staff or designee ( all non-interviewable resident weekly x4 weeks, then monthly x3, then quarterly . Results reviewed at the Quarterly QI meeting. 11-30-11 Compliance date: 11/30/2011 All new hires will be in-serviced, during orientation, on abuse/neglect and reporting. On 11/30/2011 at 7:00 PM, verification of the credible allegation was evidenced by interviews of direct care staff related to mandatory reeducation on abuse, review of the new "Abuse Prohibition Training " packet dated 11/22/2011, review of in-service rosters on reeducation of staff on abuse, review of disciplinary actions delivered to all staff involved in the incident on 10/30/2011, that included ADON, NA #1 and NA#2 being terminated from their job positions. All direct care staff reported they received reeducation on abuse, the importance of reporting and protecting the residents at the facility.

Based on resident interview, staff interviews and facility policy review, the facility failed to implement their policies and procedures to identify, protect, investigate, and report allegations of rough handling by staff for one ( 1 )of one (1 )sampled resident. (Resident # 93) Immediate Jeopardy began on 10/30/2011 and was identified on 11/29/2011 at 12:36 PM. Immediate Jeopardy was removed on 11/30/2011 at 6:55 PM, when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) the facility was in the process of full implementation and monitoring their corrective action. Findings include: Facility policy titled "ABUSE, NEGLECT,OR MISAPPROPRIATION OF RESIDENT PROPERTY POLICY "dated 2/2009 documented staff would be trained about the abuse policies during orientation and retraining programs for employees will be conducted on a regular basis. Training would include how staff report their knowledge related to allegation without fear of reprisal, what constitutes abuse, neglect, and misappropriation of resident property. The facility policy also documented that abuse prevention program includes: 1- Investigation of all incidents, complaints and allegation of abuse 2- Protection of residents during investigation, 3- Reporting and responding to the outcome of investigation. Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had no short or long term memory problems and had no behavioral problems for the last 3 months. The MDS also documented the resident was completely dependent on staff for all her Activities of Daily Living (ADLs). During the interview on 11/14/2011 at 10:00 AM, Resident #93 stated that Nurse Assistant (NA) #1 was rough with her about 2 weeks ago after requesting to be changed. Resident #93 reported she turned her call light on at around 10:30 PM needing to be changed as a result of a bowel movement She reported that she overheard NA #1 telling Nurse # 1 that she was getting ready to leave so Resident # 93 would have to wait for the next shift (11:00 PM - 7:00 PM) to change her. Nurse # 1 who works the second shift (3:00 PM-11:00 PM) told NA # 1 that she still had time to change her ( Resident #93) because it was not 11:00 PM yet. Resident #93 stated NA #1 came to her room after talking to Nurse #1. The resident further reported NA #1 "shoved" her, pulled her legs and hands. The resident also stated NA#1 was rough when wiping her bottom and caused the catheter to come out. Resident #93 further stated she was very upset about NA #1's behavior, she reported , the incident to Nurse #2 who was also a night shift nurse ( 11:00 PM-7:00 PM). The resident added Nurse # 2 reinserted the catheter and told her she was going to report the incident to Assistant Director of Nursing (ADON), who will come to speak with her about the incident. The resident added the ADON or any other member of the facility had not come to speak with her about the incident by the time of this interview. During the interview with ADON on 11/15/2011 at 8:55 AM, she was asked whether it had been reported to her about Resident # 93 being handled roughly by NA #1. ADON stated, "I heard something about verbal confrontation between Resident # 93 and NA # 1. I don't remember the specifics. I thought Nurse #2 who works night shift (11: 00 PM- 7:00 PM) had done something about it." The ADON added "I just thought it was hearsay." The ADON was asked about the facility's policy on investigation of allegation of abuse of the residents' at the facility. The ADON reported that any allegation of abuse of a resident was to be reported to her and she was to start the investigation immediately by suspending the staff and then writing a 24 hours report, 5 days report then faxing the report to the state agency. During the interview with the Director of Nursing (DON) on 11/15/2011 at 9:00 AM, she stated no one had reported to her about Resident # 93 being handled roughly by NA #1. She (DON) further stated her expectation was for any allegation of abuse to be investigated immediately. She further added that usually the ADON was notified first about an allegation of abuse and the expectation was for the ADON to begin the investigation immediately. During a telephone interview with Nurse #2 who works third shift (11:00 PM- 7:00 PM) on 11/15/2011 at 9:30 AM, she stated she came to work on 10/30/2011 at 10:40 PM. It was about 10:45 PM when she noticed Resident #93's call light was on. She found out the resident needed to be changed. NA #1 was ready to leave after working her 3:00 PM- 11: 00 PM shift. She(NA#1) was asked by Nurse # 1 who was also at the nurse's station to go and assist Resident #93. NA #1 was upset when she was told by Nurse #1 that she still had time to change Resident #93. Nurse #2 further reported that she heard Resident #93 calling for assistance yelling "Nurse! Nurse!" as soon as NA # 1 had left the room. Nurse # 2 stated she went to Resident # 93''s room to find out what she needed. Resident #93 reported to her that NA #1 was rough when wiping her bottom and had caused the catheter to come out. Resident #93 also reported that NA#1 "shoved " her, pulled her hands and legs. Nurse #2 further stated she looked at the resident's bottom to see whether the catheter had come out with the balloon still inflated. She reinserted a new catheter back. She (Nurse #2) added she reported the incident to the ADON the next morning. During a follow up interview with Resident #93 on 11/15/2011 at 5: 25 PM, she stated that on the night of the incident, NA #1 was working with NA #2 .Resident #93 stated that she turned on her call light at about 10:30 PM, and it was answered at about 10:50 PM. Resident stated that NA #2 came to her room and made a statement that " why did you wait until it was time for the second shift staff to leave to put on your call light? " The resident added NA#2 made a statement that she (Resident #93) would have to wait for the next (third) shift to come in to change her. Resident #93 added NA #2 went and told NA #1 that she (Resident #93) needed to be changed. NA #1 went to Nurse # 1 who was the night shift (3: 00 PM- 11:00 PM) to complain that she (Resident #93) needed to be changed but it was almost end of the shift. Nurse #1 told NA # 1 that it was not 11: 00 PM yet, and that she could still change her (Resident #93). Resident #93 stated that NA #1 came into the room with NA #2. She (Resident #93) added NA#1 shoved her over by pulling and pushing her legs, and was wiping her bottom really rough as if she was scrubbing the floor. Resident # 93 stated she was yelling in pain "Ouch! Ouch! Ouch!" The resident further stated NA #1 was chewing on a straw and did not say anything. She (Resident #93) added "I felt disgusted, my feelings were hurt. My pain was worse. I was not crying, I was saying Ouch! Ouch! To let them know they were hurting me. My catheter came out." The resident reported that when Nurse #2 came in on the 11:00 PM-7: 00 PM shift, she reinserted a new catheter. The resident also added she would never allow NA #1 and NA #2 to change her or give her any kind of care after the incident. The administrator was notified of the immediate jeopardy on 11/30/2011 at 9:15 AM. The facility provided an allegation of compliance on 11/30/2011 at 6:55 PM. The allegation of compliance indicated: What corrective action will be accomplished for those residents affected by the deficient practice? ? Resident #93 assessed and interviewed upon notification of her concern. 11-15-11 ? Resident was interview by the Social Worker on 11-15-11. ? Resident re-interviewed by the Social Worker on 11-16-11. ? 24 hour report initiated. 11-15-11 by the Director of Nursing. ? NA #1, and NA#2 were suspended from employment after urine screens obtained. 11-15-11 by Director of Nursing. ? NA #1 with allegation of physical abuse reported by the facility to the Fayetteville Police Department. 11-15-11 by Facility Administrator. ? 5 day report completed and NA#1, and NA#2 were terminated from employment. 11-18-11 by Director of Nursing. ? Administrator/Director of Nursing re-in serviced on reporting abuse neglect and prevention of abuse neglect. 11-18-11 by Regional Vice President of Operations ? Re-training of Department Heads on Abuse/Neglect- prevention and reporting, Elder Justice Act, and Resident Concern Process. 11-18-11 by Facility Administrator. ? Re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. 11-18-11 by Facility Administrator. ? 2nd re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. Elder Justice Act, Resident Concern Process, 24/5 reporting process and to include new forms. 11-18-11 by Facility Administrator. ? Retraining of all staff on Abuse/Neglect-prevention and reporting process. (to include Nurses, Nurse ' s Aides, Housekeeping, Dietary, Administrative Staff, Maintenance, and Contracted Services) 11-22-11 by Administrator, Director of Nurses, and Staff Development Coordinator. ? Interviewable residents were interviewed for potential resident concerns related to potential abuse. 11-16-11 for that resident and other interviewable residents on that hall by Social Worker. Activities Director assisted with completion of interviews on 11-19-11. What corrective action will be accomplished for those residents having potential to be affected by the same deficient practice? ? Administrator/Director of Nursing Services re-in serviced on Reporting Abuse & Neglect, ? Preventing Abuse & Neglect, Training all facility on Reporting Abuse Neglect, and Prevention of abuse and Neglect. 11-18-11 by Regional Vice President of Operations. ? . Re-training of Department Heads on Abuse/Neglect- prevention and reporting. Elder Justice Act, Resident Concern Process. 11-18-11 by Administrator. ? Re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. - ? 11-18-11 by Administrator. ? 2nd re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process ? Elder Justice Act, Resident Concern Process, 24/5 reporting process and to include new forms. 11-18-11 by Administrator. ? All new hires will be in-serviced, during orientation, on abuse/neglect and reporting by Staff Development Coordinator or designee. ? Interviewable residents were interviewed for potential resident concerns- 11-16-11 for that resident and other interviewable residents on that hall. On 11-19-11 all other residents in facility by Social Worker & Activities Director. ? Retraining of all staff on Abuse/Neglect - prevention and reporting process. (to include Nurses, Nurse ' s Aides, Housekeeping, and Dietary. Administrative Staff, Maintenance, and Contracted Services) 11-22-11 by Administrator, Director of Nursing Services, and Staff Development Coordinator. ? Monitor non-interviewable residents for changes that would deviate from their normal behavior ; ( done by using resident census-walking rounds tool) by Social Worker and Activities Director. What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not occur: ? Administrator/Director of Nursing Services re-inserviced on Reporting Abuse & Neglect, Preventing Abuse & Neglect, Training all facility & on Reporting Abuse Neglect, and Prevention of abuse and Neglect. 11-18-11 by Regional Vice President of Operations. ? Re-training of Department Heads on Abuse/Neglect- prevention and reporting, Elder Justice Act, Resident Concern Process. 11-18-11 by Facility Administrator. ? Re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. ? 11-18-11 by Facility Administrator. ? 2nd re-training of Administrative Nurses- Abuse/Neglect-prevention and reporting process. Elder Justice Act, Resident Concern Process, 24/5 reporting process to include new forms. 11-18-11 by Facility Administrator. ? Department Head Meeting Agenda will include the administrator asking the department heads: " Has anyone made you aware of any reports of abuse/neglect? " ? All new hires will be in-serviced, during orientation, on abuse/neglect and reporting by Staff Development Coordinator or designee by Staff Development Coordinator or Designee. ? All staff, including new hires, will be in-serviced on recognizing " Burn Out " and signs of aggression, seeking assistance, and reporting to supervisor any co-workers who may be showing signs of " Burn Out " by Staff Development Coordinator or designee. ? Re-Training on Abuse/Neglect- prevention and reporting process. (to include Nurses, Nurse ' s Aides, Housekeeping, Dietary, Administrative Staff, Maintenance, and Contracted Services) 11-22-11 by Administrator, Director of Nursing Services, and Staff Development Coordinator) ? Resident Care Audits will be done by Administrative Nurses to observe preservation of resident dignity, and absence of care giver burn out, abuse and neglect. (To include all three shifts, Nurse and Nurse Aides)-3 per week on each shift x4 weeks- then weekly x3 months- and reviewed at the Quarterly QI meeting. ? Monitor non-interviewable residents for changes that would deviate from their normal behavior; (done by using resident census-walking rounds tool) by Administrative Nursing staff or designee. Monitoring: ? Re-inservice on Abuse/Neglect prevention. 100% of staff in all departments(to include all 3 shifts Nurses, Nurse Aides, Housekeeping, Dietary, Maintenance, and Contract Employees) by Designated Administrative Staff. Will be done every two weeks x3, then monthly x3, then quarterly by Administrative Nursing Staff or designee. ? Resident interviews for potential concerns weekly x4 weeks then monthly x3, then quarterly by Social Worker or designee. Results will be reviewed at the Quarterly QI Meeting . ? Random staff interviews ( 5 staff members) weekly x4 weeks, then monthly x3, then quarterly. Interviews will cover questions relating to recognition and reporting of abuse/neglect and " Burn Out " by Administrative Nursing Staff or designee. Results will be reviewed at the Quarterly QI Meeting. ? Daily monitoring of staff to observe for signs of burn-out/aggression utilizing a QI tool.(will include all three shifts, Nurses, Nurse ' s Aides, Dietary, Housekeeping, Administrative Staff, Maintenance, and Contract Employees) by Administrative Nursing staff and or designee. ? Resident Care Audits will be done by Administrative Nurses to observe the preservation of resident dignity, and absence of care giver burn out, abuse and neglect. ( To include all three shifts, Nurses and Nurse Aides)- 3 per week on each shift x4 weeks- then weekly x3 months- and reviewed at the Quartely QI meeting. ? Non-interviewable resident audit tool will be done by Administrative Staff or designee ( all non-interviewable resident weekly x4 weeks, then monthly x3, then quarterly . Results reviewed at the Quarterly QI meeting. 11-30-11 Compliance date: 11/30/2011 All new hires will be in-serviced, during orientation, on abuse/neglect and reporting. On 11/30/2011 at 7:00 PM, verification of the credible allegation was evidenced by interviews of direct care staff related to mandatory reeducation on abuse, review of the new "Abuse Prohibition Training" packet dated 11/22/2011, review of in-service rosters on reeducation of staff on abuse, review of disciplinary actions delivered to all staff involved in the incident on 10/30/2011, that included ADON, NA #1 and NA#2 being terminated from their job positions. All direct care staff reported they received reeducation on abuse, the importance of reporting and protecting the residents at the facility.