Every finding on record at The Carrolton of Lumberton

Based on observations, record review, and interviews with resident, staff, Pharmacy Director and Nurse Practitioner, the facility failed to protect the residents' right to be free from misappropriation of narcotic pain medications (Tramadol, Hydrocodone-Acetaminophen, Oxycodone, and Oxycodone-Acetaminophen) for 9 of 9 residents reviewed for misappropriation of controlled medications (Residents #21, #2, #16, #34, #43, #52, #69, #79, and #87). Findings included: a.) Resident #21 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive and debility. A physician's order with a start date of 10/16/23 which remained as an active order for Resident #21 revealed Tramadol 50 milligrams (mg) tablets, one tablet by mouth two times a day for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/27/25 at 7:09 PM a total of 30 Tramadol 50 mg tablets for Resident #21 were delivered to the facility. The delivery receipt was signed off as received by Nurse #1, a night shift nurse, on 10/28/25. There was no signature on the delivery sheet from a second nurse. Attempts were made to contact Nurse #1 on 2/12/26 and 2/13/26 with no response. There was no declining count sheet (an inventory log used to record a running total for each controlled medication) found for the 30 Tramadol 50 mg tablets that were delivered to the facility on [DATE] for Resident #21. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #21 was cognitively intact. During an observation on 2/13/26 at 4:30 PM Resident #21 was observed sitting in her room in a wheelchair with her eyes closed. She showed no signs or symptoms of distress/pain. b.) Resident #2 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (narrowed or blocked blood vessels, typically affecting legs and feet, that can cause pain and cramping in the leg muscles). A physician's order with a start date of 1/1/25 which remained as an active order for Resident #2 revealed oxycodone 5 mg tablets, one tablet by mouth every six hours as needed for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 8/10/25 at 5:04 PM a total of 60 oxycodone 5 mg tablets for Resident #2 were delivered to the facility. The delivery receipt was signed as received by Nurse #15. The delivery receipt was not signed off as received by a second nurse. There was no declining count sheet found for the 60 oxycodone 5 mg tablets that were delivered to the facility on 8/10/25 for Resident #2. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/19/25 at 7:11 PM a total of 60 oxycodone 5 mg tablets for Resident #2 were delivered to the facility. The delivery receipt was not signed off as received by a nurse. There was no declining count sheet found for the 60 oxycodone 5 mg tablets that were delivered to the facility on [DATE] for Resident #2. The MDS quarterly assessment dated [DATE] revealed Resident #2 had severely impaired cognition. During an observation on 2/13/26 at 4:30 PM Resident #2 was lying in bed. She was not oriented and could not engage in conversation. She showed no signs or symptoms of distress/pain. c.) Resident #16 was admitted to the facility on [DATE] with diagnoses including cancer and heart failure. A physician's order with a start date of 5/8/24 which remained as an active order for Resident #16 revealed Tramadol 50 mg tablets, one tablet by mouth every 8 hours as needed for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 8/19/25 at 7:34 PM a total of 30 Tramadol 50 mg tablets were delivered to the facility for Resident #16. The delivery receipt was signed by Nurse #1 on 8/19/25. There was no signature on the delivery sheet from a second nurse. Attempts were made to contact Nurse #1 on 2/12/26 and 2/13/26 with no response. There was no declining count sheet found for the 30 Tramadol 50 mg tablets that were delivered to the facility on 8/19/25 for Resident #16. The MDS comprehensive assessment dated [DATE] revealed Resident #16 was cognitively intact. During an observation and interview on 2/13/26 at 4:40 PM with Resident #16 she was observed lying in bed and voiced no concerns about her care or pain medications. d.) Resident #34 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA) and heart failure. A physician's order with a start date of 2/12/25 which remained as an active order for Resident #34 revealed Tramadol 50 mg tablets, one tablet by mouth every 6 hours as needed for moderate and severe pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/12/25 at 5:09 PM a total of 60 Tramadol 50 mg tablets were delivered to the facility for Resident #34. There was no nurse signature on the delivery sheet. There was no declining count sheet found for the 60 Tramadol 50 mg tablets that were delivered to the facility on [DATE] for Resident #34. The MDS comprehensive assessment dated [DATE] revealed Resident #34 had severely impaired cognition. During an observation on 2/12/26 at 4:00 PM Resident #34 was observed sitting in his room in his wheelchair with his Responsible Party present. Resident #34 could not engage in conversation. Resident #34's Responsible Party was interviewed and voiced no concerns regarding Resident #34's pain medication. e.) Resident #43 was admitted to the facility on [DATE] with diagnoses including deep vein thrombosis (blood clot in deep veins). A physician's order with a start date of 2/25/25 which remained as an active order for Resident #43 revealed Tramadol 50 mg tablets, one tablet by mouth every 8 hours for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/6/25 at 8:50 PM a total of 90 Tramadol 50 mg tablets were delivered to the facility for Resident #43. The delivery receipt was signed by Nurse #1 on 10/7/25. There was no signature on the delivery sheet from a second nurse. There was no declining count sheet found for the 90 Tramadol 50 mg tablets that were delivered to the facility on [DATE] for Resident #43. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/29/25 at 7:27 PM a total of 45 Tramadol 50 mg tablets were delivered to the facility for Resident #43. The delivery receipt was signed by Nurse #1 on 10/30/25. There was no signature on the delivery sheet from a second nurse. There was no declining count sheet found for the 45 Tramadol 50 mg tablets that were delivered to the facility on [DATE] for Resident #43. Attempts were made to contact Nurse #1 on 2/12/26 and 2/13/26 with no response. f.) Resident #52 was admitted to the facility on [DATE] with diagnoses including arthritis and diabetes. A physician's order with a start date of 10/29/25 which remained as an active order for Resident #52 revealed oxycodone-acetaminophen 5-325 mg tablets, one tablet by mouth every 6 hours as needed for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/29/25 at 7:27 PM a total of 60 oxycodone-acetaminophen 5-325 mg tablets were delivered to the facility for Resident #52. The delivery receipt was signed by Nurse #1 on 10/30/25. There was no signature on the delivery sheet from a second nurse. There was no declining count sheet found for the 60 oxycodone-acetaminophen 5-325 mg tablets that were delivered to the facility on [DATE] for Resident #52. The MDS comprehensive assessment dated [DATE] revealed Resident #52 had severely impaired cognition. During an observation on 2/11/25 at 2:00 PM Resident #52 was lying in bed and could not engage in conversation. She was smiling and showed no signs or symptoms of distress/pain.g.) Resident #69 was admitted to the facility on [DATE] with diagnoses including diabetes and renal disease.A physician's order with a start date of 10/24/24 which remained as an active order for Resident #69 for hydrocodone-acetaminophen 10-325 mg tablets, one tablet by mouth every 8 hours as needed for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 9/3/25 at 7:18 PM a total of 45 hydrocodone-acetaminophen 10-325 mg tablets were delivered to the facility for Resident #69. The delivery receipt was signed by Nurse #1 on 9/4/25. There was no signature on the delivery sheet from a second nurse. Attempts were made to contact Nurse #1 on 2/12/26 and 2/13/26 with no response. There was no declining count sheet found for the 45 hydrocodone-acetaminophen 10-325 mg tablets that were delivered to the facility on 9/3/25 for Resident #69. The MDS comprehensive assessment dated [DATE] revealed Resident #69 was cognitively intact. During an interview on 2/11/25 at 2:00 PM Resident #69 voiced no concerns about receiving her pain medications. h.) Resident #79 was admitted to the facility on [DATE] with diagnoses including heart failure and renal disease.A physician's order with a start date of 4/5/24 that remained as an active order for Resident #79 for hydrocodone-acetaminophen 5-325 mg tablets, one tablet by mouth every 8 hours as needed for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/23/25 at 7:41 PM a total of 60 hydrocodone-acetaminophen 5-325 mg tablets were delivered to the facility for Resident #79. The delivery receipt was signed by Nurse #1 on 10/24/25. There was no signature on the delivery sheet from a second nurse. Attempts were made to contact Nurse #1 on 2/12/26 and 2/13/26 with no response. There was no declining count sheet found for the 60 hydrocodone-acetaminophen 5-325 mg tablets that were delivered to the facility on [DATE] for Resident #79. The MDS quarterly assessment dated [DATE] revealed Resident #79 had moderate cognitive impairment. During an observation on 2/11/26 at 2:45 PM Resident #79 was observed lying on bed. Resident #79 could not engage in conversation. She showed no signs or symptoms of distress/pain.i.) Resident #87 was admitted to the facility on [DATE] with diagnoses including heart failure. A physician's order with a start date of 1/20/23 which remained as an active order for Resident #87 for hydrocodone-acetaminophen 10-325 mg tablets, one tablet by mouth every 6 hours as needed for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/5/25 at 5:02 PM a total of 60 hydrocodone-acetaminophen 10-325 mg tablets were delivered to the facility for Resident #87. The delivery receipt was signed by the weekend Nurse Supervisor and by Nurse #5 on 10/5/25. There was no declining count sheet found for the 60 hydrocodone-acetaminophen 10-325 mg tablets that were delivered to the facility on [DATE] for Resident #87. The MDS quarterly assessment dated [DATE] revealed Resident #87 had severely impaired cognition. During an observation on 2/11/25 at 2:30 PM Resident #87 was lying in bed and showed no signs or symptoms of distress or pain.During an interview on 2/12/26 at 9:30 AM the Director of Nursing (DON) stated on Monday morning 11/3/25 she was notified by the weekend supervisor that they could not find Resident #21's Tramadol. The DON stated she called the pharmacy and was told that 30 tablets of Tramadol 50 mg for Resident #21 were sent to the facility on [DATE]. The DON stated she checked all of the medication carts to see if it had been put on another cart by mistake. The DON stated that all 8 medication carts in the facility were checked and the Tramadol for Resident #21 delivered on 10/27/25 was never found and the declining count sheet for the Tramadol for Resident #21 was never found. The DON stated she immediately notified the Administrator and the facility's Chief Nursing Officer. She stated the Pharmacy Director and the Medical Director were also notified. The DON stated that she, the Chief Nursing Officer, and the facility's Nurse Consultant began auditing all controlled medications that included current and discharged residents from 8/1/25 through 11/4/25. During the audit they discovered that eight additional residents (Residents #2, #16, #34, #43, #52, #69, #79, and #87) were found to have missing controlled medications for active orders. The DON stated that during the medication cart audits they were able to determine that the missing controlled medications were mainly from the 200-hall medication cart. She indicated that they started interviewing the 200-hall staff and were told during staff interviews that there was a Medication Aide (Medication Aide #1) who had been acting suspicious. The DON stated they drug tested all nursing staff, and Medication Aide #1 tested positive for the missing medications. Medication Aide #1 was terminated, and Health Care Personnel Registry was notified. The DON stated the process used before the missing controlled medications in November 2025 included that when controlled medications were delivered to the facility one nurse would go through the delivery tote that held the medications and distribute the medications to the medication carts. The DON stated there was no assigned nurse to distribute the medications to the carts, it was whichever nurse was available when the delivery driver came in. The nurse would distribute the medications to the carts then sign the delivery sheet. The DON stated the medication delivery sheet had two signature lines and the nurse that checked the medication in was to sign and the nurse who received the medication on the medication cart was to sign. The DON stated during their investigation they discovered that two nurses were not signing off on the medication delivery sheets. The DON stated once the nurses signed the delivery sheets, the delivery sheets were placed in her box outside of her office. The DON stated she was responsible for reviewing the declining count sheets and the delivery sheets once they were completed. The DON stated she did not identify a problem with the declining count sheets until the missing medications were identified on 11/3/25 because the declining counts sheets were missing, the missing controlled medications were not recorded in the narcotic book, and she did not verify delivery sheets to ensure the medications were actually on the medication carts. The DON stated the new process was for the delivery sheets and declining counts sheets to be placed in a lockbox once completed and she would review the sheets for accuracy. The DON stated that prior to the identification of the missing medications on 11/3/25, she or Unit Manager #1 would do periodic audits of the controlled medications, and the Consultant Pharmacist also conducted periodic audits of controlled medications. The DON stated they had not identified any concerns with controlled medications until this occurred with Resident #21's medications. The DON stated that Residents #21, #2, #16, #34, #43, #52, #69, #79, and #87 continued to receive their medications as ordered due to having extra refills on the cart. During an interview on 2/12/26 at 2:00 PM the facility's Chief Nursing Officer stated she was notified on 11/3/25 of the missing controlled medications for Resident #21. She stated an investigation was initiated at that time. The Chief Nursing Officer stated once they determined that the controlled medications were missing, they began auditing all controlled medications and identified eight additional residents (Residents #2, #16, #34, #43, #52, #69, #79, and #87) with missing medications. She stated the Drug Enforcement Agency (DEA) and law enforcement were notified, and Health Care Personnel Registry was notified regarding Medication Aide #1. The Chief Nursing Officer indicated they reported a total of 660 missing controlled tablets for active orders to the DEA. She stated they identified during their investigation that Nurse Practitioner #2 would order refills of the controlled medications for residents on her visits without checking to see if the order needed to be refilled first which caused controlled medications to accumulate on the medication carts. The Chief Nursing Officer stated they had changed the process, and the Nurse Practitioner and the Medical Director now checked with a nurse to determine if a refill was needed before writing the refill orders. The Chief Nursing Officer stated this would help to reduce the number of controlled medications stored on the medication carts and reduce the risk of diversion. During an interview on 2/12/26 at 2:30 PM the facility's Nurse Consultant stated during the investigation of the missing controlled medications in November 2025, they found that there were excessive controlled medications being stored on the medication carts. The Nurse Consultant stated they determined that Nurse Practitioner #2, who was interim while Nurse Practitioner #1 was out on leave, was evaluating residents and writing orders for refills for the controlled medications without first determining if a refill was needed at that time. This led to excessive amounts of the controlled medications being delivered and stored on the medication carts. The Nurse Consultant stated that Nurse Practitioner #2 was no longer working at the facility. The Nurse Consultant stated the facility worked with the pharmacy and changed the process to where the pharmacy would not fill the order until a staff nurse confirmed that a refill was needed. The Nurse Consultant stated due to having excessive amounts of the controlled medications stored on the medication carts the residents continued to receive their medications. During a phone interview on 2/12/26 at 4:00 PM Nurse Practitioner #2 stated she was no longer evaluating residents in the facility due to Nurse Practitioner #1 no longer being on leave. Nurse Practitioner #2 stated when she evaluated residents for pain assessments, which was usually once a month, she would go ahead and order pain medication refills. She stated she did not necessarily check with a nurse to see if a refill was needed at the time. Nurse Practitioner #2 stated she had spoken to the facility's Nurse Consultant during the investigation of the missing medications in November 2025 and was made aware of the new process for refilling controlled medications. During a phone interview on 2/13/26 at 1:05 PM the Pharmacy Director stated he was made aware of the nine residents (Residents #21, #2, #16, #34, #43, #52, #69, #79, and #87) who were identified in November 2025 as having missing controlled medications. The Pharmacy Director stated they audited their system, their delivery sheets and the returned medications that were sent back to the pharmacy and confirmed that the medications missing for the nine residents were filled by the pharmacy, delivered to the facility, and none of the missing controlled medications had been returned to the pharmacy. The Pharmacy Director stated when medications were delivered to the facility they sent two copies of the delivery sheets, one copy went with the delivery driver, and the second copy was to be signed by a nurse and should be sent back to the pharmacy by fax. The Pharmacy Director stated that when refill orders for controlled medications were received in the pharmacy and they had not filled it in a while they would go ahead and refill the medication. He stated due to the number of missing controlled medications from the facility, the pharmacy had changed their process and now before refilling controlled medications, including as needed medications, the nurse from the facility must call to request the refill. This new process would help to ensure excessive controlled medications were not sent if they were not needed. During an interview on 2/13/26 at 1:30 PM Nurse Practitioner #1 stated she and the Medical Director were made aware of the nine residents (Residents #21, #2, #16, #34, #43, #52, #69, #79, and #87) who had missing controlled medications in November 2025. Nurse Practitioner #1 stated she was aware of the new ordering process for controlled medications and now checked with the nurse to see if a refill was needed before she wrote refill orders. Nurse Practitioner #1 stated there had been no reports made to her regarding Resident #21, Resident #2, Resident #16, Resident #34, Resident #43, Resident #52, Resident #69, Resident #79, or Resident #87 having unrelieved pain. The facility provided a corrective action plan that was not able to be validated.

Based on observations, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to obtain orders to access and manage a port-a-cath (an implantable device placed under the skin, usually in the chest, to provide long-term, easy access to veins for chemotherapy, medications, blood draws, or intravenous fluids) for 1 of 1 sampled resident with a port-a-cath (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses to include personal history of traumatic brain injury with persistent vegetative state. The hospital discharge summary completed on 12/20/2024 for Resident #1 revealed a left chest port-a-cath was placed by vascular surgery on 12/18/2024 for future access, but it was not yet mature (approximately 7 to 14 days for the site to heal to allow for use).A progress note written by the NP on 12/4/2025 revealed Resident #1 was admitted to the hospital on [DATE] for pneumonia and sepsis (a serious condition in which the body responds improperly to an infection), and 10/14/2025 for seizure like activity. It further listed a port-a-cath was placed surgically on 12/18/2024.The quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 indicated he had no speech, was rarely/never understood and rarely/never understood others. His cognitive skills for daily decision making indicated, severely impaired-never/rarely made decisions. The care plan for Resident #1 last revised 1/7/2026 did not reveal a plan of care regarding a port-a-cath.The hospital physician's history and physical dated 1/30/2026 revealed Resident #1 was admitted to the hospital on [DATE] with seizures and a catheter associated urinary tract infection. It further read that the resident had a left upper chest port-a-cath that was available for medication administration. The hospital discharge summary for Resident #1 dated 2/5/2026 revealed he was being discharged to the facility following treatment for seizures and a urinary tract infection with sepsis. It indicated that the resident's left chest port-a-cath was last flushed with normal saline (sterile solution of salt and water) and heparin (an anticoagulant) on 2/5/2026.A review of Resident #1's physician orders from 12/20/2024 through 2/11/2026 revealed no orders related to accessing and maintaining the resident's port-a-cath. An observation of Resident #1 was completed with Nurse #4 on 2/12/2026 at 3:53 PM. The observation revealed a left chest port-a-cath.An interview with Nurse #4 was completed on 2/12/2026 at 3:55 PM. Nurse #4 stated she didn't know if there were orders to access and maintain the port-a-cath, because she was a licensed practical nurse (LPN), and only registered nurses (RN) could access and flush a port-a-cath.An interview was completed with the Unit Manager on 2/13/2026 at 8:12 AM. The Unit Manager stated that she was the nurse responsible for Resident #1's readmission from the hospital on 2/5/2026. She stated she did not realize there should have been orders to access and flush the port-a-cath, because she was an LPN and the care of a port-a-cath was not in her scope of practice. The Unit Manager indicated that the second nurse that reviewed the orders was also an LPN.An interview with the Director of Nursing (DON) was conducted on 2/13/2026 at 7:50 AM. The DON stated Resident #1 had a port-a-cath due to poor vascular access. She further stated that when the resident returned from the hospital on [DATE] the discharge summary had noted the port-a-cath was too immature to access at that time. The DON indicated that typically orders should have been obtained regarding the care and maintenance for the port-a-cath upon admission. She stated she was unsure of how long it took for a port-a-cath to heal, but that it would not take a year. The DON further stated that the facility had never accessed Resident #1's port-a-cath or provided any maintenance or care for it. She stated the hospital Discharge summary dated [DATE] indicated the port had been flushed at the hospital on 2/5/2026. She stated she thought there should have been orders in place to access and flush the port-a-cath routinely to keep it patent and prevent it from clotting off (ensuring it is open, unobstructed, and working properly). The DON indicated that accessing the port had to be done with a special needle and then flushed with normal saline and heparin for maintenance. She stated the facility didn't have a policy for routinely flushing a port-a-cath and that it would be ordered on an individual basis. She indicated that usually a port-a-cath was accessed monthly or every 6 weeks by an RN to maintain patency. The DON stated that accessing and flushing a port-a-cath was not on the list of competencies for nurses at the facility, and that training and education would have to be provided by the NP. An interview with the NP was completed on 2/13/2026 at 1:42 PM. The NP stated that she was aware Resident #1 had a port-a-cath for administration of intravenous (IV) fluids, medications, and blood draws, because he had poor vascular access. She further stated that she was not exactly sure how long it took a port-a-cath to heal, but they were usually able to be used approximately 2 weeks after placement. The NP indicated Resident #1's port-a-cath had not been accessed or flushed at the facility since it was placed in December 2024. The NP indicated she was aware a port-a-cath should be accessed and flushed routinely and that there had not been orders to access and maintain the port-a-cath after it was placed in December 2024. She stated that Resident #1 was admitted to the hospital at least 2 times in 2025 and she assumed that the hospital was accessing it and flushing it during the hospital stays must have been enough to keep it patent. The NP indicated she had mentioned ordering the special needles used to access a port-a-cath while speaking to nursing staff in the nurses' station on 2/9/2026, but the nursing staff indicated they did not access the port-a-cath. She could not recall which nurses made that statement. She further stated she was going to discuss care for the port-a-cath with the physician, but she had not done it yet. The NP indicated that the port-a-cath should be accessed monthly to maintain patency and she was going to write the orders and educate the registered nurse staff.

Based on record review and interviews with staff, Consultant Pharmacist, Pharmacy Nurse Consultant, and Pharmacy Director, the facility failed to have effective safeguards and systems in place for the accounting of controlled medications and the return of discontinued controlled medications to the pharmacy to prevent drug diversion for 9 of 9 residents reviewed for misappropriation of medications (Resident #69, #43, #2, #21, #16, #34, #52, #79, and #87). Findings included: a. A physician's order for Resident #69 with a start date of 8/8/25 revealed Lorazepam 0.5 milligrams (mg) tablets, one tablet by mouth every 24 hours as needed for anxiety for 14 days. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 8/8/25 at 7:13 PM a total of 14 Lorazepam 0.5 mg tablets were delivered to the facility for Resident #69. The delivery receipt was signed by Nurse #1 on 8/8/25. There was no signature on the delivery sheet from a second nurseThere was no declining count sheet (an inventory log used to record a running total for each controlled medication) found for the 14 tablets of Lorazepam 0.5 mg that were delivered to the facility on 8/8/25 for Resident #69. Review of Resident #69's Medication Administration Record (MAR) for August 2025 revealed the as needed Lorazepam 0.5 mg order showed no documentation that the medication was administered to Resident #69 after the delivery on 8/8/25 at 7:13 PM. A review of Resident #69's physician's orders included an order (start date of 10/24/24) for hydrocodone-acetaminophen 10-325 mg tablets, one tablet by mouth every 8 hours as needed for pain. This order remained active. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 9/3/25 at 7:18 PM a total of 45 hydrocodone-acetaminophen 10-325 mg tablets were delivered to the facility for Resident #69. The delivery receipt was signed by Nurse #1 on 9/4/25. There was no signature on the delivery sheet from a second nurse. There was no declining count sheet found for the 45 hydrocodone-acetaminophen 10-325 mg tablets that were delivered to the facility on 9/3/25 for Resident #69. Attempts were made to contact Nurse #1 on 2/12/26 and 2/13/26 with no response. b. A physician's order for Resident #43 with a start date of 2/25/25 which remained as an active order revealed Tramadol 50 mg tablets, one tablet by mouth every 8 hours for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/6/25 at 8:50 PM a total of 90 Tramadol 50 mg tablets were delivered to the facility for Resident #43. The delivery receipt was signed by Nurse #1 on 10/7/25. There was no signature on the delivery sheet from a second nurse. There was no declining count sheet found for the 90 Tramadol 50 mg tablets that were delivered to the facility on [DATE] for Resident #43. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/29/25 at 7:27 PM a total of 45 Tramadol 50 mg tablets were delivered to the facility for Resident #43. The delivery receipt was signed by Nurse #1 on 10/30/25. There was no signature on the delivery sheet from a second nurse. There was no declining count sheet found for the 45 Tramadol 50 mg tablets that were delivered to the facility on [DATE] for Resident #43. Attempts were made to contact Nurse #1 on 2/12/26 and 2/13/26 with no response. c. A physician's order for Resident #2 with a start date of 1/1/25 which remained as an active order revealed oxycodone 5 mg tablets, one tablet by mouth every six hours as needed for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 8/10/25 at 5:04 PM a total of 60 oxycodone 5 mg tablets for Resident #2 were delivered to the facility. The delivery receipt was signed as received by Nurse #15. The delivery receipt was not signed off as received by a second nurse. There was no declining count sheet found for the 60 oxycodone 5 mg tablets that were delivered to the facility on 8/10/25 for Resident #2. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/19/25 at 7:11 PM a total of 60 oxycodone 5 mg tablets for Resident #2 were delivered to the facility. The delivery receipt was not signed off as received by a nurse. There was no declining count sheet found for the 60 oxycodone 5 mg tablets that were delivered to the facility on [DATE] for Resident #2. d. A physician's order for Resident #21 with a start date of 10/16/23 which remained as an active order revealed Tramadol 50 milligrams (mg) tablets, one tablet by mouth two times a day for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/27/25 at 7:09 PM a total of 30 Tramadol 50 mg tablets for Resident #21 were delivered to the facility. The delivery receipt was signed off as received by Nurse #1, a night shift nurse, on 10/28/25. There was no signature on the delivery sheet from a second nurse. Attempts were made to contact Nurse #1 on 2/12/26 and 2/13/26 with no response. There was no declining count sheet (an inventory log used to record a running total for each controlled medication) found for the 30 Tramadol 50 mg tablets that were delivered to the facility on [DATE] for Resident #21. e. A physician's order for Resident #16 with a start date of 5/8/24 which remained as an active order revealed Tramadol 50 mg tablets, one tablet by mouth every 8 hours as needed for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 8/19/25 at 7:34 PM a total of 30 Tramadol 50 mg tablets were delivered to the facility for Resident #16. The delivery receipt was signed by Nurse #1 on 8/19/25. There was no signature on the delivery sheet from a second nurse. Attempts were made to contact Nurse #1 on 2/12/26 and 2/13/26 with no response. There was no declining count sheet found for the 30 Tramadol 50 mg tablets that were delivered to the facility on 8/19/25 for Resident #16. f. A physician's order for Resident #34 with a start date of 2/12/25 which remained as an active order for revealed Tramadol 50 mg tablets, one tablet by mouth every 6 hours as needed for moderate and severe pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/12/25 at 5:09 PM a total of 60 Tramadol 50 mg tablets were delivered to the facility for Resident #34. There was no signature on the delivery sheet. There was no declining count sheet found for the 60 Tramadol 50 mg tablets that were delivered to the facility on [DATE] for Resident #34. g. A physician's order for Resident #52 with a start date of 10/29/25 which remained as an active order revealed oxycodone-acetaminophen 5-325 mg tablets, one tablet by mouth every 6 hours as needed for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/29/25 at 7:27 PM a total of 60 oxycodone-acetaminophen 5-325 mg tablets were delivered to the facility for Resident #52. The delivery receipt was signed by Nurse #1 on 10/30/25. There was no signature on the delivery sheet from a second nurse. There was no declining count sheet found for the 60 oxycodone-acetaminophen 5-325 mg tablets that were delivered to the facility on [DATE] for Resident #52. h. A physician's order for Resident #79 with a start date of 4/5/24 that remained as an active order revealed hydrocodone-acetaminophen 5-325 mg tablets, one tablet by mouth every 8 hours as needed for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/23/25 at 7:41 PM a total of 60 hydrocodone-acetaminophen 5-325 mg tablets were delivered to the facility for Resident #79. The delivery receipt was signed by Nurse #1 on 10/24/25. There was no signature on the delivery sheet from a second nurse. Attempts were made to contact Nurse #1 on 2/12/26 and 2/13/26 with no response. There was no declining count sheet found for the 60 hydrocodone-acetaminophen 5-325 mg tablets that were delivered to the facility on [DATE] for Resident #79. i. A physician's order for Resident #87 with a start date of 1/20/23 which remained as an active order revealed hydrocodone-acetaminophen 10-325 mg tablets, one tablet by mouth every 6 hours as needed for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/5/25 at 5:02 PM a total of 60 hydrocodone-acetaminophen 10-325 mg tablets were delivered to the facility for Resident #87. The delivery receipt was signed by the weekend Nurse Supervisor and by Nurse #5 on 10/5/25. There was no declining count sheet found for the 60 hydrocodone-acetaminophen 10-325 mg tablets that were delivered to the facility on [DATE] for Resident #87. During an interview on 2/12/26 at 9:30 AM the Director of Nursing (DON) stated on 11/3/25 she was notified by the weekend supervisor that they could not find Resident #21's Tramadol for an active order. She reported that they began auditing the medication carts and identified there were missing controlled medications including Resident #69's discontinued Lorazepam that was delivered on 8/8/25. The DON stated she called the pharmacy and was told that 14 Lorazepam 0.5 mg tablets were delivered to the facility for Resident #69 on 8/8/25. She stated that the 14 Lorazepam tablets delivered on 8/8/25 and the declining count sheet were never found. The DON indicated she confirmed with the pharmacy that 14 Lorazepam 0.5 mg tablets were sent to the facility on 8/8/25 and none were returned back to the pharmacy. The DON stated that Resident #69's MAR was reviewed and there was no documentation that Lorazepam was administered from the 8/8/25 delivery. The DON added that there was no declining count sheet for the 8/8/25 delivery of Lorazepam for Resident #69 and it was not recorded in the narcotic book. The DON stated she immediately notified the Administrator and the facility's Chief Nursing Officer. She stated the Pharmacy Director and the Medical Director were also notified. The DON stated that she, the Chief Nursing Officer, and the facility Nurse Consultant began auditing all controlled medications that included current and discharged residents from 8/1/25 through 11/4/25. The DON stated that during the medication cart audits they were able to determine that the missing controlled medications were mainly from the 200 hall medication cart. She reported that the facility then started interviewing 200 hall staff and were told during staff interviews that there was a Medication Aide (Medication Aide #1) who had been acting suspicious. The DON stated they drug tested all nursing staff, and Medication Aide #1 tested positive for the missing Lorazepam. Medication Aide #1 was terminated, and Health Care Personnel Registry was notified. The DON stated the process used before the missing Lorazepam was identified in November 2025 included that when controlled medications were delivered to the facility one nurse would go through the delivery tote and distribute the medications to the medication carts. The DON stated there was no assigned nurse to distribute the medications to the carts, it was whichever nurse was available when the delivery driver came in. The nurse would distribute the medications to the carts then sign the delivery sheet. The DON stated the medication delivery sheet had two signature lines and the nurse that checked the medication in was to sign and the nurse who received the medication on the medication cart was to sign. The DON stated during their investigation they discovered that two nurses were not signing off on the medication delivery sheets. The DON stated once the nurses signed the delivery sheets, the delivery sheets were placed in her box outside of her office. The DON stated she was responsible for reviewing the declining count sheets and the delivery sheets once they were completed. The DON explained that she did not identify a problem with the declining count sheet until 11/3/25 because the declining count sheet was missing, the Lorazepam was not recorded in the narcotic book, and she did not verify delivery sheets to ensure the medications were actually on the medication carts. The DON stated that they verified during their investigation that the declining count sheets were missing for nine residents (Resident #69, #43, #2, #21, #16, #34, #52, #79, and #87). The DON added that the new process was the delivery sheets and declining counts sheets would now be placed in a lockbox once completed and she would review the sheets for accuracy. The DON stated that prior to the identification of the missing medication on 11/3/25, she or Unit Manager #1 would do periodic audits of the controlled medications, and the Consultant Pharmacist also conducted periodic audits of controlled medications. The DON stated they had not identified any concerns with controlled medications until this was found in November 2025. The DON stated discontinued controlled medication declining count sheets were to be removed from the narcotic book with the witness of another staff member and the declining count sheet placed in her box. Then she would place the medication in a sealed bag and complete a return drug form then fax the form to the pharmacy. The sealed bag would be locked in the narcotic box on the medication cart until the pharmacy delivery driver picked it up. The DON indicated that process did not occur for Resident #69's Lorazepam because she did not receive a discontinued declining count sheet notifying her the Lorazepam order was discontinued for Resident #69. During an interview on 2/12/26 at 1:00 PM Unit Manager #1 stated she was responsible for checking medication orders, but she did not audit controlled medications on the medication carts, and she thought the DON was responsible for the controlled medications. During a phone interview on 2/13/26 at 9:00 AM the Consultant Pharmacist stated she was in the facility for monthly medication regimen reviews. She stated she was made aware of the missing controlled medications, including the discontinued Lorazepam, in November 2025. The Consultant Pharmacist stated that she did not conduct medication cart audits including auditing the controlled medications. She stated the pharmacy employed a Nurse Consultant that checked the medication carts and she thought he did random controlled medication audits, but she was not certain of this. The Consultant Pharmacist stated the Pharmacy Nurse Consultant had not reported any concerns to her regarding controlled medications. During a phone interview on 2/13/26 at 1:05 PM the Pharmacy Director stated in November 2025 he was made aware of Resident #69's missing Lorazepam that was delivered to the facility on 8/8/25. He stated the pharmacy audited their system, their delivery sheets and the returned medications that were sent back to the pharmacy and confirmed that the missing Lorazepam for Resident #69 was filled by the pharmacy, delivered to the facility on 8/8/25, and had not been returned to the pharmacy. The Pharmacy Director stated when medications were delivered to the facility they sent two copies of the delivery sheets, one copy went with the delivery driver, and the second copy was to be signed by a nurse and should be sent back to the pharmacy through fax. He stated medications should be returned to the pharmacy when the orders were discontinued. The Pharmacy Director stated the pharmacy did not track discontinued medication orders including controlled medications. He stated it was the facility's responsibility to remove the controlled medications from the medication cart when the order was discontinued and return any remaining medication to the pharmacy. During a phone interview on 2/19/26 at 3:00 PM the facility's Pharmacy Nurse Consultant stated he conducted random medication cart audits, but he was not responsible for conducting audits of the controlled medications. He stated he only checked that the narcotic box was locked when he did medication cart audits, but he never reviewed the controlled medications or the declining count sheets, and it was not a part of his medication cart audits. During a follow up interview on 2/13/26 at 2:00 PM the DON indicated she was not aware the Consultant Pharmacist did not conduct random audits of the controlled medications. She indicated she was not aware that Unit Manager #1 did not check the controlled medications. The DON stated Resident #69's discontinued Lorazepam should have been removed from the medication cart and returned to the pharmacy when the order was discontinued after 14 days, and that did not occur.

Based on record review, and staff and Consultant Pharmacist's interviews, the facility failed to a.) act on the Consultant Pharmacist's recommendation to address a residents (Resident #12) diuretic medication Metolazone (used to treat high blood pressure and fluid retention caused by heart failure or kidney disease) that was prescribed for increased edema. The Consultant Pharmacist reported during the monthly medication regimen review in October 2025 and November 2025 that Resident #12 was receiving Metolazone outside of the physician ordered parameters which were to hold the medication if the residents systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. b.) the Consultant Pharmacist failed to identify and address during the December 2025 and January 2026 monthly medication regimen reviews that Metolazone continued to be administered to Resident #12 outside of the ordered blood pressure parameters. This resulted in Resident #12 continuing to receive the medication when it should have been held. This occurred for 1 of 6 residents reviewed for medication administration (Resident #12). Findings included. a.) Resident #12 was admitted to the facility on [DATE] with diagnoses including heart failure, hypertension, and kidney disease. A physician's order dated 9/5/25 for Resident #12 revealed Metolazone 5 milligram (mg) tablets. Give 1 tablet by mouth one time a day every Monday, Wednesday, and Friday for edema (swelling caused by excessive fluid trapped in body tissues). Hold for systolic blood pressure less than 110, or diastolic blood pressure less than 60. Review of the Medication Administration Record (MAR) dated September 2025 for Resident #12 revealed Metolazone 5 milligram tablets were initialed as administered on the following dates with systolic blood pressure readings less than 110 or diastolic blood pressure less than 60: 9/10/25 administered by Nurse #2 with blood pressure 103/629/12/25 administered by Nurse #2 with blood pressure 77/609/15/25 administered by Nurse #2 with blood pressure 99/549/17/25 administered by Nurse #2 with blood pressure 98/669/19/25 administered by Nurse #2 with blood pressure 103/689/22/25 administered by Nurse #2 with blood pressure 99/569/24/25 administered by Nurse #2 with blood pressure 89/649/26/25 administered by Nurse #2 with blood pressure 106/789/29/25 administered by Nurse #2 with blood pressure 110/53 Review of the Medication Administration Record (MAR) dated October 2025 for Resident #12 revealed Metolazone 5 milligram tablets were initialed as administered on the following dates with systolic blood pressure readings less than 110 or diastolic blood pressure less than 60: 10/01/25 administered by Nurse #2 with blood pressure 89/5610/03/25 administered by Nurse #2 with blood pressure 89/6110/06/25 administered by Nurse #2 with blood pressure 96/6410/08/25 administered by Nurse #2 with blood pressure 98/6110/15/25 administered by Nurse #2 with blood pressure 105/6410/17/25 administered by Nurse #2 with blood pressure 110/5310/20/25 administered by Nurse #2 with blood pressure 108/8010/22/25 administered by Nurse #2 with blood pressure 91/7110/29/25 administered by Nurse #2 with blood pressure 104/6810/31/25 administered by Nurse #2 with blood pressure 93/64 Review of the Consultant Pharmacist's medication regimen review dated 10/9/25 revealed a note informing the Director of Nursing (DON) that Resident #12 had received Metolazone outside of the ordered blood pressure parameters on several occasions in September 2025 and in October 2025. Record review revealed Unit Manager #1 noted on the Consultant Pharmacist's medication regimen review dated 10/9/25 that nursing staff was educated. Unit Manager #1 did not specify if Nurse #2 received the education or what education was provided. Review of the Medication Administration Record (MAR) dated November 2025 for Resident #12 revealed Metolazone 5 milligram tablets were initialed as administered on the following dates with systolic blood pressure readings less than 110 or diastolic blood pressure less than 60: 11/03/25 administered by Nurse #2 with blood pressure 98/5811/05/25 administered by Nurse #2 with blood pressure 97/6911/07/25 administered by Nurse #2 with blood pressure 103/6011/12/25 administered by Nurse #2 with blood pressure 99/6111/14/25 administered by Nurse #2 with blood pressure 97/6211/17/25 administered by Nurse #2 with blood pressure 102/7211/19/25 administered by Nurse #2 with blood pressure 100/6111/21/25 administered by Nurse #2 with blood pressure 97/6011/24/25 administered by Nurse #2 with blood pressure 101/6311/26/25 administered by Nurse #2 with blood pressure 100/5811/28/25 administered by Nurse #2 with blood pressure 103/60 Review of the Consultant Pharmacist's medication regimen review dated 11/6/25 revealed a note informing the DON that Resident #12 had received Metolazone outside of the ordered blood pressure parameters. Record review revealed Unit Manager #1 noted on the Consultant Pharmacist's medication regimen review dated 11/6/25 that nursing staff was educated regarding the Metolazone. Unit Manager #1 did not specify if Nurse #2 received the education or what education was provided. During an interview on 2/11/26 at 1:15 PM Nurse #2 stated she did administer Metolazone to Resident #12 on the above dates. She stated she was a new nurse and thought the order to hold the medication was if both the systolic and the diastolic blood pressure was less than 110/60. Nurse #2 stated she misunderstood the parameters that were ordered and the Metolazone was given in error. Nurse #2 stated she was consistently assigned to Resident #12 and did not realize that she had been administering Metolazone to Resident #12 in error on so many occasions since September 2025. Nurse #2 indicated the medication error had not been brought to her attention until now. During a phone interview on 2/13/26 at 9:00 AM the Consultant Pharmacist stated she completed monthly medication reviews for the facility. She stated she did see that Resident #12's Metolazone was administered outside of the parameters and included that in her monthly reports that were sent to the DON in October 2025 and November 2025. The Consultant Pharmacist indicated that she typically did not go back and review the previous months recommendations that were sent to the DON and just expected that the nursing recommendations would be followed. During an interview on 2/13/26 at 2:40 PM the DON stated she and Unit Manager #1 shared the responsibility for reviewing and acting on the monthly pharmacy reports. She was not aware that Metolazone continued to be administered to Resident #12 outside of the parameters. The DON stated the Consultant Pharmacist did address the medication error in her monthly reports in October and November 2025. The DON stated Unit Manager #1 noted on the October 2025 and November 2025 pharmacy reports that education was provided to nursing staff. The DON stated all nursing staff should have been included in the education provided by Unit Manager #1 including Nurse #2. The DON stated Unit Manager #1 was not in the facility at the time, and she was not certain where the documentation was regarding the education that was provided by Unit Manager #1 or if Nurse #2 received education regarding following blood pressure parameters. The DON stated further education would be provided to all nursing staff including Nurse # 2, regarding medication administration including following blood pressure parameters. b.) Review of the Medication Administration Record (MAR) dated December 2025 for Resident #12 revealed Metolazone 5 milligram tablets were initialed as administered on the following dates with systolic blood pressure readings less than 110 or diastolic blood pressure less than 60: 12/01/25 administered by Nurse #2 with blood pressure 99/6312/03/25 administered by Nurse #2 with blood pressure 102/7012/05/25 administered by Nurse #2 with blood pressure 106/6912/08/25 administered by Nurse #2 with blood pressure 99/6512/10/25 administered by Nurse #2 with blood pressure 95/6812/12/25 administered by Nurse #2 with blood pressure 95/6212/15/25 administered by Nurse #2 with blood pressure 105/6912/17/25 administered by Nurse #2 with blood pressure 97/6212/19/25 administered by Nurse #2 with blood pressure 96/6512/22/25 administered by Nurse #2 with blood pressure 108/6112/24/25 administered by Nurse #2 with blood pressure 95/5612/26/25 administered by Nurse #2 with blood pressure 108/6212/29/25 administered by Nurse #2 with blood pressure 105/68 Review of the Consultant Pharmacist's medication regimen review dated 12/3/25 revealed no recommendations regarding Resident #12's Metolazone. Review of the Medication Administration Record (MAR) dated January 2026 for Resident #12 revealed Metolazone 5 milligram tablets were initialed as administered on the following dates with systolic blood pressure readings less than 110 or diastolic blood pressure less than 60: 1/02/26 administered by Nurse #2 with blood pressure 98/641/07/26 administered by Nurse #2 with blood pressure 107/611/09/26 administered by Nurse #2 with blood pressure 94/631/14/26 administered by Nurse #2 with blood pressure 101/621/16/26 administered by Nurse #2 with blood pressure 102/611/19/26 administered by Nurse #2 with blood pressure 102/571/21/26 administered by Nurse #2 with blood pressure 99/681/26/26 administered by Nurse #2 with blood pressure 105/601/30/26 administered by Nurse #2 with blood pressure 109/55 Review of the Consultant Pharmacist's medication regimen review dated 1/27/26 revealed no recommendations were made regarding Resident #12's Metolazone. During a phone interview on 2/13/26 at 9:00 AM the Consultant Pharmacist stated she completed monthly medication reviews for the facility. She stated she did not address Metolazone for Resident #12 in the December 2025 or January 2026 monthly pharmacy reports, and she had previously reported the discrepancy to the DON. The Consultant Pharmacist indicated this was missed on the December 2025 and January 2026 medication regimen reviews. During an interview on 2/13/26 at 2:40 PM the Director of Nursing (DON) stated the Consultant Pharmacist did address the medication error in her monthly reports in October and November 2025 regarding Resident #12's Metolazone. The DON stated Resident #12's Metolazone was not addressed by the Consultant Pharmacist on the December 2025 or the January 2026 pharmacy reports. The DON indicated she did not review Resident #12's Metolazone in December 2025 or January 2026 to ensure the medication was not administered outside of the parameters.

Based on observation, record review, and staff, resident, Nurse Practitioner and the Consultant Pharmacist interviews, the facility failed to hold the medication Metolazone (a diuretic medication used to treat high blood pressure and fluid retention caused by heart failure or kidney disease) when a resident's blood pressure was less than 110 systolic or less than 60 diastolic according to the parameters ordered by the physician. This resulted in a significant medication error as Resident #12 received 57 doses when the medication should have been held. Resident #12 experienced no significant outcome from receiving the medication. This occurred for 1 of 6 residents reviewed for medication administration (Resident #12). Findings included. Resident #12 was admitted to the facility on [DATE] with diagnoses including heart failure, hypertension, and kidney disease. A physician's order dated 9/5/25 for Resident #12 revealed Metolazone 5 milligram (mg) tablets. Give 1 tablet by mouth one time a day every Monday, Wednesday, and Friday for edema (swelling caused by excessive fluid trapped in body tissues). Hold for systolic blood pressure less than 110, or diastolic blood pressure less than 60. Review of the Medication Administration Record (MAR) dated September 2025 for Resident #12 revealed Metolazone 5 milligram tablets were initialed as administered on the following dates with systolic blood pressure readings less than 110 or diastolic blood pressure less than 60: 9/10/25 administered by Nurse #2 with blood pressure 103/629/12/25 administered by Nurse #2 with blood pressure 77/609/15/25 administered by Nurse #2 with blood pressure 99/549/17/25 administered by Nurse #2 with blood pressure 98/669/19/25 administered by Nurse #2 with blood pressure 103/689/22/25 administered by Nurse #2 with blood pressure 99/569/24/25 administered by Nurse #2 with blood pressure 89/649/26/25 administered by Nurse #2 with blood pressure 106/789/29/25 administered by Nurse #2 with blood pressure 110/53 Review of the Medication Administration Record (MAR) dated October 2025 for Resident #12 revealed Metolazone 5 milligram tablets were initialed as administered on the following dates with systolic blood pressure readings less than 110 or diastolic blood pressure less than 60: 10/01/25 administered by Nurse #2 with blood pressure 89/5610/03/25 administered by Nurse #2 with blood pressure 89/6110/06/25 administered by Nurse #2 with blood pressure 96/6410/08/25 administered by Nurse #2 with blood pressure 98/6110/15/25 administered by Nurse #2 with blood pressure 105/6410/17/25 administered by Nurse #2 with blood pressure 110/5310/20/25 administered by Nurse #2 with blood pressure 108/8010/22/25 administered by Nurse #2 with blood pressure 91/7110/29/25 administered by Nurse #2 with blood pressure 104/6810/31/25 administered by Nurse #2 with blood pressure 93/64 Review of the Medication Administration Record (MAR) dated November 2025 for Resident #12 revealed Metolazone 5 milligram tablets were initialed as administered on the following dates with systolic blood pressure readings less than 110 or diastolic blood pressure less than 60: 11/03/25 administered by Nurse #2 with blood pressure 98/5811/05/25 administered by Nurse #2 with blood pressure 97/6911/07/25 administered by Nurse #2 with blood pressure 103/6011/12/25 administered by Nurse #2 with blood pressure 99/6111/14/25 administered by Nurse #2 with blood pressure 97/6211/17/25 administered by Nurse #2 with blood pressure 102/7211/19/25 administered by Nurse #2 with blood pressure 100/6111/21/25 administered by Nurse #2 with blood pressure 97/6011/24/25 administered by Nurse #2 with blood pressure 101/6311/26/25 administered by Nurse #2 with blood pressure 100/5811/28/25 administered by Nurse #2 with blood pressure 103/60 Review of the Medication Administration Record (MAR) dated December 2025 for Resident #12 revealed Metolazone 5 milligram tablets were initialed as administered on the following dates with systolic blood pressure readings less than 110 or diastolic blood pressure less than 60: 12/01/25 administered by Nurse #2 with blood pressure 99/6312/03/25 administered by Nurse #2 with blood pressure 102/7012/05/25 administered by Nurse #2 with blood pressure 106/6912/08/25 administered by Nurse #2 with blood pressure 99/6512/10/25 administered by Nurse #2 with blood pressure 95/6812/12/25 administered by Nurse #2 with blood pressure 95/6212/15/25 administered by Nurse #2 with blood pressure 105/6912/17/25 administered by Nurse #2 with blood pressure 97/6212/19/25 administered by Nurse #2 with blood pressure 96/6512/22/25 administered by Nurse #2 with blood pressure 108/6112/24/25 administered by Nurse #2 with blood pressure 95/5612/26/25 administered by Nurse #2 with blood pressure 108/6212/29/25 administered by Nurse #2 with blood pressure 105/68 Review of the Medication Administration Record (MAR) dated January 2026 for Resident #12 revealed Metolazone 5 milligram tablets were initialed as administered on the following dates with systolic blood pressure readings less than 110 or diastolic blood pressure less than 60: 1/02/26 administered by Nurse #2 with blood pressure 98/641/07/26 administered by Nurse #2 with blood pressure 107/611/09/26 administered by Nurse #2 with blood pressure 94/631/14/26 administered by Nurse #2 with blood pressure 101/621/16/26 administered by Nurse #2 with blood pressure 102/611/19/26 administered by Nurse #2 with blood pressure 102/571/21/26 administered by Nurse #2 with blood pressure 99/681/26/26 administered by Nurse #2 with blood pressure 105/601/30/26 administered by Nurse #2 with blood pressure 109/55 Review of the Medication Administration Record (MAR) dated February 2026 for Resident #12 revealed Metolazone 5 milligram (mg) tablets were initialed as administered on the following dates with systolic blood pressure readings less than 110 or diastolic blood pressure less than 60: 2/02/26 administered by Nurse #2 with blood pressure 93/582/04/26 administered by Nurse #2 with blood pressure 102/582/06/26 administered by Nurse #2 with blood pressure 102/632/09/26 administered by Nurse #2 with blood pressure 103/592/11/26 administered by Nurse #2 with blood pressure 107/67 Review of Resident #12's progress notes from 9/10/25 through 2/11/26 revealed no documentation indicating Resident #12 had a change in her condition. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #12 was cognitively intact. She required staff assistance with activities of daily living and received diuretic medications. During an interview on 2/11/26 at 1:15 PM Nurse #2 stated she did administer Metolazone to Resident #12 on the above dates. She stated she was a new nurse and thought the order to hold the medication was if both the systolic and the diastolic blood pressure was less than 110/60. Nurse #2 stated she misunderstood the parameters that were ordered and the Metolazone was given in error. Nurse #2 stated she was consistently assigned to provide care to Resident #12. Nurse #2 stated Resident #12 was alert and oriented to person, and place, and was out of bed and in her wheelchair this morning and has had no change in her condition. An observation and interview conducted on 2/11/26 at 1:30 PM revealed Resident #12 was in her room sitting in her wheelchair. She was in no distress. Resident #12 voiced no concerns with her care. During an interview on 2/11/26 at 1:39 PM the Nurse Practitioner stated Resident #12 was prescribed Metolazone due to increased edema and was also on another diuretic medication each day. The Nurse Practitioner stated that Resident #12 had heart failure and her blood pressure did run low which was why the parameters were in place for the diuretics. She stated the order was to hold the Metolazone if either the systolic was less than 110 or if the diastolic was less than 60. The Nurse Practitioner stated she was not aware that Resident #12 had received Metolazone outside of the parameters. The Nurse Practitioner indicated she recently evaluated Resident #12 and although Resident #12 had received the Metolazone when it should have been held she has had no change in her condition. She stated the hold parameters were put in place for a reason and the nurse should have followed the parameters and held the dose when Resident #12's blood pressure was outside of the parameters. During a phone interview on 2/13/26 at 9:00 AM the Consultant Pharmacist stated she completed monthly medication reviews for the facility. The Consultant Pharmacist stated that taking Metolazone when it was not indicated could cause hypotension and contribute to an increased risk of falls. During an interview on 2/13/26 at 2:40 PM the Director of Nursing (DON) stated she was not aware that Metolazone continued to be administered to Resident #12 outside of the parameters. The DON stated Resident #12 has had no falls and no change in her condition. The DON stated further education would be provided to all nursing staff regarding medication administration including following blood pressure parameters.

Based on record review, observations, and Registered Dietician (RD) and staff interviews, the facility failed to honor residents' choices to have food items stored in the refrigerator and reheated for later consumption for 3 of 9 residents reviewed for self-determination (Resident #28, Resident #48, Resident #71).The findings included:a. Resident #28 was admitted to the facility on [DATE] with diagnoses to include acute unspecified protein calorie malnutrition.Review of Resident #28's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired and was coded independent for eating.The care plan dated 12/8/2025 for Resident #28 revealed a plan of care for risk for malnutrition related to weight loss, acute on chronic illness, and impaired mobility. The goal of care was for her intake of nutrients to meet her metabolic needs. Interventions included she was to receive her diet and supplements as prescribed.An interview with Resident #28 was completed on 2/10/2026 at 11:25 AM. Resident #28 stated she really didn't like the food provided by the facility. She further stated she would prefer to eat foods provided to her by her husband from home or local restaurants. Resident #28 indicated the facility would not allow her to store any cooked foods in the refrigerator or reheat the food for her. She stated that she would like to store food items brought to her in the refrigerator, but she was told by the facility that it was not allowed. b. Resident #48 was admitted on [DATE] with diagnosis to include stroke.Review of Resident #48's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and was coded as independent for eating.An interview with Resident #48 was completed on 2/10/26 at 11:14 AM. Resident #48 stated he did not like the food provided by the facility. He further stated that in the past he enjoyed ordering a pizza once per month and would eat some of the pizza for dinner and save the rest in the refrigerator and have it reheated for his lunch and dinner the following day. Resident #48 stated that recently he was told that he was not allowed to store any cooked food items in the refrigerator or reheat the food and the pizza that he ordered and purchased was thrown away by the staff. Resident #48 stated that he would like to store food items in the refrigerator, but he was told that the facility did not allow this. c. Resident #71 was admitted on [DATE] with diagnosis to include stroke and diabetes.Resident #71's quarterly Minimum Data Set (MDS) dated [DATE] revealed that he was cognitively intact. An interview with Resident #71 was completed on 2/10/26 at 1:28 PM. Resident #71 stated that he did not like the food provided by the facility. He further stated that he would prefer to eat foods including healthy, diabetic foods provided by his family. Resident #71 stated that he was told that the facility would not allow him to store any cooked foods in the refrigerator or reheat the food for him. He stated that he would like to store food items brought in by his family in the refrigerator but was told by the facility that it was not allowed and the facility did not allow residents to have a personal refrigerator in their room.An observation of the 300-hall nourishment room was completed on 2/10/2026 at 10:35 AM. A sign on the refrigerator for residents read in part, No cooked food may be stored in refrigerator. No stored foods per Carrolton policy.An interview with the Dietary Manager was conducted on 1/10/2026 at 10:38 AM. The Dietary Manager stated that it was the facility's policy not to allow residents to store food in the nourishment room refrigerator to prevent any potentially hazardous food illnesses from leftover food or foods that were prepared someplace else. She indicated that residents were allowed to keep drinks and nutritional supplements in the nourishment room refrigerator.An interview with the Registered Dietician (RD) was conducted on 2/12/2026 at 1:47 PM. The RD stated that one of his recommendations to facilities was that previously cooked food items could usually be safely stored in the refrigerator for up to 3 days.An interview with the Director of Nursing (DON) was completed on 2/13/2026 at 2:40 PM. The DON stated she expected residents to be allowed to make choices about their food. She further stated that residents should be given the choice to store leftovers in the refrigerator for later consumption.An interview with the Administrator was completed on 2/10/2026 at 11:30 AM. The Administrator stated the facility policy was not to allow residents to store food in the refrigerator and not to reheat foods. He indicated that any cooked foods that were not eaten within 4 hours were discarded. The Administrator stated that residents were not allowed to have personal refrigerators in their rooms.

Based on record review and staff and Nurse Practitioner interviews, the facility failed to provide effective supervision of a cognitively impaired resident (Resident #91) who was known to exhibit wandering behavior and rummaging. This failure resulted in Resident #91 obtaining and ingesting one gel capsule of an over-the-counter cold and flu medication containing acetaminophen, dextromethorphan (cough suppressant) and phenylephrine (nasal decongestant) that was in an unlocked drawer in the receptionist's desk located in the lobby area of the facility. This deficient practice was identified for 1 of 4 residents reviewed for supervision to prevent accidents (Resident #91).Findings included:Resident #91 was admitted on [DATE] with a diagnosis which included Lewy body dementia, atrial fibrillation (irregular heart rate), hypertension, diabetes, chronic obstructive pulmonary disease, heart failure, thyroid disease and kidney disease.Resident #91's care plan dated 3/10/24 and currently active indicated that the resident was at risk for cognitive decline related to history of delirium and diagnosis of neurocognitive disorder with Lewy Body dementia. The intervention for this problem indicated to monitor, document and report any changes in cognitive function. Resident #91's quarterly Minimum Data Set, dated [DATE] indicated that the resident had moderate cognitive impairment, wandering was not exhibited during the look back period and the resident used a wheelchair for mobility.A review of Resident # 91's electronic health record revealed a nursing progress note dated 12/27/25 at 2:51 PM written by the Unit Coordinator which indicated that Resident #91 went through the unattended receptionist's desk in the lobby and found an over-the-counter cold capsule. Resident #91 ingested the contents. The on-call provider was notified, and the staff were advised to monitor the resident and encourage fluids. The on-call provider was to be notified of any new or worsening symptoms. The note stated that Resident #91 was symptomatic with no description of the symptoms exhibited.A review of the manufacturer's instructions for the cold and flu relief gel capsule indicated to ask a doctor before use if you have: liver disease, heart disease, high blood pressure, thyroid disease or diabetes. Common side effects include but are not limited to confusion, dizziness, nervousness, and nausea.An interview was conducted with the Unit Coordinator on 2/12/26 at 2:55 PM. The Unit Coordinator stated that she was assigned to Resident #91 on 12/27/25 from 7:00 AM to 7:00 PM. The Unit Coordinator stated that on the afternoon of 12/27/25, she was in the nurse's station which is adjacent to the lobby when the Receptionist informed her that as she was returning to her desk, the Receptionist witnessed from across the room, Resident #91 ingesting a cold and flu gel capsule from the unlocked unattended desk drawer at the Receptionist's desk. The Receptionist informed the Unit Coordinator that she was unable to get to the resident in time to prevent her from taking the medication. The Unit Coordinator stated the Receptionist observed Resident #91 go into the receptionist's desk drawer, obtain one gel capsule of the cold and flu medication that was loose in the drawer and ingested it before staff could stop her. The Unit Coordinator stated that the Receptionist stated that she had the cold and flu medication loose in the desk drawer and Resident #91 opened the desk drawer, found the medication and ingested it. The Unit Coordinator indicated that throughout the day, residents were frequently in the common area in the front of the building where the receptionist's desk was and most of the residents don't wander or go into things. The Unit Coordinator stated that staff tried to supervise the residents in the common area the best they could but there was no system in place to ensure that the residents in the area were continuously monitored. The Unit Coordinator stated that the lobby area was an open area with television and seating that the residents were free to sit in and can propel wheelchairs throughout the area unrestricted with the receptionist's desk at the front of the area by the door to the facility. The Unit Coordinator indicated that Resident #91 exhibited behaviors of wandering throughout the facility, entering other resident rooms and common areas and rummaging through other residents' belongings. The Unit Coordinator stated that prior to this incident, Resident #91 would take items from other resident rooms, and it was difficult to redirect her. The Unit Coordinator stated that staff tried to monitor Resident #91 and redirect her when she wandered or rummaged through other residents' belongings. The Nurse Coordinator stated that initially after Resident #91 ingested the medication, she seemed okay but then she became drowsy and lethargic, so she was sent to the emergency room. A message was left on the Receptionist's voicemail on 2/13/26 at 2:12 PM with no return call received.A nursing progress note dated 12/27/25 at 5:51 PM written by the Weekend Supervisor revealed that the on-call provider and emergency medical services were called at 5:15 PM. Resident #91 was lethargic and not responding after she ingested over-the-counter cold medication. Resident #91 was sent to the emergency department for evaluation. An interview was conducted with the Weekend Supervisor on 2/13/26 at 1:55 PM. The Weekend Supervisor stated that Resident #91 had dementia and was confused with wandering and rummaging behaviors. The Weekend Supervisor stated that while she was on duty on 12/27/25 from 7:00 AM to 7:00 PM, the Unit Coordinator reported that Resident #91 went into the unlocked, unattended receptionist's desk drawer and obtained a cold and flu gel capsule and ingested it. The Weekend Supervisor indicated that Resident #91 was cognitively impaired with a diagnosis of dementia, propelled her wheelchair independently throughout the facility and at times was agitated and difficult to redirect with increased confusion. The Weekend Supervisor stated that after Resident #91 ingested the cold medication Resident #91 was drowsy and lethargic, so the supervisor stated she informed the on-call provider. The Weekend Supervisor stated that she obtained an order to send Resident #91 to the emergency department for altered mental status. The Weekend Supervisor stated that Resident #91 was evaluated in the emergency department and returned to the facility the same day? with no new orders.A review of the emergency department Discharge summary dated [DATE] at 6:18 AM indicated that Resident #91 arrived in the emergency department on 12/27/25 at 5:51 PM with vital signs which were blood pressure 151/89 millimeters of Mercury (mm/Hg) (normal range is below 120/80 mmm/Hg) pulse 61 (normal range is 60-110), respirations 17 (normal range 16-20 breaths per minute), temperature 97.4 degrees (normal range is 97 to 99 degrees Fahrenheit) and oxygen saturation 96 percent (normal range is 96-100 percent). Resident #91 presented to the emergency department with altered mental status that began earlier in the day after she ingested a dose of over-the-counter cold and flu medication that she took from the receptionist's desk drawer. The discharge summary indicated that the supervisor at the facility reported that after taking the cold and flu medication, Resident #91 was very confused, not responding to her name, and was wandering into other residents' rooms at the facility. While in the emergency department, lab work, electrocardiogram, computed tomography (CT) scan of the head and urinalysis were obtained with the results being unremarkable. The note indicated that Resident #91's condition remained stable with no changes in vital signs or mental status while in the emergency department and the resident was discharged to the facility at 6:18 AM on 12/28/25 with no new physician orders. The discharge summary indicated that the facility was to follow up with the primary care physician if Resident #91 exhibited any worsening or change in symptoms. An interview was conducted with the Nurse Practitioner on 2/11/26 at 1:50 PM. The Nurse Practitioner stated that Resident #91 should not have had access to the medication and that the resident was confused with impaired cognition, wandering and rummaging behavior. The Nurse Practitioner stated that ingesting the medication had the potential for an adverse effect but Resident #91 did not suffer harm due to this incident. The Nurse Practitioner stated that one dose of the over-the-counter cold medication containing acetaminophen, dextromethorphan and phenylephrine wouldn't normally cause lethargy but the effect of a medication, even an over-the-counter medication, is individual. The Nurse Practitioner stated that it was her professional opinion that the gel capsule was not related to Resident #91's change in status with increased lethargy. The Nurse Practitioner stated that she had no concern that the cold medication was related to Resident #91's change in status and thought that it was related to the resident's diagnosis of Lewy Body Dementia which can cause waxing and waning cognition. An interview was conducted with the Director of Nursing (DON) on 2/13/26 at 2:30 PM. The DON stated that the incident should not have happened, and the resident should have been supervised and kept free from hazards. The DON indicated that all staff were responsible for supervising the residents but there was no system in place to ensure that a staff member was continuously monitoring the residents in the common areas, including the lobby area. The DON stated that staff are frequently passing in and out of the lobby area. Prior to this incident, the facility had not considered unlocked drawers to be a potential hazard to the residents. An interview with the Administrator on 2/13/26 at 4:15 PM revealed that he expected that the residents would be kept free from hazards and supervised to prevent accidents. The Administrator stated that all staff were responsible for supervising the residents in common areas including the lobby area. Prior to this incident, the facility had not considered unlocked drawers to be a potential hazard to a cognitively impaired resident.

Based on observations, record review, and staff interviews, the facility failed to discard expired medications and record an opened date on ophthalmic drops that had shortened expiration dates on 2 of 6 medication carts that were reviewed for medication storage (200 hall medication cart #1 and medication cart #2). Findings included. a.) An observation of the 200-hall medication cart #1 on 2/10/26 at 2:50 PM along with Nurse #1 revealed the following medications: One bottle of Latanoprost .005% ophthalmic drops that was opened with no opened date labeled on the bottle. Review of the manufacturer's guidelines for Latanoprost ophthalmic solution instructed that once a bottle was opened for use, it may be stored at room temperature for 6 weeks then discarded. One bottle of Rocklatan ophthalmic drops that was opened with no opened date labeled on the bottle. Review of the manufacturer's guidelines for Rocklatan ophthalmic solution (a combination of two medications) instructed that once a bottle was opened for use, it may be stored at room temperature for 6 weeks then discarded. b.) An observation of the 200-hall medication cart #2 on 2/10/26 at 3:00 PM along with Nurse #1 revealed the following medications: Pyridium (phenazopyridine) 95 milligram tablets, a urinary analgesic, with an expiration date of March 2025. One bottle of Dorzolamide 2% ophthalmic drops with an expiration date of 11/30/25. During an interview on 2/10/26 at 2:05 PM Nurse #1 stated she was the assigned nurse today for medication cart #1 and medication cart #2. Nurse #1 stated all nurses were responsible for checking the medication carts for expired medications and recording opened dates on the eye drops. Nurse #1 indicated she had not administered any of the expired medications today and she had not checked for expiration dates on either medication cart. Nurse #1 further stated she did not open the eye drops on medication cart #1 and the eye drops should have been dated when opened. During an interview on 2/13/26 at 2:34 PM the Director of Nursing (DON) stated the assigned nurse was responsible for checking medication carts for expired medications and to ensure all medications with shortened expiration dates were labeled with an opened date. The DON stated the expired medications should have been discarded and the eye drops should have been labeled with opened dates.

Based on record review and staff interviews, the facility failed to ensure the facility assessment identified and addressed the care required for the population of residents with a port-a-cath (a small implanted device placed under the skin in the chest to provide easy, long-term access to a vein for chemotherapy, medication, intravenous (IV) fluids, or blood sampling), and to address the staff training necessary to competently provide port-a-cath care for residents for 1 of 1 resident (Resident #1).Findings included:Review of the facility assessment revealed the assessment was last updated on 9/8/2025. The document indicated the facility had completed education, training and competencies with staff specific to resident care needs; however, the document lacked training and competency to care for residents who required a port-a-cath.Resident #1 was admitted to the facility on [DATE]. Review of the electronic medical record (EMR) revealed Resident #1's port-a-cath was placed 12/18/2024 during a hospitalization for pneumonia.An interview with the Director of Nursing (DON) was completed on 2/13/2026 at 11:04 AM. The DON confirmed that the nursing staff had not received training and competencies regarding the care of a port-a-cath. An interview with the Administrator was conducted on 2/13/2026 at 9:40 AM. The Administrator confirmed the facility had one resident with a port-a-cath. The Administrator also stated he was not aware the nursing staff had not received education and had competencies checked regarding providing care for residents with a port-a-cath. He indicated that he was responsible for updating the facility assessment with input from the DON and other administrative staff. The Administrator confirmed he had just updated the facility assessment 1/1/2026 to reflect the change in therapy providers. The Administrator indicated he knew that all of the care needs regarding residents should be reflected in the facility assessment.

Based on observations, record review, and Consulting Pharmacist and staff interviews, the facility failed to administer the physician ordered hypotensive medication (a medication to increase blood pressure) 6 times in one month when the blood pressure reading required the administration of the medication for 1 of 3 residents (Resident #18) sampled for medication review. Findings included: Resident #18 was admitted to the facility on [DATE]. Diagnoses included high blood pressure and Vitamin D deficiency. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #18 was moderately cognitively impaired. A physician's order written on 09/11/24 for Midodrine (medication used to treat orthostatic hypotension (sudden fall in blood pressure that can occur when a person assumes a standing position) 5 milligrams (mg) give one tablet by mouth as needed for blood pressure less than 110/60 millimeter of mercury (mm/Hg). A physician's order written on 11/15/24 for Metoprolol Tartrate (a medication to treat high blood pressure) 25 mg give one tablet by mouth twice daily; hold for systolic blood pressure (SBP) less than 110 mm/Hg or diastolic blood pressure (DBP) less than 60 mm/Hg. A review of the November Medication Administration Record (MAR) revealed the Metoprolol Tartrate 25 mg was held 6 days due to low blood pressure readings as evidenced by nursing initials and a checkmark. The MAR also revealed the Midodrine 5 mg was not administered as evidenced by no nursing initials or checkmark. The blood pressure recordings were as follows: 11/06/24 90/40 mm/Hg 11/06/24 106/53 mm/Hg 11/07/24 100/60 mm/Hg 11/11/24 106/64 mm/Hg 11/12/24 108/57 mm/Hg 11/14/24 100/56 mm/Hg An interview with Medication Aide (MA) #1 on 11/20/24 at 10:30 AM revealed on 11/06/24, 11/07/24 and 11/14/24, the MA #1 stated as a medication aide she was not allowed to administer as needed (PRN) medications and she would have had to notify the nurse to administer the Midodrine when the blood pressure was low. MA #1 stated she did not notify the charge nurse on duty that Resident #18's blood pressure was within the parameters to receive the ordered Midodrine 5 mg and she should have. An interview was conducted with Nurse #6 on 11/21/24 at 11:10 AM. Nurse #6 confirmed she did not administer the Midodrine to Resident #18 on 11/06/24 and 11/11/24. Nurse #6 stated she did not realize the order was in place to administer Midodrine if the blood pressure was less than 110/60 mm/Hg. An interview was conducted with MA #2 on 11/21/24 at 12:55 PM. MA #2 stated she did not notify the charge nurse on duty on 11/12/24 that Resident #18 needed the Midodrine due to his low blood pressure. MA #2 stated as a medication aide she was not allowed to administer as needed medications, and she would have had to notify the nurse to administer the Midodrine. MA #2 stated she did not realize the order to administer Midodrine was in place. An interview was conducted with the Consulting Pharmacist via phone on 11/21/24 at 3:27 PM. The Pharmacist stated if the blood pressure the nursing staff had taken and recorded was within the parameters to receive the Midodrine 5 mg, she would have expected the nursing staff to administer the medication to help elevate the resident's blood pressure and reduce the possibility of getting orthostatic hypotension. She stated not giving the Midodrine to raise the blood pressure may cause the resident's blood pressure to go even lower with the next dose of Metoprolol. The Pharmacist added that she had not done the monthly drug regimen review as yet for Resident #18, but if she had she would have put in her report a recommendation noting missed opportunities to administer the Midodrine based on the blood pressure parameters. An interview was conducted with the Director of Nursing (DON) on 11/21/24 at 3:30 PM. The DON stated if there were parameters in place to hold a medication or give a medication, he expected his nursing staff to follow the order as written. The DON stated the Medication Aides should have notified the nurse of the blood pressure so the Nurse could have administered the ordered medication. The DON added that parameters were in place for a reason and not following the order could result in a negative outcome for the resident.

Based on record review and staff interviews, the facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage a day, 7 days a week for 13 of 139 days reviewed. Findings included: Review of the PBJ (Payroll Based Journal) Staffing Data Report Fiscal Year - Quarter 2, 2024 (January 1-March 31, 2024) documented the facility had no RN coverage on 01/13/24, 01/20/24, 01/21/24, 02/03/24, 02/18/24, 02/24/24, 03/02/24, 03/24/24, and 03/30/24; and for Quarter 3, 2024 (April 1-June 30, 2024) on 04/06/24, 04/28/24, 05/04/24, 05/11/24, 05/12/24, and 05/26/24. Review of the facility daily staffing documentation revealed the DON (Director of Nursing) had worked 8 consecutive hours as a staff nurse on 01/21/24 and 04/06/24 after he had fulfilled his full time DON obligation (40 hours) as the DON for both weeks. In an interview with the Administrator on 11/19/24 at 12:44 PM he stated the facility had hired an RN Weekend Supervisor and there had been no recent issues with RN coverage. He noted that on some of the days that there was no weekend RN coverage the DON had worked as a staff nurse to fill the need. In an interview with the Nursing Scheduler/Payroll Manager on 11/21/24 at 11:11 AM she confirmed there was no RN coverage in the building for 8 hours on the following dates: 01/13/24, 01/20/24, 02/03/24, 02/18/24, 02/24/24, 03/02/24, 03/24/24, 03/30/24, 04/28/24, 05/04/24, 05/11/24, 05/12/24, and 05/26/24. She reported that the facility did have RN coverage in the building for 12 consecutive hours on 01/21/24 and 04/06/24. She explained the DON had worked on the floor on 02/24/24 and 04/06/24 but because he was salaried and did not punch the time clock the hours were not reported on the PBJ report. She stated that on both days the DON worked as a staff nurse, he had already worked 40 hours as the full time DON. She noted that the problem on the weekends with staffing a Registered Nurse (RN) for 8 consecutive hours was because the weekend RN Supervisor that had been employed was not reliable. She stated the facility had hired a new RN Weekend Supervisor and there have not been any recent problems with staffing. In an interview with the DON on 11/21/24 at 11:00 AM he stated that on the two days he worked as a staff nurse, he had already worked 40 hours as the full time DON both weeks. He reported that the staffing problem had occurred because the RN Weekend Supervisor they had was not dependable. He noted the position had been filled and there had been no problems with RN coverage since.

Based on observations, record review, and Consulting Pharmacist, Nurse Practitioner and staff interviews, the facility failed to a) clarify a physician's order for 26 days to determine the right dose to be administered for a daily topical medication to manage pain related to osteoarthritis (degeneration of bone that can cause pain) for Resident #60, b) follow the physician's orders to remove a lidocaine patch (medicated topical pain patch) after 12 hours of use to prevent potential skin irritation, redness, swelling, and/or discomfort for Resident #67 and c) to administer the correct ordered dose of a supplemental medication three times for Resident #18. This was for 3 of 3 residents sampled for medication review. Findings included: 1a. Resident #60 was admitted to the facility on [DATE]. Diagnoses included Dementia and osteoarthritis (type of degenerative joint disease). The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #60 was severely cognitively impaired. A physician order written on 10/24/24 revealed an order for Diclofenac Sodium External 1% (an anti-inflammatory ointment used to treat pain) apply to left hand topically (on top of skin) three times daily for osteoarthritis. The order did not indicate the dose (# of grams) to be applied. Review of the October Medication Administration Record revealed Diclofenac Sodium External 1% apply to left hand topically three times daily, but did not indicate the dose (# of grams) to be applied. The medication was being applied three times daily as evidenced by nursing initials and check marks on the MAR from 10/24/24 through 10/31/24 for a total of 24 doses. Review of the November Medication Administration Record revealed Diclofenac Sodium External 1% apply to left hand topically three times daily, but did not indicate the dose (# of grams) to be applied. The medication was being applied three times daily as evidenced by nursing initials and check marks on the MAR from 11/01/24 through 11/19/24 for a total of 57 doses. A medication pass observation was conducted with Nurse #7 on 11/20/24 at 9:15 AM. Nurse #7 reviewed Resident #60's orders and noted he was to receive Diclofenac Sodium External 1% ointment to apply to his left hand. She was unable to locate Diclofenac Sodium External 1% for Resident #60. At this time, Nurse #7 went to the medication storage room to obtain a house stock of the Diclofenac 1% ointment. Upon return to the medication cart, Nurse #7 proceeded to apply the Diclofenac 1% ointment, but realized the order did not indicate the dose to be applied. Nurse #7 asked the Unit Manager to get the order clarified. The order was then rewritten to apply Diclofenac Sodium External 1% apply 2 grams to left hand topically three times daily for osteoarthritis. Nurse #7 applied the ordered 2 grams of the Diclofenac 1% ointment to Resident #60's left hand. An interview was conducted with Nurse #7 on 11/20/24 at 9:30 AM. Nurse #7 revealed she did not realize the order for the Diclofenac 1% ointment did not have a dose indicated on the order but she knew from other residents the usual dose was between 2 - 4 grams, and stated she could not say for certain how many grams she applied to Resident #60. Nurse #7 stated she should have clarified the order to ensure she was administering the appropriate dose. Nurse #7 confirmed she had administered the ointment 15 times since 10/24/24 through 11/19/24 and was not aware of the actual dose to be applied. An interview was conducted with Nurse #5 on 11/20/24 at 4:15 PM. Nurse #5 reviewed the order for Diclofenac 1% ointment for Resident #60 and confirmed there was no dose on the order to know how much to apply. Nurse #5 stated she would squeeze some (not specific amount) on the measuring strip that was provided in the box and then apply it. Nurse #5 stated she administered the ointment 18 times since 10/24/24 through 11/19/24 and she should have clarified the order before applying the ointment. An interview was conducted with Medication Aide #2 on 11/20/24 at 1:00 PM. MA #2 stated the order did not say how much to apply so she just put a small amount on Resident #60 and she did not measure the amount. MA #2 stated she should have reported to the nurse that the order did not indicate a dose and it should have been clarified. MA #2 confirmed she applied the Diclofenac 1% ointment to Resident #60 6 times since 11/01/24. An interview was conducted Medication Aide #3 via phone on 11/20/20 at 1:22 PM. MA #3 confirmed she applied the Diclofenac 1% ointment 8 times since 10/24/24 through 11/19/24 and stated she would just put some in a cup and then apply it to Resident #60, but she did not measure it. MA #3 stated she should have reported to her nurse that the order needed to be clarified to be sure to apply the correct dose. An interview was conducted with Medication Aide #4 on 11/20/20 at 1:30 PM. MA #4 reported she would apply a small amount Diclofenac 1% on the measuring strip that was provided, but she did not know how many grams she applied. MA #4 confirmed she applied the ointment one time on 11/02/24. An interview was conducted with Nurse #6 on 11/21/24 at 10:22 AM. Nurse #6 reported that she did not usually work on that unit but confirmed she had applied the Diclofenac 1% on 11/13/24 to Resident #60 without knowing the actual number of grams to be applied. Nurse #6 stated she should have clarified this order for the actual dose to be applied. An interview was conducted with the Consulting Pharmacist via phone on 11/21/24 at 3:27 PM. The Pharmacist reviewed the order for Resident #60 for the Diclofenac 1% and stated the order should have indicated the dose amount to be applied. The Pharmacist stated she would have expected the order to be clarified back when it was put in on 10/24/24 and added that receiving too much of the Diclofenac 1% ointment would inhibit the absorption of the ointment and receiving too little of the ointment by not having it evenly spread throughout his hand, the resident may exhibit unrelieved pain. The Pharmacist added the last time she completed her monthly drug regimen review for this resident was on 10/09/24. An interview was conducted with the Director of Nursing (DON) on 11/21/24 at 3:30 PM. The DON stated he would have expected the order for the Diclofenac 1% to be clarified when the order was first initiated on 10/24/24. The DON added that the nursing staff should always utilize the 5 rights of drug administration whenever they are administering physician order medications which includes the right dose. 1b. Resident #67 was admitted to the facility on [DATE]. Diagnoses included pain. The MDS annual assessment dated [DATE] revealed Resident #67 was cognitively intact and was on a pain medication regimen for occasional moderate pain. A physician's order was written on 02/24/24 for Lidocaine external patch 4%, apply to back topically one time a day for pain. Remove after 12 hours. Review of the November 2024 Medication Administration Record (MAR) revealed the Lidocaine external patch 4% was signed off as being removed by Nurse #5 on 11/19/24 at 9:00 PM. During a medication pass with Medication Aide (MA) #1 on 11/20/24 at 8:30 AM, MA #1 revealed she was going to apply a Lidocaine Patch 4% to Resident #67's back. Prior to applying the patch, MA #1 noted the existing patch on Resident #67's back was dated 11/19/24. MA #1 stated, the nurse left your patch on last night, and she then removed the existing patch. There was no redness or skin irritation noted. MA #1 applied the new patch to Resident #67's back. An interview with Nurse #5 on 11/20/24 at 4:14 PM revealed she should not have signed off on the MAR that she removed the Lidocaine patch when she did not. Nurse #5 stated she was quickly signing off her medications to be administered and had signed off the removal of the Lidocaine patch before she was supposed to remove the patch and then forgot to remove the patch because she got busy. An interview with the Nurse Practitioner (NP) on 11/21/24 at 2:40 PM via phone revealed she would have expected the Lidocaine Patch to be removed after 12 hours as ordered. The NP stated wearing lidocaine patches for more than 12 hours can cause skin irritation, redness, swelling, and discomfort. The NP stated if there was no irritation noted it would be okay for MA #1 to apply the new patch as ordered. An interview was conducted with the Director of Nursing on 11/21/24 at 3:30 PM. The DON stated he would have expected his nursing staff to remove the Lidocaine Patch as ordered. 1c. Resident #18 had a physician's order written on 11/15/24 for Vitamin D3 125 micrograms (mcg) 5000 units one tablet by mouth once daily. A medication pass observation was conducted on 11/20/24 at 8:30 AM with Medication Aide #1 for Resident #18. MA #1 reviewed Resident #18's orders and noted he was to receive Vitamin D3 125 mcg/5,000 units one tablet daily. MA #1 checked her medication cart for this supplement and was noted to have a bottle of Vitamin D3 25 mcg/400 unit bottle only. MA #1 did not administer the Vitamin D3 25 mcg/400 unit dose. An interview with Medication Aide #1 on 11/20/24 at 8:30 AM revealed the order for the Vitamin D3 125 mcg/5,000 units changed on 11/15/24 and they were waiting for it to arrive from the Pharmacy. MA #1 stated there was no order to give the Vitamin D3 25 mcg/400 unit tablet until the Vitamin D3 125 mcg/5000 unit tablets arrived. The MA stated there was no order to hold the Vitamin D3 125 mcg/5000 units until it was available. MA #1 stated she should have notified the Nurse that the medication was not available so that the Nurse could obtain an order to hold the Vitamin D3 125 mcg/5000 until it was available. During reconciliation of the medication pass conducted with Medication Aide #1, a review of the November 2024 Medication Administration Record (MAR) revealed the medication to treat a Vitamin D deficiency, Vitamin D3 125 mcg 5000 units, was signed off as given by Medication Aide #5 on 11/16/24, MA #4 on 11/17/24 and MA #1 on 11/18/24 and 11/19/24. An interview with MA #1 on 11/20/24 at 10:10 AM revealed she administered the Vitamin D3 25 mcg/400 units tablet on 11/18/24 and 11/19/24. She stated she misread the bottle of Vitamin D3 and thought it was 125 mcg but it was 25 mcg. A phone interview with MA #4 on 11/20/24 at 1:00 PM revealed she administered the Vitamin D3 25 mcg/400 units tablet on 11/18/24 and 11/19/24. She stated she misread the bottle of Vitamin D3 and thought it was 125 mcg but it was 25 mcg. A phone interview was attempted with MA #5 on 11/20/24 at 1:17 PM. MA #4 did not return call. An interview was conducted with the Consulting Pharmacist via phone on 11/21/24 at 3:27 PM. The Pharmacist stated that not receiving the ordered dose but getting a lower than intended dose would not cause ill effects or harm. The Pharmacist stated, however, that she would have expected the Medication Aides to read the label carefully to ensure they was administering the ordered dose according to the 5 rights of drug administration (right patient, right drug, right dose, right route of administration, and right time). An interview was conducted with the Director of Nursing on 11/21/24 at 3:30 PM. The DON stated it was the responsibility of the Medication Aides to read the labels carefully to make sure the right medication and the right dose was being administered and that they should have alerted the Nurse to notify the physician to hold the Vitamin D3 125 mcg/5000 units until it arrived.

Based on observations, record review and staff interviews, the facility inaccurately documented the removal of a lidocaine patch (medicated topical pain patch) and the presence of a fall mat for 1 of 3 residents (Resident #67) observed during a medication pass, and inaccurately documented the removal of a dressing to an arterial venous access (vascular access to arm used for dialysis treatments) for 1 of 2 residents (Resident #69) observed for dialysis. Findings included: Resident #67 was admitted to the facility on [DATE]. Diagnoses included stroke with left side weakness, abnormalities of gait and mobility, lack of coordination, pain, and limitation of activities due to disability. 1a. A physician's order was written on 02/24/24 for Lidocaine external patch 4%, apply to back topically one time a day for pain. Remove after 12 hours. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #18 was cognitively intact and was on a pain medication regimen for occasional moderate pain. During a medication pass with Medication Aide (MA) #1 on 11/20/24 at 8:30 AM, MA #1 revealed she was going to apply a Lidocaine Patch 4% to Resident #67's back. Prior to applying the patch, MA #1 noted the existing patch on Resident #67's back was dated 11/19/24. MA #1 stated, the nurse left your patch on last night, and she then removed the existing patch. There was no redness or skin irritation noted. MA #1 applied the new patch to Resident #67's back. Review of the November 2024 Medication Administration Record (MAR) revealed the Lidocaine external patch 4% was signed off as being removed by Nurse #5 on 11/19/24 at 9:00 PM. An interview with Nurse #5 on 11/20/24 at 4:14 PM revealed she should not have signed off on the MAR that she removed the Lidocaine patch when she did not. Nurse #5 stated she was quickly signing off her medications to be administered and had signed off the removal of the Lidocaine patch before she was supposed to remove the patch and then forgot to remove the patch because she got busy. An interview was conducted with the Director of Nursing (DON) on 11/21/24 at 3:30 PM. The DON stated he would have expected his nursing staff to remove the Lidocaine Patch as ordered and to then to sign it off on the Medication Administration Record after it was removed. The DON stated had Nurse #5 removed the Lidocaine Patch from Resident #67 and then signed it off as completed there would be no error or inaccurate documentation. 1b. A physician's order was written on 02/27/24 for nurse to check fall mat placement every shift. An observation of Resident #67's room on 11/20/24 at 10:10 AM revealed there was no fall mat at his bedside. Review of the November 2024 MAR revealed the order to check fall mat placement was signed off as being checked for placement by Medication Aide #1 on 11/20/24. An interview with MA #1 on 11/20/24 at 10:10 AM revealed she signed off on the MAR that the fall mat was in place and she should not have since it was not there. She stated she was just clicking off all medications and must have clicked off the fall mat placement in error. An interview was conducted with the Director of Nursing on 11/21/24 at 3:30 PM. The DON revealed the fall mat was needed to aide in keeping Resident #67 from serious injury if he should fall from bed. The DON reported he would have expected Medication Aide #1 to check for fall mat placement before signing off that it was in place. 2. Resident #69 was admitted to the facility on [DATE]. Diagnoses included, in part, end stage renal disease (ESRD) and dependent on dialysis. The MDS admission assessment dated [DATE] revealed Resident #69 was moderately cognitively impaired and was receiving dialysis services. A physician's order written on 10/11/24 revealed Resident #69 was to receive dialysis on Monday, Wednesday, and Friday. A dialysis communication sheet sent to the facility dated 10/20/24 written by the Dialysis Nurse revealed under other concerns a note indicating please remove gauze dressing from dialysis site the night of dialysis. Leaving it on can damage the access. A physician's order was written on 11/01/24 to remove dressing to left arm dialysis access site approximately one hour after return from dialysis each evening shift on Monday, Wednesday, and Friday. Review of the November 2024 MAR revealed the order to remove the dressing to left arm dialysis access site was signed off as being removed by Nurse #5 on 11/20/24. An observation of Resident #69 on Thursday, 11/21/24 at 9:30 AM, revealed Resident #69 was noted to have his dressing in place to his left arm access site. An interview with Nurse Aide #4 on 11/21/24 at 9:30 AM revealed she was getting Resident #69 ready for his bed bath at this time and she was removing the dressing from Resident #69's left arm access site. She stated the dressing had been on since yesterday's dialysis treatment and she did not see any blood seeping through the dressing and felt it was safe to remove. An interview was conducted with Nurse #5 on 11/21/24 at 10:45 AM. Nurse #5 revealed there was no order to remove the dressing so she did not remove the dressing. Nurse #5 reviewed the physician orders and confirmed there was an order in the MAR to remove the dressing. Nurse #5 stated she should not have signed off removing the dressing when she did not remove the dressing. Nurse #5 stated she did not realize she signed the order off in the MAR. An interview was conducted with the Director of Nursing on 11/21/24 at 3:30 PM. The DON reported there had been a concern in the past that the dressing to Resident #69's access site was not being removed the night of the dialysis treatment and he had addressed the concern with his nursing staff to ensure the dressing was removed after each dialysis treatment on Monday, Wednesday and Friday. The DON stated he had an order put in place on 11/01/24 to remind nursing staff to remove the dressing from the access site. He stated Nurse #5 should not have documented that she removed the dressing, when in fact, she did not. He stated it was inaccurate documentation.

Based on record review, observation, and staff interviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse for 2 of 4 residents reviewed for abuse (Resident #35 and Resident #78). On 08/28/24 Resident #35 attempted to grab belongings out of Resident #84's hat, Resident #84 told him to stop but he continued. In response, Resident #84 grabbed Resident #35 by the arm and shook him causing Resident #35 to fall to the floor. Resident #84 then attempted to run Resident #35 over with his wheelchair. Resident #35 was not injured. On 09/23/24 Resident #78 entered Resident #76's room and Resident #76 slapped Resident #78 on the left cheek with an open hand and Resident #78 sustained mild redness to her left cheek which resolved within minutes after being assessed. Findings included: 1. Resident #35 was admitted to the facility on [DATE] with diagnoses that included, anxiety disorder, cognitive communication deficit, lack of coordination, and unsteadiness on his feet. Review of a quarterly MDS assessment dated [DATE] revealed Resident #35 had severely impaired cognition. He had no moods or behaviors during the assessment look back period. Review of a care plan for Resident #35 (initiated on 02/26/23) documented the focus area of a behavior problem related to wandering into other resident's rooms and removing their personal items such as stuffed animals and toys thinking they belong to him. The goal was for Resident #35 to have fewer episodes by the review date. Interventions included anticipation of his needs and to praise any indication of the resident's progress or improvement in behavior. Resident #84 was admitted to the facility on [DATE] with diagnoses that included schizoaffective bipolar type disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 had moderately impaired cognition. He had displayed physical and verbal behavioral symptoms directed toward others on 1 to 3 days during the assessment look back period. He used a wheelchair for mobility. A progress note written by the Unit Manager on 08/27/24 at 10:22 AM documented that Resident #84 was noted to have behaviors. He became upset and was threatening other residents. He cursed at another resident threatening him with a plastic straw. The Nurse Practitioner (NP) was called. A new order was received to increase Seroquel (antipsychotic medication) and to send to the hospital for evaluation. In an interview with the Unit Manager on 11/19/24 at 4:13 PM she stated she did not see what happened regarding Resident #84 on 08/27/24. A staff member (she could not remember who) told her Resident #84 was having behaviors in the hallway. She explained she did not know who any of the other residents were but knew that there had been no physical contact between residents. She reported she called the NP and received an order to increase Resident #84's Seroquel medication and to send him to the hospital for evaluation. She added it was her practice to call the NP when a resident began to have behaviors instead of waiting for the NP to do rounds so that a further increase in behaviors could be avoided. She stated that because there had been no contact between residents there was no abuse issue, and she did not notify the Administrator. An interview was conducted with the NP on 11/20/24 at 2:21 PM. She stated he was familiar with Resident #84. She recalled she had been contacted on 08/27/24 because the resident was in a rage, and she had increased his antipsychotic medication (Seroquel) at that time. The care plan for Resident #84 dated 08/27/24 documented the following focal area: Resident #84 has a behavior problem related to a diagnosis of schizoaffective disorder and a history of intracranial injury with loss of consciousness. On 08/11/24 the resident washed and dried a sanitizer wipe container to use for drinking and refused to use a water pitcher, on 08/23/24 the resident cursed at housekeeping and threw a trash can, and on 08/27/24 the resident threatened others, ran into another resident's wheelchair, cursed at another resident while pointing a plastic straw in a threatening/stabbing motion. The resident was sent to the hospital for assessment. The goal was for Resident #84 to have fewer episodes by the next review date. Interventions included an increase in the dosage of his antipsychotic medication, administer medications as ordered and monitor for side effects, anticipate and meet his needs, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from the situation and take to an alternate location, and a psychological evaluation as needed. An interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 11/19/24 at 3:50 PM. The DON stated he had not been aware that any incident involving Resident #84 had occurred on 08/27/24 until today. The ADON stated she had only heard about it. She was aware his antipsychotic medication had been increased and no further action had been taken. An interview was conducted on 11/20/24 at 3:05 PM with the Case Manager at the hospital who cared for Resident #84 on 08/27/24. She stated on 08/27/24 Resident #84 presented at the emergency room for assessment related to a verbal altercation. She reported that Resident #84 was assessed as safe for discharge by the psychiatric team and the medical physician. He returned to the nursing home on 08/27/24. A progress note written in the medical record of Resident #35 by the Assistant Director of Nursing (ADON) on 08/28/24 at 3:16 PM documented she had heard a resident yelling for help in the dining room. She entered the dining room and noted Resident #35 was on the floor and Resident #84 in from of Resident #35 in his wheelchair trying to run Resident #35 over with his wheelchair. Resident #35 was yelling out for help. The residents were separated and Resident #35 was assessed by the nurse and the NP. No new injuries were observed. Other residents in the dining room for the activity reported Resident #84 pushed Resident #35 to the ground. A progress note written in the medical record of Resident #84 by the ADON on 08/28/24 at 3:47 PM documented that she had heard yelling from the dining room and noted Resident #84 in his wheelchair over Resident #35 attempting to run him over. Resident #84 was yelling that Resident #35 took his money. The residents were separated. An order was received to send Resident #84 to the hospital for evaluation. The Initial Allegation Report dated 08/28/24 documented an allegation of resident abuse. Resident #84 was noted to have pushed Resident #35 to the floor while participating in group activities in the dining hall. The incident was witnessed by other residents and staff. Both residents were immediately separated and Resident #35 was assessed. No injuries were noted to Resident #35. The provider was notified and an order was received to send Resident #84 to the hospital for evaluation. Emergency medical services (EMS) and police were dispatched. Resident #35 complained of right ankle pain and range of motion to the right ankle was at baseline. Pharmacological intervention was initiated by the primary nurse. No mental anguish was noted. A witness statement written by the DON documented he had been sitting in the conference room on 08/28/24 when he heard a resident yell. He immediately got up and went into the dining room to see Resident #35 sitting on the ground. Resident #84 shouted, He tried to take my hat, and it has my money in it. Resident #35 was assessed and got off the floor into a chair. Resident #84 was immediately removed from the dining room and taken to the front lobby with one to one (1:1) supervision. The medical director, attending physician, and NP were all notified. Order were given to send Resident #84 to the emergency department for psychiatric evaluation related to combative behaviors. Resident #35 was taken to the DON office and interviewed regarding the altercation. Resident #35 stated, He pushed me down. I don't hurt. Resident #35's skin was assessed by the primary nurse and DON and no injuries were noted. The statement was signed by the DON but was not dated. An interview was conducted with the ADON on 11/19/24 at 1:07 PM. She stated Resident #84 was involved in a resident to resident altercation over money (08/28/24). She explained when she arrived at the dining hall Resident #84 was in his wheelchair leaning over Resident #35 who was on the ground. Resident #84 was trying to run over Resident #35 with his wheelchair. Resident #84 said, Don't take my money! She stated she separated the residents. She told the Unit Manager to call the NP who gave the facility an order to send Resident #84 to the hospital for an assessment. The following interview between the ADON and Resident #53 was documented by the ADON. She documented that she had spoken with Resident #53 regarding the incident that occurred between Resident #84 and Resident #35. The ADON wrote that Resident #53 told her Resident #35 passed Resident #84 in the dining room. Resident #84 had his hat sitting on the table with belongings in it. When Resident #35 passed the table he attempted to grab the belongings out of Resident #84's hat. Resident #84 told Resident #35 several times not to but Resident #35 continued to grab his things. Resident #84 then stated, I'm going to get you, I'm going to get you. Then Resident #84 proceeded to grab Resident #35 by his arm and shake him, causing him to fall to the ground. This undated statement was signed by the ADON and Resident #53. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #53 had intact cognition. The ADON documented an interview she conducted with Resident #33. The written statement is not dated. She documented she had spoken with Resident # 33 about the incident that happened between Resident #84 and Resident #35. Resident #33 told her he saw Resident #84 grab Resident #35 by his arm and Resident #35 fell to the floor. Resident #33 told the ADON he did not see Resident #35 take anything from Resident #84. This statement was signed by the ADON only. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #33 had intact cognition. The Investigation Report dated 08/30/24 completed by the DON related to the 08/28/24 allegation of resident abuse involving Resident #84 and Resident #35 was substantiated. Resident #84 was no longer a resident at the facility and was not available for interview. An interview was conducted with the Director of Nursing (DON) on 11/19/24 at 1:58 PM. He stated he was present when the resident to resident altercation occurred on 08/28/24 with Resident #84 and Resident #35. He reported that he had been in the conference room when he heard a resident yelling from the dining hall. When he arrived Resident #35 was on the floor and Resident #84 was over him. He took Resident #84 to the front lobby with 1:1 supervision until the ambulance arrived to take him to the hospital for assessment. He helped the ADON do a skin assessment on Resident #35 and started an initial report of abuse. An interview was conducted with the interim Administrator on 11/19/24 at 12:44 PM. He stated that Resident #84 had a history of resisting care, and cursing at and throwing things at staff. He explained the staff were scared of him. He stated since Resident #84 went to the hospital and did not return he expected the other residents and staff would be safe. 35173 2) Resident #76 was admitted to the facility on [DATE]. Diagnoses included dementia and cognitive communication deficit. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #76 was severely cognitively impaired, had no functional limitations in range of motion and required no mobility device. She demonstrated no behaviors during this look back period and required supervision with one staff physical assistance with bed mobility and was independent with transfers. The care plan for Resident #76's active care plan as of 9/22/24 did not include any information related to physical behaviors. Resident #78 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's, dementia, cognitive communication deficit, and metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently). The MDS dated [DATE] 5 day assessment revealed Resident #78 was severely cognitively impaired and demonstrated wandering behavior for 4 to 6 days during this assessment. She had no functional limitations with range of motion and required no mobility device and limited assistance with one staff physical assistance with bed mobility and was independent with transfers. The care plan for Resident #78 initiated on 07/03/24 revealed a plan of care was in place for an elopement risk/wanderer related to impaired cognition and safety awareness, new environment and disorientation to place, and independently able to ambulate with a goal that the resident's safety will be maintained through the review date. Interventions included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, and books; frequently monitor resident's location; document wandering behavior and attempted diversional interventions as needed; and identify pattern of wandering. A plan of care initiated on 07/09/24 was also in place for potential behavior problem related to a history of metabolic encephalopathy and dementia with agitation with a goal that the resident would have no evidence of behavior problems by review date. Interventions included administering medications as ordered; monitor/document for side effects and effectiveness; anticipate and meet the resident's needs; and intervene as necessary to protect the rights and safety of others. The initial allegation report dated 09/23/24 completed by the Administrator documented that Resident #78 entered into Resident #76's room. Resident #76 saw Resident #78 enter her room and slapped her (Resident #78) on the left cheek with an open hand. Both residents were immediately separated and Resident #76 was placed on one to one (1:1) observation. Resident #78 was noted to have no injury and denied pain. A handwritten witness statement dated 09/23/24 by Medication Aide (MA) #3 revealed MA #3 was walking on the 500 hall when she saw Resident #78 walking out of Resident #76's room. She heard Resident #76 fussing and asked Resident #78 what was going on. Resident #78 stated she had to get Resident #76 together because she was in my house. Resident #78 stated yeah, she hit my side of the head. Resident #76 stated I sure did and would do the same if somebody was in your house, too. An interview was conducted with MA #3 via phone on 11/20/24 at 2:15 PM. MA #3 reported she did not witness Resident #76 hitting Resident #78. MA #4 stated she had heard Resident #76 yelling about Resident #78 being in her room and she asked Resident #78 what had happened. MA #3 stated Resident #78 told her Resident #76 hit her on the side of her face. MA #3 stated Resident #78 had some mild redness to her left cheek. MA #3 stated she asked Resident #76 if she hit Resident #78 and Resident #76 stated she did because Resident #78 came into her house. MA #3 stated both residents appeared to be calm after the event and both residents were separated. MA #3 stated Resident #76 was placed on a one to one (1:1) where one staff observed her continuously to ensure the safety of the other residents. MA #3 stated she had not seen Resident #76 hit any resident prior to this event. MA #3 stated Resident #78 wandered around the facility freely and at times she would get confused as to where her room was. MA #3 stated she believed Resident #78 thought that Resident #76's room was hers. MA #3 stated Resident #78 would not stay in the other rooms or go through the person's belongings and that once she realized she was in the wrong room, she would leave. MA #3 stated she notified the Director of Nursing of what happened. A Psychiatry Progress Note for Resident #76 written by Nurse Practitioner (NP) #1 on 09/23/24 revealed Resident #76 presented with an episode of physical aggression towards another resident (Resident #78) which was a behavioral disturbance consistent with her Dementia diagnosis. Staff reports indicated that the resident was easily agitated and can be aggressive further supporting the diagnosis. The resident's cognitive impairment was evident during the telehealth visit as she was unable to recall the incident or the name of the facility where she resided. The plan was to initiate Depakote for mood stability to manage the resident's behavioral disturbance associated with dementia. The medication should help to reduce the resident's agitation and aggressive behavior. A follow up in-person visit was planned for 09/27/24 to further evaluate the resident's condition. The resident's need for a one on one was discussed and deemed unnecessary at that time. A Psychiatry Progress note written for Resident #78 by NP #1 dated 09/23/24 revealed, in part, Resident #78 experienced an altercation at the facility during which she was struck in the face. Examination revealed minor redness on the face which resolved quickly. There were no injuries noted and the resident did not report any pain or discomfort. The summary of the investigation report dated 09/28/24 completed by the Administrator documented the allegation involving Resident #76 and Resident #78 was substantiated. The incident was not witnessed by a staff member. The incident was vocalized to staff by both Resident #78 and Resident #76. Both residents were immediately separated. Resident #78 was assessed and noted with mild redness to the left side of her face which resolved after a few minutes. Resident #78 denied pain. An observation of Resident #76 was conducted on 11/18/24. Resident #76 was in her room with the door closed. She was pleasant but not oriented to time or place. Resident #76 had no recollection of any resident coming into her room. Observations of Resident #78 were conducted daily throughout the survey on 11/18/24 at 1:30 PM and 4:00 PM, on 11/19/24 at 9:00 AM, 10:00 AM, 11:00 AM, and 3:30 PM, on 11/20/24 at 9:30 AM, 10:45 AM, 11:35 AM, and 3:10 PM, and on 11/21/24 at 8:30 AM, 9:15 AM, 11:20 AM, and 1:10 PM. Resident #78 was alert but not oriented to time or place. Resident #78 was noted to be sitting in the common area during these times. She was not noted to be wandering in other rooms. An interview was conducted with the Social Worker (SW) on 11/20/24 at 2:30 PM. The SW stated after the event between Resident #76 and Resident #78 occurred on 09/23/24, Resident #78 was on frequent monitoring to ensure she was not wandering into other resident's rooms. The SW stated it was an isolated event and she had not seen Resident #76 hit any other residents before. An interview was conducted with the Director of Nursing (DON) on 11/20/24 at 3:30 PM. The DON reported he was made aware of Resident #76 slapping Resident #78 in the face by MA # on 09/23/24 at 1:00 PM. He stated Resident #78 wandered throughout the facility and often sat in the common area which was close to Resident #76's room. He stated Resident #78 was confused and from time to time, not very often, she would accidentally go into other residents' rooms thinking it was her room. The DON stated he assessed Resident #78 after the incident and she had some mild redness to her left cheek which resolved quickly. The DON stated he felt it was an isolated incident between Resident #76 and Resident #78.

Based on record review, and Resident Representative (RR), Hospital Case Manager, Psychiatric Provider, and staff interviews, the facility failed to permit a resident to return to the facility after being transferred to the hospital for evaluation due to a resident to resident altercation for 1 of 1 resident reviewed for hospitalization (Resident #84). The findings included: Resident #84 was admitted to the facility 3/15/24 with diagnoses that included schizoaffective disorder, bipolar type and unspecified intracranial injury. Review of the facility Action Summary Report revealed Resident #84 had been discharged /transferred to another hospital on 08/28/24. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident had moderately impaired cognition. He had physical and verbal behavioral symptoms directed towards other that occurred on 1 to 3 days. He used a wheelchair for mobility. He had a traumatic brain injury and schizophrenia. He had received antipsychotic and antidepressant medications during the assessment look back period. A progress note written by the Assistant Director of Nursing (ADON) on 08/28/24 at 3:47 PM documented that she had heard yelling from the dining room and noted Resident #84 in his wheelchair over Resident #35 attempting to run him over. Resident #84 was yelling that Resident #35 took his money. The residents were separated. The psychiatric provider and the RR were notified. An order was received to send Resident #84 to the hospital for evaluation. An interview was conducted with the ADON on 11/19/24 at 1:07 PM. She stated Resident #84 was involved in a resident to resident altercation over money. She recalled she had instructed the Unit Manager to call the provider and get an order to send Resident #84 to the hospital for evaluation. She stated she did not remember telling the hospital Case Manager that Resident #84 could not return to the facility because he was a danger to the other residents, but that it was so long ago that she may have. She noted that no order had been entered into the electronic medical record to send Resident #84 to the hospital or to refuse to readmit the resident on 08/28/24 because the Unit Manager had taken a verbal order from the provider and forgotten to write it. She stated she did not know that the facility had an obligation to take Resident #84 back once he was assessed to be a safe discharge from the hospital. She thought the facility had the right to deny his readmission. She also thought the psychiatric provider had given an order to the Unit Manager to not take the resident back but had not spoken to the psychiatric provider herself. The resident was not readmitted to the nursing home. An interview was conducted with the Psychiatric provider on 11/20/24 at 2:21 PM. She stated he was familiar with Resident #84. She recalled she had been contacted on 08/27/24 because the resident was in a rage, and she had increased his antipsychotic medication (Seroquel) at that time. On 08/28/24 she gave an order to send the Resident #84 back to the hospital for evaluation due to his involvement in a resident to resident altercation. She stated that was the only order she gave. She did not speak to the hospital on 08/28/24 and did not give an order for Resident #84 not to return to the facility. She noted it was the responsibility of the facility to take the resident back once deem to no longer be a threat. She stated she had consulted with her supervising physician who agreed with the increase in the medication Seroquel and explained it would take time for the increase in the medication to be effective and change the resident's behavior. She stated the facility could have made adjustments to take the resident back. An interview was conducted on 11/20/24 at 3:05 PM with the hospital Case Manager who cared for Resident #84 on 08/28/24. She stated she had cared for Resident #84 on 08/27/24 also when he presented to the hospital after a verbal altercation at the facility. On 08/27/24 he was cleared by psychiatry to return to the facility which he did. On 08/28/24 Resident #84 presented again at the hospital for assessment. She spoke with the ADON at the facility who informed her Resident #84 could not return to the facility because he pushed a resident and assaulted staff. The hospital Case Manager explained to the facility that Resident #84 had been evaluated by the psychiatry team and the medical physician and was assessed as safe to return to the facility. She told the ADON that the hospital was not a drop off destination and was not part of a facility discharge plan, but the ADON refused to take the resident back. The hospital Case Manager stated she contacted a family member who picked the resident up from the hospital and took him home. She stated the family member was in disbelief that the facility refused to take him back. A progress note written by the Social Worker at the facility on 09/12/24 at 2:49 PM documented that he had a meeting with the RR for Resident #84 and provided him with an FL2 form (a medical form that a doctor completes to describe a patient's medical condition and the level of care they need), order summary and NCTracks (a multi-payer Medicaid Management Information System for the North Carolina Department of Health and Human Services) Approved FL2 in case the family needed the forms to place the resident elsewhere. An interview was conducted with the facility Social Worker on 11/21/24 at 9:49 AM. He stated the RR of Resident #84 came to the facility seeking documentation to place the resident at another facility. He explained that the resident had gone to the hospital for evaluation and normally would return once cleared by the hospital physician as not a danger, but Resident #84 did not return. He concluded once the resident left the facility he was no longer involved with his care except for when the RR requested documents to place the resident elsewhere. An interview was conducted with the RR on 11/21/24 at 12:33 PM. He stated he was not prepared to care for Resident #84 at his home. He explained the hospital had contracted him on 08/28/24 and asked him to pick up the resident because the nursing home would not take him back and that he was ready for discharge. He stated he was able to set up a room and make accommodations for Resident #84's wheelchair in his home. The RR reported Resident #84 had not received his checks since he left the facility, and the RR had gone through all his savings in an effort to care for Resident #84 and provide basic needs such as food. He stated he did not have any help and was providing all of Resident #84's care himself. He explained he was working with a doctor to find placement for Resident #84 but that so far two other facilities had denied him admission based on a history of violent behaviors. An interview was conducted with the Director of Nursing (DON) on 11/19/24 at 1:58 PM. He stated he was present when the resident to resident altercation occurred with Resident #84. He reported that Resident #84 was taken to the front lobby with 1:1 supervision until the ambulance arrived to take him to the hospital for assessment. He noted the facility had an obligation to hold his bed for 30 days after a discharge to the hospital. He stated he was aware that the facility could not refuse to take the resident back after he was cleared by the hospital as a safe discharge. He was not aware the hospital had been told the resident could not return. He stated he knew the resident had gone home with a family member. An interview was conducted with the Administrator on 11/19/24 at 12:44 PM. He stated he had not been involved with the case because the DON had filed all the reports to the State. He noted that he was not aware the ADON had refused to take the resident back. He thought it was a judgement call by the ADON at the time because staff feared Resident #84 who hollered and cursed them. He stated he was aware it was the facility's obligation to take Resident #84 back when he was evaluated as safe for discharge by the hospital.

Based on observations, record review, and resident and staff interview the facility failed to secure a resident's indwelling urinary catheter tubing to prevent tension or trauma for 1of 1 resident reviewed for urinary catheter (Resident #54). Findings included: Resident #54 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer sacral region stage IV and dementia. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #54's cognition was moderately impaired, was incontinent of bowel and bladder, had a stage IV sacral pressure ulcer, and had an indwelling urinary catheter. Review of Resident #54's care plan revised 11/2024 addressed the use of an indwelling urinary catheter. Resident #54 had a stage IV pressure ulcer to her sacrum and potential for further pressure ulcer development and infections related to: mobility impairments, incontinent of bowel and bladder, diabetes, fragile skin integrity, and indwelling urinary catheter. A stage IV sacral pressure wound dressing observation was conducted on 11/20/24 at 9:20 AM with the Wound Treatment Nurse. During the observation, Resident #54 was lying in bed with her urinary catheter tubing hanging off the right side of the bed without the tubing being secured, and the catheter bag was hooked to the lower right side of the bed. An interview was conducted on 11/20/24 at 9:30 AM with Resident #54. When the Resident was asked if the catheter tubing was secured to her leg to prevent pulling on the tubing she replied, I asked my nurse for one, but never got it, and often I don't have one. An interview was conducted on 11/20/24 at 9:33 AM with the Wound Treatment Nurse. She said the resident's catheter tubing should have been secured by her nurse and was not. The Wound Nurse was observed to remove a new stat-lock (a catheter tubing stabilizing device) out of the top drawer of her treatment cart and secured resident's urinary tubing to her upper right thigh, which the resident thanked her for doing. An interview was conducted on 11/20/24 at 9:35 AM with Nurse #2. Nurse #2 stated residents with urinary catheter tubing do not have to have a stabilizing device on their catheter tubing, and stated Resident #54 did not want one. An interview was conducted on 11/20/24 at 9:38 AM with the Assistant Director of Nursing (ADON). She stated Resident #54 should have had her urinary catheter tubing secured to her thigh per facility policy, and did not. The ADON stated there should be a stabilizing device in place for every resident in the facility with an indwelling urinary catheter. An interview was conducted with the Administrator on 11/20/24 at 9:45 AM. The Administrator explained that every indwelling urinary catheter should have a stabilizing device in place to prevent trauma caused by pulling on the catheter tubing.

Based on observations and staff interviews the facility failed to discard expired opened multidose medications for 2 of 4 medication carts reviewed (300 and 400-hall medication carts). Findings included: a. An observation of the 300 Hall medication cart was conducted on 11/21/24 at 10:30 AM in the presence of Nurse #5. The medication cart contained an opened bottle of Geri-dryl (generic antihistamine brand of Benadryl) 25 milligrams (mg) with an expiration date of 10/24. An interview was conducted with Nurse #5 on 11/21/24 at 10:30 AM and she revealed the night shift nurses were supposed to check the medication carts during their shift for any expired medications. She stated she also checked her medication cart for expired medications but she overlooked the Geri-dryl bottle. Nurse #5 stated she did not administer any of this medication today. b. An observation of the 400 Hall medication cart was conducted on 11/21/24 at 11:30 AM in the presence of Nurse #5. The medication cart contained an opened bottle of Liquid Tylenol (pain relieving medication) 16 ounces with an expiration date of 09/24/24 and an opened bottle of Simethicone (a medication to relieve intestinal gas) 80 mg with an expiration date of 08/24/24. An interview was conducted with Nurse #5 on 11/21/24 at 11:30 AM and she revealed the night shift nurses were supposed to check the medications carts during their shift for any expired medications. She stated she also checked her medication cart for expired medications but she overlooked the Liquid Tylenol and the Simethicone. She stated both medications were expired and should have been removed from the medication cart and that neither medication was administered today. An interview was conducted with the Director of Nursing (DON) on 11/21/24 at 3:30 PM. The DON stated it was the facilities responsibility to ensure that all medications on the medication carts should not be expired. He stated the night shift nurses were responsible for going through the medication carts and the medication rooms since they had more down time to ensure that there were no medications on the carts or in the storage room that had expired.

Based on observations, record review and staff interviews the facility failed to ensure it was free of medication error rates greater than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 1 of 3 residents (Resident #60) observed during medication administration preparation. Findings included: Resident #60 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #60 was severely cognitively impaired. On 11/20/24 at 9:15 AM a medication administration preparation was observed with Nurse #7 for Resident #60. Nurse #7 was observed preparing the following medications for administration: Allopurinol (a medication to treat gout) 100 milligrams (mg) one tablet, Ciprofloxacin (an antibiotic medication to treat infection) 500 mg (2 tablets), Finasteride (a medication to treat enlarged prostate) 5 mg one tablet, Haldol (a medication to treat psychosis) 5 mg one tablet, Protonix (a medication to treat reflux disease) 20 mg one tablet, Seroquel (a medication to treat depression) 25 mg one tablet, Flomax (a medication to treat enlarged prostate) 0.4 mg capsule and aspirin (a cardiac supplement) 81 mg one tablet. Nurse #7 was noted have put all the medications except for the Flomax in a medication dispensing cup. A review of the Ciprofloxacin medication dispensing card for Resident #60 revealed one tablet should be administered twice daily. Nurse #7 was observed putting two tablets in the dispensing cup. A review of the Protonix medication dispensing card for Resident #60 revealed a bright yellow sticker which read do not crush under special instructions. Nurse #7 placed the medication in the dispensing cup. An interview with Nurse #7 at this time revealed she had dispensed all the medications ordered for Resident #60 and was going to crush them to be administered to him. Nurse #7 stated this completed her medication preparation for Resident #60 and stated she was going to crush all the medications in the dispensing cup at this time and was prepared to administer them to Resident #60. Nurse #7 stated that after she crushed all the other medications, she would open the Flomax capsule and pour the contents into the medication dispensing cup. Nurse #7 stated Resident #60 liked his crushed medications mixed in with apple sauce. Nurse #7 proceeded to crush all the medications that were in the dispensing cup with the exception of the Flomax capsule. Nurse #7 placed all of the medications in the small bag provided bag provided to crush the medications and positioned the bag in the machine to be crushed. Nurse #7 was asked at this time if all the medications should be crushed and she replied yes except for the Flomax because she would open the capsule and pour it over the other crushed medications before administering. Nurse #7 was also asked if she followed the physician's order for the Ciprofloxacin medication. Nurse #7 counted the amount of medications that should have been in the dispensing cup and realized at this time she put 2 tablets of the Ciprofloxacin in the dispensing cup instead of 1. Nurse #7 removed one of the tablets of Ciprofloxacin. Nurse #7 reviewed the dispensing card for the Protonix medication and read out loud do not crush from the label. Nurse #7 stated she had never realized the instruction do not crush was on the dispensing card and she had always crushed the medication. Nurse #7 removed the do not crush protonix medication from the bag. A phone interview was conducted with the Consulting Pharmacist on 11/21/24 at 3:27 PM. The Pharmacist stated that administering more than the ordered dose of the Ciprofloxacin could have caused the Resident stomach discomfort such as nausea, vomiting, and diarrhea. The Pharmacist stated the do not crush instructions were important to follow for the Protonix medication because if the medication was crushed in causes the medication to be least effective in managing the resident's gastrointestinal symptoms. An interview with the Director of Nursing (DON) on 11/20/24 at 3:30 AM revealed Nurse #7 should have read the entire order on the dispensing card and in her electronic medical record before dispensing the Ciprofloxacin medication in the medication cup and she should be following any special instructions, such as do not crush prior to administration. The DON stated the special instructions of do not crush were there for a reason and the direction should be followed.

Based on observations, record review, and Dialysis Nurse and staff interviews, the facility failed to follow the physician's orders to remove a dressing to an arterial venous fistula (a surgically created connection between artery and vein in the arm used for dialysis treatments) one hour after dialysis treatment to monitor for bleeding at the access cite and to prevent potential damage to the access cite for 1 of 2 residents (Resident #69) reviewed for dialysis. Findings included: Resident #69 was admitted to the facility on [DATE]. Diagnoses included, in part, end stage renal disease (ESRD) and dependent on dialysis. The MDS admission assessment dated [DATE] revealed Resident #69 was moderately cognitively impaired and was receiving dialysis services. Resident #69's care plan dated 10/22/24 revealed a plan of care for requiring hemodialysis with a goal that resident would have no signs or symptoms of complications from dialysis through the review date. Interventions to include, in part, monitor/document/report as needed any signs or symptoms of infection to access site such as redness, swelling, warmth or drainage. A physician's order written on 10/11/24 revealed Resident to receive dialysis on Monday, Wednesday, and Friday. A dialysis communication sheet dated 10/20/24 written by the Dialysis Nurse revealed under other concerns a note indicating please remove gauze dressing from dialysis site the night of dialysis. Leaving it on can damage the access. A physician's order was written on 11/01/24 to remove dressing to left arm dialysis access site approximately one hour after return from dialysis each evening shift on Monday, Wednesday, and Friday. Review of the November 2024 MAR revealed the order to remove the dressing to left arm dialysis access site was signed off as being removed by Nurse #5 on 11/20/24. An interview was conducted with Nurse #5 on 11/21/24 at 10:45 AM. Nurse #5 revealed there was no order to remove the dressing so she did not remove the dressing. Nurse #5 reviewed the physician orders and confirmed there was an order in the MAR to remove the dressing. Nurse #5 stated she did not usually remove the dressing from access sites and that the Medication Aide's removed the dressings. An observation of Resident #69 on Thursday, 11/21/24 at 9:30 AM, revealed Resident #69 was noted to have his dressing in place to his left arm access site. An interview with Nurse Aide #4 on 11/21/24 at 9:30 AM revealed she was getting Resident #69 ready for his bed bath at this time and she was removing the dressing from Resident #69's left arm access site. She stated the dressing had been on since yesterday's dialysis treatment and she did not see any blood seeping through the dressing and felt it was safe to remove. An interview was conducted with the Dialysis Nurse via phone on 11/21/24 at 2:55 PM. The Dialysis Nurse stated she notified the facility on 10/20/24 via a communication form to be sure to remove the dressing to the fistula site for Resident #69 the day of receiving the dialysis treatment. The Dialysis Nurse stated leaving the dressing on for extended period of time causes indents to the arterial venous fistula and makes it difficult to access the fistula in order to dialyze. An interview was conducted with the Director of Nursing on 11/21/24 at 3:30 PM. The DON reported there had been a concern in the past that the dressing was not being removed the night of the dialysis treatment and he had addressed the concern with his nursing staff to ensure the dressing was removed after each dialysis treatment on Monday, Wednesday and Friday and had an order put in place on 11/01/24 to remind nursing staff to remove the dressing. He stated Nurse #5 should have been aware of the physician's order as it was part of Resident #69's medication administration record. The DON stated the dressing could be removed from nursing staff with the expectation that if there was any bleeding noted, the nursing staff such as Nurse Aides and Medication Aides would notify the licensed nurse in charge.

Based on observations, record review, and staff interviews, facility staff failed to implement their policy for Enhanced Barrier Precautions (EBP) when Nurse #1 and Nurse #3 failed to apply a gown before entering residents' room to provide care for 2 of 2 residents (Resident #40 and Resident #12). The deficient practice occurred for 2 of 2 staff members observed for infection control practices. Findings included: Review of the facility's policy titled Enhanced Barrier Precautions (EBP) dated 04/01/24 read in part: EBPs require use of gown and gloves by staff during high-contact patient care activities. During an observation on 11/20/24 and 11/21/24 an EBP sign was posted by Resident #40 and Resident #12's room door that read in part: All Health Personnel must: wear gloves and gown for the following high-contact resident care activities: Device care or use for tracheostomy, or wound care, with any skin opening requiring a dressing. a. An observation was conducted on 11/20/24 at 2:05 PM of Nurse #3 providing tracheostomy care for Resident #40. Nurse #3 performed hand hygiene upon entering the room and applied a clean pair of gloves and mask, but did not apply a gown. Nurse #3 removed the old gauze around the tracheostomy and cleaned around the inner and outer cannula of the tracheostomy with a normal saline soaked gauze. He then removed his gloves and performed hand hygiene. He applied a clean pair of gloves, and gown after being asked prior to the inner cannula change if a gown was required for trach care. Nurse #3 was asked prior to the inner cannula change if a gown was needed during high contact resident care activities like tracheostomy care. Nurse #3 stated he did not think a gown was necessary. Nurse #3 then read the EBP sign on the resident's door during the interview and agreed that a gown was indeed necessary when doing high-contact care activities, which included tracheostomy care. An interview conducted with Nurse #3 on 11/20/24 at 2:30 PM revealed he received training on the facility's EBP policy and procedure. Nurse #3 stated he was aware Resident #40 was on EBP due to having a tracheostomy and Nurse #3 indicated he did not wear a gown when providing Resident #40's tracheostomy care prior to reading the sign on the door because he did not think it was a high-contact care. Nurse #3 indicated after he reviewed the EBP signage on Resident #40's door, he realized then that according to the signage he should have worn a gown when providing tracheostomy care. b. On 11/21/24 at 2:07 PM an observation was made of Wound Nurse #1 in Resident #12's room finishing up with wound dressing changes on two of the resident's wounds, one on the resident's right forearm and the other on her lower right leg. Wound Nurse #1 stated Resident #12 was under EBP for multiple wounds that needed daily dressings and treatment. The EBP signage located on Resident #12's door instructed staff to wear a gown and gloves during high contact resident care activities such as changing briefs or assisting with toileting and wound care for chronic wounds. Gowns were available in the personal protective equipment (PPE) cart located just outside the resident's door. Nurse #1 was observed in the resident's room, performing hand hygiene and applying gloves. Wound Nurse #1 completed Resident #12's wound care without applying a gown. An interview was conducted on 11/21/24 at 2:15 PM with Wound Nurse #1. Wound Nurse #1 was asked if Resident #1 was under any kind of precautions and she replied yes, Enhanced Barrier Precaution's which meant she needed to wear a gown and gloves before entering the resident's room. Wound Nurse #1 stated she would typically wear a gown while providing wound care however had just forgotten to put it on. She stated she would normally put on a gown while providing any wound care in the building. On 11/21/24 at 3:00 PM during an interview with the Assistant Director of Nursing (ADON), who was also the facility's Infection Control Preventionist (ICP), stated all the staff knew to abide by the different types of precautions posted on the residents' door and to follow the assigned PPE during high contact resident care activities. The interview revealed Wound Nurse #1 and Nurse #3 should have both worn a gown while providing either tracheotomy care or wound care for Resident #40 and Resident #12.

Based on observation, staff interviews, Nurse Practitioner interview, and record review, the facility failed to provide the necessary supervision to prevent accidents for a resident (Resident #1) with severe cognitive impairment, poor safety awareness, and known behaviors that included exit seeking, wandering into other residents' rooms, and physical aggression for 1 of 1 resident reviewed for accidents. On 2/16/23 Resident #1 exited the facility unsupervised and without staff's knowledge and was found 1.7 miles away from the facility. This had a high likelihood of resulting in serious harm to Resident #1. On 3/11/23 Resident #1 was observed by Nurse #1 in Resident #6's room leaning over her bed with his hands pulling her shirt near her shoulder, their faces were inches apart, and Resident #1 had his lips pursed as though he was trying to kiss Resident #6 on her mouth. On 3/25/23 Resident #2 was heard calling out for help and when staff entered her room Resident #1 was observed naked from the waist down rubbing Resident #2's feet. These incidents initiated by Resident #1 had a high likelihood of causing serious physical injury to the victims. Resident #2 and Resident #6 did not have the cognitive ability to express an adverse outcome. A reasonable person expects to be protected from the presence of unwanted persons and advancements into their personal space in their home environment resulting in serious psychosocial harm with feelings such as intense fear, distress, and anxiety. Immediate Jeopardy (IJ) began on 2/16/23 when Resident #1 exited the facility unsupervised and without staff's knowledge. Immediate Jeopardy was removed on 4/5/23 when the facility provided and implemented and acceptable credible allegation for IJ removal. The facility will remain out of compliance at a lower scope and severity level E (no actual harm with the potential for more than minimal harm that is not IJ) to ensure that education is completed, and monitoring systems put into place are effective. Findings included: 1a. Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance and anxiety disorder. A nursing progress note dated 2/3/23 written by Nurse #6 indicated Resident #1 was anxious and going from room to room and to the front exit stating someone was coming to pick him up. A Care Plan dated 2/6/23 focused on elopement risk indicated Resident #1 was at risk for elopement related to disorientation to place, impaired safety awareness, and wandering behavior. Goals included Resident #1's safety will be maintained through the review period. Interventions included distract resident from wandering by offering diversions, identify pattern for wandering, monitor location, and provide structural activities. Resident #1's admission Minimum Data Set (MDS) dated [DATE] indicated he was severely cognitively impaired. He displayed physical behaviors directed at others and other behaviors not directed at others and wandered 4 to 6 days of the review period. Resident #1 was independent for walking and locomotion. A 72-hour wander risk assessment dated [DATE] indicated Resident #1 was at high risk for wandering. An Event Report dated 2/16/23 completed by the Administrator included the following Elopement timeline: -start time 12:38 PM -12:50 PM: The nurse noticed Resident #1 was not in his room. She proceeded to the front lobby area and resident was not in the facility. The administrator was notified. -12:52 PM: Code Orange [announced over the speaker to indicate an unsupervised exit] was called. -12:53 PM: Resident #1's Responsible Party, physician, and the police were notified. -Staff members searched inside and outside the facility. -1:17 PM: Resident #1 was found by a staff member (Receptionist). The report indicated that the Administrator reviewed the security camera footage and observed a visitor opened the door and let Resident #1 walk out the front door. During an interview on 4/4/23 at 10:00 AM, the Administrator indicated they did not have access to the security footage and corporate reviewed the footage and provided them with the information and timeline. A police report dated 2/16/23 at 1:00 PM indicated the officer reported to the facility in reference to a missing person. The facility reported Resident #1 left the facility at 12:38 PM. As the officer was filling out the report, the Receptionist called the Administrator stating she had located Resident #1. Resident #1 was returned to the facility safe and unharmed. The officer could not be reached for interview. During an interview on 4/3/23 at 2:20 PM, Nurse #6 revealed that she arrived to Resident #1's room on 2/16/23 around 1:00 PM and noticed he was gone. She searched the facility and could not find him. She notified the Administrator, and he paged overhead to look for him. Management staff went out looking for him by car. Nurse #6 indicated that Resident #1 previously wandered around the facility and would walk to the front lobby. Nurse #6 indicated that the front door was locked and had to be unlocked by pushing a button behind the receptionist's desk. A telephone interview was conducted on 4/4/23 at 9:30 AM. The Receptionist indicated that she was at lunch when Resident #1 left the facility. She revealed that Resident #1 was in the front lobby when she left for her lunch break. The staff members with offices off the lobby covered door duty while she was gone. The Receptionist indicated that she used a red button on the wall behind her desk to unlock the door for visitors, and a family member went behind her desk to push the button to get out of the front door. When she got back from her lunch break, staff was searching for Resident #1 by car. The Receptionist found Resident #1 in a parking lot of a credit union and he got into her car with her. Resident #1 was not alert and oriented and attempted to exit the car while she was driving. The Receptionist added that Resident #1 had to cross a very busy, dangerous road to get to his location. A web search revealed the temperature for 2/16/23 at 12:35 PM was approximately 72 degrees Fahrenheit (wunderground.com). Google maps indicated the distance between the facility and the parking lot where Resident #1 was found was 1.7 miles and was an estimated 33-minute walk. An observation was made 4/4/23 at 4:30 PM of the suspected route Resident #1 took down the street from the facility to the T-intersection. Speed limit was 45 miles per hour. The facility was off a two-lane road with very few sidewalks and large ditches on both sides of the road. The street came to a T-intersection with a four-lane road. Resident #1 had to cross the four-lane road. There were few sidewalks and many parking lots to cross to get to his final location. During an interview on 4/6/23 at 9:35 AM, the previous Director of Nursing (DON) indicated that Resident #1 left the facility after another family member allowed him out the front door. Prior to the incident Resident #1 would wander around the facility but she was not aware if he tried to get out the front door prior. The previous DON indicated that anyone with dementia that wanders was at risk for elopement and should be Care Planned for elopement risk. During an interview on 4/6/23 at 11:30 AM, the Administrator indicated that Resident #1 did not display exit seeking behaviors prior to leaving the building unsupervised on 2/16/23 around 12:38 PM. A visitor opened the door using the button behind the receptionist's desk. Following the incident, the facility provided letters to all families asking them not to let residents out the front door. The Administrator indicated he was not aware of exit seeking behavior prior to the elopement. 1b. Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance and anxiety disorder. A Psychiatry Initial Consult dated 2/2/23 indicated staff reported Resident #1 was restless, anxious, agitated, and wandering. He was not sleeping. An as needed antianxiety was started. His admission MDS dated [DATE] indicated he was severely cognitively impaired. He displayed physical behaviors directed at others 1 to 3 days of the review period and other behaviors not directed at others 4 to 6 days of the review period. Resident #1 was independent for walking and locomotion. He wandered 4 to 6 days of the review period. A Care Plan dated 2/21/23 focused on behaviors related to Resident #1's episodes of combativeness towards staff, pacing, and going into other residents' rooms. Goals included Resident #1 will have fewer behaviors through the review period. Interventions included administer medications as ordered, anticipate resident's needs, and monitor behavioral episodes and attempt to find an underlying cause. Record review indicated Resident #1 was on 15-minute checks 2/16/23 through 3/12/23 following an elopement. Staff signed a sheet indicating they were assigned to monitor Resident #1 at that time. A telephone interview was conducted on 4/3/23 at 3:35 PM. Nurse #2 indicated that at the beginning of March 2023, Resident #1 was walking through a common are when another resident (from the assisted living section of the facility) reached her hand out to him. Resident #1 grabbed her wrist and twisted her arm behind her back. Staff directed him to let go and he hit her on the back of the head. The residents were separated. The other resident was shaken, and the police were called. Nurse #2 added this was Resident #1's first physical interaction with another resident. Resident #1 had been on 1:1 supervision in the past for an elopement but was agitated having someone following him. The supervision was changed to 15-minute checks, and he did well with those. An Incident Report dated 3/11/23 (a Saturday) written by Nurse #1 indicated that Resident #1 was found leaning over Resident #6 in her bed. Resident #6's admission MDS dated [DATE] indicated she had moderate cognitive impairment. During an interview on 4/3/23 at 3:20 PM, Nurse #1 indicated that on 3/11/23, she found Resident #1 in Resident #6 ' s room leaning over her bed with his hands pulling her shirt near the shoulder and their faces inches apart. When Nurse #1 got his attention, he looked at her then back to Resident #6, pulling her by the shirt with his lips pursed as though he was trying to kiss her mouth. Nurse #1 did not observe the residents' lips touching. A Nurse Aide (NA) was able to assist with getting Resident #1 out of the room. Resident #6 was crying, and Nurse #1 assisted her in calling her family member. Nurse #1 notified Resident #6 ' s family member and the Director of Nursing (DON) by telephone. The DON advised her to fill out an incident report. Nurse #1 believed she put the pulling of the shirt and attempted kiss in her incident report. That was the first time she had seen Resident #1 touching another resident, but he did wander in and out of residents' rooms. Nurse #1 indicated that staff monitored him throughout the day and intervened as needed. Resident #1 was usually able to be redirected. Nurse #1 was unsure if Resident #1 was on 15-minute checks at that time. Record review indicated NA #5 had signed the 15-minute check off sheet for 3/11/23 from 11:00 AM to 1:00 PM (the time the incident occurred). A telephone interview was conducted on 4/4/23 at 2:20 PM with NA #5 who was assigned to Resident #1 at the time of the 3/11/23 incident. NA #5 could not recall if she was assigned to Resident #1 at the time of the incident on 3/11/23. She indicated that Resident #1 was calm when she worked with him, and she had not observed behaviors directed at other residents. NA #5 revealed Resident #1 usually walked the halls with her and did not attempt to go in other residents' rooms. Resident #6 was sleeping during attempts to interview on 4/3/23 at 10:00 AM and at 4/5/23 at 10:25 AM. During an interview on 4/6/23 at 10:30 AM, the DON revealed following the 3/11/23 incident, Resident #1's nurse called her to report finding him in Resident #6's room and appeared to be trying to kiss her. The DON reviewed the incident report when she returned to work but did not recall if it noted he was pulling her shirt and trying to kiss her. She did not conduct further staff or resident interviews. The DON indicated Resident #6 was frail and he could have injured her. At the time of the incident on 3/11/23, Resident #1 was on 15-minute checks due to an elopement. She was not aware of which NA was assigned to Resident #1 at the time of the incident. The DON explained that Resident #1 had previously been on one to one (1:1) supervision but became agitated having someone with him all the time. The facility switched to 15-minute checks with someone assigned to monitor him throughout the day and sign off on a timesheet. She was unsure how he got into Resident #6 without staff's knowledge. The DON revealed the intervention for the incident was to continuing monitoring Resident #1 with 15-minute checks. She was unsure why the 15-minute checks were discontinued on 3/12/23 and states she was not involved in the decision. She did not follow up with interviewing other staff or the NA assigned to Resident #1 at the time. During an interview on 4/6/23 at 11:30 AM the Administrator revealed he was not aware Resident #1 appeared to be attempting to kiss Resident #6 on the 3/11/23 incident. No new interventions were put into place because the administrator was not aware of the attempted kiss. The 15-minute checks for Resident #1 were discontinued due to not having exit seeking behaviors. The Administrator revealed Resident #1 had a previous resident to resident incident with an assisted living resident earlier in March 2023. A progress note dated 3/25/23 (a Saturday) at 10:00 PM written by Nurse #3 indicated she heard Resident #2 calling out from her room. When she entered, she observed Resident #1 naked from the waist down pulling the covers off Resident #2 and touching her feet. Resident #1 did not leave the room when prompted. The police were called. A progress note dated 3/25/23 at 11:10 PM written by Nurse #4 for the same incident added that after the other nurse left the room, Resident #1 was pulling clothes from Resident #2's closet and touching her feet. Resident #1 grabbed a plastic spoon with the handle pointing outward and tried to get around Nurse #4 to Resident #2 in her bed. Nurse #4 pulled Resident #1 out of the room backwards by his t-shirt. Resident #2's admission MDS dated [DATE] indicated she had moderate cognitive impairment. A written statement from Nurse #4 revealed that on 3/25/23 around approximately 9:30 PM, Nurse #3 came to the nurse's station requesting assistance. She could hear loud voices on the 300 hall. Resident #1 was naked from the waist down rummaging through Resident #2's belongings. Resident #2 was crying out. Resident #1 was pulling off Resident #2's bedding and rubbing her feet. Resident #2 was getting more upset. Resident #1 was not able to be redirected to leave the room. Nurse #3 left to call the police. Resident #1 continued pulling things from the closet and touching Resident #2's feet. Nurse #4 pulled Resident #1 from the room. A telephone interview was conducted on 4/3/23 at 11:00 AM. Nurse #4 indicated that on 3/25/23 she was not working with Resident #1, but his nurse asked for her assistance as she was not able to redirect him. When Nurse #4 arrived at Resident #2's room, Resident #1 was naked from the waist down, pulling things out of her closet and rubbing her feet and legs. Resident #1 had pulled the blankets off Resident #2. Resident #2 was crying out and yelling to get him out. The nurses decided to call the police. Resident #1 grabbed a plastic spoon with the handle sticking out and tried to get around her to Resident #2 in her bed. Nurse #4 revealed she pulled Resident #1 out of the room by the back of his t-shirt. When the police arrived, Resident #1 was resting calmly in bed after receiving anxiety medication. Nurse #4 indicated that Resident #1 frequently wandered in and out of other residents' rooms but could usually be redirected. Resident #1 was not on 15-minute checks at the time of the incident. Nurse #4 revealed she no longer worked at the facility. A written statement from Nurse #3 indicated that on 3/25/23, she heard Resident #2 calling for help. Resident #1 was in her room naked from the waist down, pulling her bedding off and touching her feet. Nurse #3 attempted to get Resident #1 out of the room and was unsuccessful. Nurse #3 retrieved Nurse #4 for assistance. They were unsuccessful at getting Resident #1 out of the room. Nurse #3 left to call the police. A telephone interview was conducted on 4/4/23 at 12:10 PM. Nurse #3 revealed that on 3/25/23 she heard someone calling out for help. She arrived at Resident #2's room and Resident #1 had removed Resident #2's bedding and had removed the air mattress control box from the foot of her bed. Resident #1 was not attempting to hit Resident #2 and gave the box to Nurse #3 when prompted. Resident #1 was naked from the waist down and was rubbing Resident #2's feet. Resident#2 was upset and was crying out. When Nurse #3 told Resident #1 to leave, he ignored her. Resident #1 was getting clothes out of Resident #2's closet and putting it on her bed. Nurse #3 revealed she left the room to call the police and Nurse #4 stayed with the residents. Resident #1 was calm in his room when the police arrived, so they did not intervene. Nurse #3 revealed that Resident #1 had wandering behaviors prior. Earlier that evening, he was found on another hall in another resident's room going through their belongings. Nurse #3 revealed that last time she had seen him he was resting in bed. During an interview on 4/3/23 at 11:40 AM, NA #1 revealed she heard yelling from Resident #2's room and observed Nurse #4 pull Resident #1 out of the room by his t-shirt. She assisted Resident #1 back to his room. Resident #1 was calm and resting in bed when the police came. NA #1 texted the Director of Nursing (DON). NA #1 indicated that earlier that night, Resident #1 was in and out of other residents' rooms but was easily directed. NA #1 indicated all staff monitored him throughout the day. A telephone interview was conducted on 4/4/23 at 12:10 PM, Nurse #5 revealed that prior to the incident on 3/25/23, Resident #1 was wandering in and out of residents' rooms and going through their drawers. Resident #1 was escorted back to his room and was last seen lying in bed before he was found in Resident #2's room. A Police Report dated 3/26/23 at 9:30 AM indicated an officer responded to an assault call at the facility involving Resident #1 and Resident #2. The responding officer could not be reached for interview at multiple attempts. During an interview on 4/6/23 at 10:30 AM the DON indicated she was made aware of the 3/25/23 incident that following the incident. She arrived the following day and spoke with the families of the residents. The DON revealed staff monitored Resident #1 throughout the day and observed his location. They did not sign off checks at the time of the incident or following. The DON revealed the facility did not have a process in place to monitor if interventions were effective. During a telephone interview on 4/4/23 at 8:45 AM, the Mental Health Nurse Practitioner (NP) revealed she had been following Resident #1 since he was admitted . Resident #1 had expressed anxiety and agitation since admission and they had been working to adjust his antianxiety, antidepressants, and antipsychotic medications. The Mental Health NP revealed she was aware of behaviors such as wandering, aggression, and refusing medication. She was not aware of the 3/25/23 altercation with another resident. During an interview on 4/4/23 at 2:20 PM, the Nurse Practitioner revealed she was aware of Resident #1's behaviors of wandering and agitation and mental health services had been working with him. She was notified Resident #1 was sent to the emergency department several times for combativeness. The first instance was at the beginning of March when he twisted the arm of another resident (a resident who resided in the assisted living section of the facility). The Nurse Practitioner revealed that both Resident #6 and Resident #2 were very frail and could have been seriously injured by the interactions. The NP was not aware of interventions regarding the altercations. During an interview on 4/6/23 at 11:30 AM the Administrator he indicated the incident reports were reviewed in daily clinical meetings and an appropriate plan was put into place. Following the incident on 3/25/23, the residents were separated, and Resident #1 was calm. The facility began investigating the incident after Adult Protective Services visited the facility on 3/29/23. Staff statements were obtained. Alert and oriented residents were interviewed on if they experienced resident or staff abuse. The Administrator was notified of immediate jeopardy on 4/4/23 at 11:47 AM. The facility provided the following immediate jeopardy removal plan with an alleged removal date of 4/5/23: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident # 1 is at risk for suffering adverse outcomes based on the facility's failure to provide supervision of a resident with severe cognitive impairment, poor safety awareness, and behaviors including wandering and physically aggressive behaviors to prevent an unsupervised exit and resident to resident altercations. Resident #1 exited the facility with the assistance of another resident's family member, who walked behind a desk and pressed the door release button. Residents #6 and #2 are the most at risk for suffering adverse outcomes based on the facility failure to supervise and prevent from accidents and hazards. All residents are at risk for suffering physical and / or psychosocial harm. Actions taken to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. A device cover (screamer cover) was placed over the release button on the day the unsupervised exit incident occurred - 2-16-23. It is a device with a hinged lid that has to be opened to access the mag lock release. Opening the device results in a piercing alarm that alerts staff members audibly that the button has been accessed. In addition to the release button, there are keypads on all exit doors that allow for staff exit when the proper code is entered. The access code was changed on 2-16-23. Staff members were made aware of the access code change and staff members are the only persons that access the keypad. There is also a keypad for releasing the door lock that is on the wall to the immediate right of the door. On 2-16-23 the resident was placed on 1:1 supervision because prior to this date, he had never eloped before. Consultation with his Attending Physician / Nurse Practitioner resulted in a change in the resident ' s medication that stabilized his mood and behaviors. Education regarding not allowing residents to exit the building was provided to all staff members (employed and contracted housekeeping, dietary, environmental services and therapy contract staff). The facility does not have contracted nursing staff. The facility administrator conducted the training and letters to the families of current patients. A letter was provided to all family members regarding the same. A letter was also added to the admission package to educate future residents and families about the importance of NOT allowing residents to exit the facility. This was done on 2/16/23. On Tuesday, April 4, 2023 Resident # 1 was relocated to a less populated hall to allow for more staff visibility from the Director of Nursing's (DON's) office, therapy suite, and nursing station. This action will diminish wandering into other resident rooms and protect all residents within the facility. Should the wandering behavior present, the resident would have to cross the central corridor in the presence of the nursing station, DON office, and therapy suite thus allowing for redirection and intervention and for supervision to prevent further occurrence. On Tuesday, April 4, 2023 Resident #1 was placed on 1:1 monitoring by a facility staff member. The monitoring will continue 24 /7 in order to ensure that all residents are free of abuse and intrusion into their personal spaces. A back up staff member will be identified to cover breaks to ensure that the resident is monitored and supervised 24/7. A full staff mandatory meeting for all direct care staff, management staff, and staff will be held on April 4, 2023 at 3:00 pm in the facility's dining room. The facility Administrator, Managing Director, [NAME] President (VP) of Property, and Corporate Nurse Consultant conducted the training session. The DON will be responsible for maintaining the list of attendees and on-going survey education. No staff member will be allowed to provide care to residents or otherwise resume normal job roles until they complete the training. Training topics will include the following: Resident supervision to prevent accidents Redirection of patients with inappropriate behaviors including protection of resident ' s rooms and personal spaces. The phrase PROTECT & REPORT was highlighted as the mantra for the educational session. Elopements Monitoring requirements for Resident # 1 (1:1 and 24/7 with breaks also covered). Immediate Jeopardy was discussed, defined, and the steps taken for IJ removal was reviewed. Retraining of facility and contracted staff (therapy, dietary, and environmental services) to ensure awareness of: Resident Supervision Elopements The facility Administrator and Director of Nursing will be responsible for full implementation of the facility plan of correction for the immediate jeopardy removal. They will be assisted by the corporate compliance, operations, and clinical team members. The credible allegation of IJ removal was validated by on-site verification on 4/6/23. Interviews conducted with staff revealed they had recent training on elopements and resident monitoring. The admission packet letter on not allowing residents out the facility was reviewed. The device cover at the reception desk was observed and the receptionist was interviewed on use. Keypads were observed on all exit doors. Education materials and staff signature sheets were reviewed. Resident #1 was observed with a 1:1 sitter in his new room. The facility's IJ removal date of 4/5/23 was validated.

Based on staff and nurse practitioner interviews, observations, and record review, the facility failed to protect two vulnerable female residents right to be free from unwanted touching and intrusions into personal space by Resident #1 (Resident #6 and Resident #2). Resident #1 had severely impaired cognition, had behaviors, and was known to wander. On 3/11/23 Resident #1 was observed by Nurse #1 in Resident #6's room leaning over her bed with his hands pulling her shirt near her shoulders, their faces were inches apart, and Resident #1 had his lips pursed as though he was trying to kiss Resident #6 on her mouth. On 3/25/23 Resident #2 was heard calling out for help and when staff entered her room Resident #1 was observed naked from the waist down rubbing Resident #2's feet. These incidents initiated by Resident #1 had a high likelihood of causing serious physical injury to the victims. Resident #2 and Resident #6 did not have the cognitive ability to express an adverse outcome. A reasonable person expects to be protected from the presence of unwanted persons and advancements into their personal space in their home environment resulting in serious psychosocial harm with feelings such as intense fear, distress, and anxiety. This occurred for 2 of 3 residents reviewed for abuse (Resident #2, and Resident #6). Immediate Jeopardy (IJ) began on 3/11/23 when Resident #1 was found leaning over Resident #2 in her bed, pulling her by the shirt and appeared to be attempting to kiss her. Immediate Jeopardy was removed on 4/5/23 when the facility provided and implemented and acceptable credible allegation for IJ removal. The facility will remain out of compliance at a lower scope and severity level E (no actual harm with the potential for more than minimal harm that is not IJ) to ensure that education is completed and monitoring systems put into place are effective. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance and anxiety disorder. His admission MDS dated [DATE] indicated he was severely cognitively impaired. He displayed physical behaviors directed at others 1 to 3 days of the review period and other behaviors not directed at others 4 to 6 days of the review period. Resident #1 was independent for walking and locomotion. He wandered 4 to 6 days of the review period. A Care Plan dated 2/21/23 focused on behaviors related to Resident #1's episodes of combativeness towards staff, pacing, and going into other residents' rooms. Goals included Resident #1 will have fewer behaviors through the review period. Goals included administer medications as ordered, anticipate resident's needs, and monitor behavioral episodes and attempt to find an underlying cause. A Psychiatry Initial Consult dated 2/2/23 indicated staff reported Resident #1 was restless, anxious, agitated, and wandering. He was not sleeping. An as needed antianxiety medication was started. Record review indicated Resident #1 was on 15-minute checks 2/16/23 through 3/12/23 following an elopement. Review of the documentation revealed staff signed a sheet with fifteen- minute increments indicating they were assigned to monitor Resident #1 for that time and date. A telephone interview was conducted on 4/3/23 at 3:35 PM. Nurse #2 indicated that at the beginning of March 2023, Resident #1 was walking through a common are when another resident (from the assisted living section of the facility) reached her hand out to him. Resident #1 grabbed her wrist and twisted her arm behind her back. Staff directed him to let go and he hit her on the back of the head. The residents were separated. The other resident was shaken, and the police were called. Nurse #2 added this was Resident #1's first physical interaction with another resident. Resident #1 had been on 1:1 supervision in the past for an elopement but was agitated having someone following him. The supervision was changed to 15-minute checks, and he did well with those. 1a. An Incident Report dated 3/11/23 (a Saturday) at 11:00 AM written by Nurse #1 indicated that Resident #1 was found leaning over Resident #6 in her bed. Resident #6 was admitted to the facility on [DATE] with diagnoses that included failure to thrive, cognitive communication deficit, and malnutrition. Her admission Minimum Data Set (MDS) dated [DATE] indicated moderate cognitive impairment. She required extensive assistance for bed mobility and transfers. Resident #1's Care Plan focus area for behaviors was updated on 3/11/23 to indicate 1:1 supervision due to entering a resident's room uninvited. No new interventions were put in place. During an interview on 4/3/23 at 3:20 PM, Nurse #1 indicated that on 3/11/23 around 11:00 AM, she found Resident #1 in Resident #6's room leaning over her bed with his hands pulling her shirt near the shoulder and their faces inches apart. When Nurse #1 got his attention, he looked at her then back to Resident #6, pulling her by the shirt with his lips pursed as though he was trying to kiss her mouth. Nurse #1 did not observe the residents' lips touching. A Nurse Aide (NA) was able to assist with getting Resident #1 out of the room. Resident #6 was upset, and Nurse #1 assisted her in calling her family member. Nurse #1 notified Resident #6's family member and the Director of Nursing (DON) by telephone. The DON advised her to fill out an incident report. Nurse #1 believed she put the pulling of the shirt and attempted kiss in her incident report. That was the first time she had seen Resident #1 touching another resident, but he did wander in and out of residents' rooms. Nurse #1 was unsure if Resident #1 was on 15-minute checks on 3/11/23. Nurse #1 indicated that staff monitored him throughout the day and intervened as needed. Resident #1 was usually able to be redirected. Record review indicated NA #5 had signed the 15-minute check off sheet for 3/11/23 from 11:00 AM to 1:00 PM (the time the incident occurred). A telephone interview was conducted on 4/4/23 at 2:20 PM with the NA assigned to Resident #1 at the time of the incident. NA #5 could not recall if she was assigned to Resident #1 at the time of the incident on 3/11/23. She indicated that Resident #1 was calm when she worked with him, and she had not observed behaviors directed at other residents. NA #5 revealed Resident #1 usually walked the halls with her and did not attempt to go in other residents' rooms. Resident #6 was sleeping during attempts to interview on 4/3/23 at 10:00 AM and at 4/5/23 at 10:25 AM. 1b. A Progress Note dated 3/25/23 (a Saturday) at 10:00 PM written by Nurse #3 indicated she heard Resident #2 calling out from her room. When she entered, she observed Resident #1 naked from the waist down pulling the covers off Resident #2 and touching her feet. Resident #1 did not leave the room when prompted. The police were called. Resident #2 was admitted to the facility on [DATE] with diagnoses that included debility, malnutrition, and cognitive communication deficit. Her admission MDS dated [DATE] indicated moderate cognitive impairment. She required extensive assistance with bed mobility, transfers and was dependent on staff for locomotion. A written statement from Nurse #3 indicated that on 3/25/23 (no time noted), she heard Resident #2 calling for help. Resident #1 was in her room naked from the waist down, pulling her bedding off and touching her feet. Nurse #3 attempted to get Resident #1 out of the room and was unsuccessful. Nurse #3 retrieved Nurse #4 for assistance. They were unsuccessful at getting Resident #1 out of the room. Nurse #3 left to call the police. A telephone interview was conducted on 4/4/23 at 12:10 PM. Nurse #3 revealed that on 3/25/23 she heard someone calling out for help on the 300-hall. She arrived at Resident #2's room and Resident #1 had removed Resident #2's bedding and had removed the air mattress control box from the foot of her bed. Resident #1 was not attempting to hit Resident #2 and gave the box to Nurse #3 when prompted. Resident #1 was naked from the waist down and was rubbing Resident #2's feet. Resident#2 was upset and was crying out. When Nurse #3 told Resident #1 to leave, he ignored her. Resident #1 was getting clothes out of Resident #2's closet and putting it on her bed. Nurse #3 revealed she left the room to call the police and Nurse #4 stayed with the residents. Resident #1 was calm in his room when the police arrived, so they did not intervene. Nurse #3 revealed that Resident #1 had wandering behaviors prior. Earlier that evening, he was found on another hall in another resident's room going through their belongings. Nurse #3 revealed that last time she had seen him that evening he was resting in bed. A progress note dated 3/25/23 at 10:00 PM written by Nurse #4 for the same incident added that after the other nurse left the room, Resident #1 was pulling clothes from Resident #2's closet and touching her feet. Resident #1 grabbed a plastic spoon with the handle pointing outward and tried to get around Nurse #4 to Resident #2 in her bed. Nurse #4 pulled Resident #1 out of the room backwards by his t-shirt. A written statement from Nurse #4 revealed that on 3/25/23 at approximately 9:30 PM, Nurse #3 came to the nurse's station requesting assistance. She could hear loud voices on the 300-hall. Resident #1 was naked from the waist down rummaging through Resident #2's belongings. Resident #2 was crying out. Resident #1 was pulling off Resident #2's bedding and rubbing her feet. Resident #2 was getting more upset. Resident #1 was not able to be redirected to leave the room. Nurse #3 left to call the police. Resident #1 continued pulling things from the closet and touching Resident #2's feet. Nurse #4 pulled Resident #1 from the room. A telephone interview was conducted on 4/3/23 at 11:00 AM. Nurse #4 indicated that on 3/25/23 she was not working with Resident #1, but his nurse asked for her assistance as she was not able to redirect him. When Nurse #4 arrived at Resident #2's room, Resident #1 was naked from the waist down, pulling things out of her closet and rubbing her feet and legs. Resident #1 had pulled the blankets off Resident #2. Resident #2 was crying out and yelling to get him out. The nurses decided to call the police. Resident #1 grabbed a plastic spoon with the handle sticking out and tried to get around her to Resident #2 in her bed. Nurse #4 revealed she pulled Resident #1 out of the room by the back of his t-shirt. When the police arrived, Resident #1 was resting calmly in bed after receiving anxiety medication. Nurse #4 indicated that Resident #1 frequently wandered in and out of other residents' rooms but could usually be redirected. During an interview on 4/3/23 at 11:40 AM, NA #1 revealed she heard yelling from Resident #2's room on 3/25/23 on evening shift and observed Nurse #4 pull Resident #1 out of the room by his t-shirt. She assisted Resident #1 back to him room. Resident #1 was calm and resting in bed when the police came. NA #1 called an off-duty nurse and texted the Director of Nursing (DON). NA #1 indicated that earlier that night, Resident #1 was in and out of other residents' rooms but was easily directed. NA #1 indicated all staff monitored him throughout the day. A telephone interview was conducted on 4/4/23 at 12:10 PM, Nurse #5 revealed that prior to the incident on 3/25/23, Resident #1 was wandering in and out of residents' rooms on the 500 hall and going through their drawers. Resident #1 was escorted back to his room and was last seen lying in bed before he was found in Resident #2's room. A Police Report dated 3/26/23 at 9:30 AM indicated an officer responded to an assault call at the facility involving Resident #1 and Resident #2. The responding officer could not be reached for interview at multiple attempts. Resident #1's Care Plan focus area for behaviors was updated on 3/26/23 to indicate indicated resident was wandering into another resident's room rummaging through other resident's items. No new interventions were put in place. An observation was made on 4/3/23 at 10:10 AM of Resident #1 in his room, calmly sitting on his bed. He was dressed and groomed, and his NA had just assisted him with shaving. Resident #1 did not respond appropriately to questions and speech was difficult to understand. An observation was made later that day of Resident #1 in the DON's office eating a snack. He did not respond to the questioning. During a telephone interview on 4/4/23 at 8:45 AM, the Mental Health Nurse Practitioner (NP) revealed she had been following Resident #1 since he was admitted . Resident #1 had expressed anxiety and agitation since admission and they had been working to adjust his antianxiety, antidepressants, and antipsychotic medications. The Mental Health NP revealed she was aware of behaviors such as wandering, aggression, and refusing medication. She indicated around 3/11/23, Resident #1 was refusing medication. The altercation on 3/11/23 was reported to her, and staff began mixing his antipsychotic medication into a drink and he would take it. She believed his behaviors improved after the medication change and he was doing well when she saw him on 3/24/23. She was not aware of the 3/25/23 altercation with another resident. During an interview on 4/4/23 at 2:20 PM, the Nurse Practitioner revealed she was aware of Resident #1's behaviors of wandering and agitation and mental health services had been working with him. She was notified Resident #1 was sent to the emergency department several times for combativeness. The first instance was at the beginning of March. The Nurse Practitioner revealed that both Resident #6 and Resident #2 were very frail and could have been seriously injured by the interactions. During an interview on 4/6/23 at 10:30 AM, the DON revealed following the 3/11/23 incident, Resident #1's nurse called her to report finding him in Resident #6's room and appeared to be trying to kiss her. The DON reviewed the incident report when she returned to work but did not recall if it noted he was pulling her shirt and trying to kiss her. She did not conduct further staff or resident interviews. The DON indicated Resident #6 was frail and he could have injured her. At the time of the incident on 3/11/23, Resident #1 was on 15-minute checks due to an elopement. She was not aware of which NA was assigned to Resident #1 at the time of the incident. Resident #1 had previously been on 1:1 supervision but became agitated having someone with him all the time. The facility switched to 15-minute checks with someone assigned to monitor him throughout the day and sign off on a timesheet. She was unsure how he got into Resident #6 ' s room without the staff's knowledge. The DON revealed the intervention for the incident was to continuing monitoring Resident #1 with 15-minute checks. She was unsure why the 15-minute checks were discontinued on 3/12/23 and states she was not involved in the decision. She did not follow up with interviewing other staff or the NA assigned to Resident #1 at the time. The DON added, she was made aware of the 3/25/23 incident that night following the incident. She arrived the following day and spoke with the families of the residents. She believed the Administrator began an investigation on 3/26/23. The DON revealed staff monitored Resident #1 throughout the day and observed his location. They did not sign off checks at the time of the incident or following. The DON revealed the facility did not have a process in place to monitor if interventions were effective. During an interview on 4/6/23 at 11:30 AM, the Administrator revealed following the initial resident to resident altercation at the beginning of March 2023, the residents and family members were interviewed. Resident #1 was taken to the emergency department for evaluation. The Administrator indicated the other resident was alert and oriented and did not feel she was abused. The Administrator revealed he was not aware Resident #1 appeared to be attempting to kiss Resident #6 during the 3/11/23 incident. No new interventions were put into place because the Administrator was not aware of the attempted kiss. The 15-minute checks for Resident #1 were discontinued due to not having exit seeking behaviors. He indicated the incident reports were reviewed in daily clinical meetings and an appropriate plan was put into place. Following the incident on 3/25/23, the residents were separated, and Resident #1 was calm. The facility began investigating the incident after Adult Protective Services visited the facility on 3/29/23. Staff statements were obtained. Alert and oriented residents were interviewed on if they experienced resident or staff abuse. The Administrator was notified of IJ on 4/4/23 at 11:47 AM. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Residents #6 and #2 are the most at risk for suffering adverse outcomes based on the facility's failure to protect them from physical abuse and intrusion into their personal space with attempts for inappropriate sexual interactions. Resident #1 is the alleged abuser. All residents are at risk for suffering physical and /or psychosocial harm as a result of the deficient practice. Incidents were reported to the state on 4/4/23 by the Administrator. Actions taken to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On Tuesday, April 4, 2023 Resident #1 was relocated to a less populated hall to allow for more staff visibility from the Director of Nursing's (DON's) office, therapy suite, and nursing station. This action will diminish wandering into other resident rooms. Should the wandering behavior present, the resident would have to cross the central corridor in the presence of the nursing station, DON's office, and therapy suite thus allowing for redirection and intervention. On Tuesday, April 4, 2023 Resident #1 was placed on 1:1 monitoring by a facility staff member. The monitoring will continue 24/7 in order to ensure that all residents are free of adverse outcomes related to physical abuse and intrusion into their personal spaces. The resident was previously on 1:1 but was tapered to 15-minute checks when the incidents occurred. The monitoring will be increased to 24/7 the resident will be monitored at all times, including when the staff member takes breaks. A backup person will be assigned to the 1:1 caregiver. A full staff mandatory meeting for all direct care staff, management staff, and contracted staff will be held on April 4, 2023 at 3:00 pm in the facility's dining room. The facility Administrator and members of the Managing Director, VP Property, and Corporate Clinical Nurse Consultant will conduct the training session. The DON will be responsible for maintaining the list of attendees and on-going survey education. No staff member will be allowed to provide care to residents or otherwise resume normal job roles until they complete the training. Training topics will include the following: Monitoring requirements for Resident # 1 to include 1:1 supervision at all times - with back up. Status of survey and interventions put in place. Training on the abuse policy and procedures to ensure full compliance with resident rights consistent with applicable state and federal law, specifically including the resident's right to be free of abuse and proper abuse reporting. Retraining of facility and contracted staff (therapy, dietary, and environmental services) to ensure awareness of: -Abuse definitions -Abuse reporting -Abuse allegation investigations -Facility Policies -Residents right to be free of abuse -Protection of all residents at the time of incident occurrence -Notification to Administrator and corporate team of all allegations The facility Administrator and Director of Nursing are responsible for the full implementation of the immediate jeopardy removal plan. The corporate operations, clinical, and compliance team will support the Administrator and Director of Nursing. Alleged immediate jeopardy removal date is 4/5/23. The credible allegation of IJ removal was validated by on-site verification on 4/6/23. Interviews conducted with staff revealed they had recent training on abuse that included types of abuse, reporting, and protecting residents involved. Education materials and staff signature sheets were reviewed. Resident #1 was observed with a 1:1 sitter. The facility's IJ removal date of 4/5/23 was validated.

Based on observation, record review and staff interviews the facility failed to provide services to prevent the development of a hand contracture for 1 of 1 resident reviewed for contractures (Resident #11). The findings included: Resident #11 was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident had a [DIAGNOSES REDACTED]. The most recent MDS (Quarterly) dated 2/23/15 revealed the resident had short and long term memory loss but was able to make decisions. The MDS revealed the resident required total assistance for all activities of daily living except for eating and had impairment of the upper extremities on both sides. The MDS revealed the resident received hospice care. The resident ' s Care Plan last reviewed on 2/25/15 revealed no information regarding contractures or range of motion for the resident ' s left hand. The resident ' s Care Guide revealed no information related to contractures or range of motion. A Nursing Admission & Re Entry form dated 3/16/15 and electronically signed by Nurse #1 under general comments read: " Full ROM (range of motion) in extremities. " On 4/15/15 at 3:25PM, Resident #11 was observed to have the left index finger and thumb extended and was observed to use the fingers to adjust the bed covers. The left middle, ring and little fingers were observed to be curled inward against the palm of the hand. The resident was observed to use the right hand to try to open the fingers on the left hand but was not able to do so. The resident stated his hand had been like this for about 3 weeks. Review of the progress notes for Resident #11 from 3/16/15 to 4/15/15 revealed no documentation of a problem with the resident ' s left hand. On 4/15/15 at 3:27PM an interview was conducted with the NA (nursing assistant) assigned to the resident on the 3PM-11PM shift. NA #1 stated when she tried to open the resident ' s left hand the resident would say that it hurt. The NA stated the resident did not receive range of motion to the hand and did not have a splint. The Director of Nursing (DON) stated in an interview on 4/16/15 at 9:47AM that Resident #11 did not have a hand splint or a hand roll. The DON stated the resident had been on hospice since 8/29/13 but the resident ' s condition had improved and there had been a discussion about discontinuing hospice. The DON stated this was a new contracture and hospice would be discontinued and a therapy referral would being made regarding the hand contracture. On 4/16/15 at 9:58AM, Resident #11 was observed lying in bed with 1/4 side rails up on the bed. The Occupational Therapist (OT) was observed to evaluate the resident ' s left hand contracture. The OT stated the resident ' s left hand was contracted and was observed to partially open the left middle, ring and little fingers. The resident was observed to use the left thumb and index finger to hold onto the side rail on the bed and assist the OT to turn over in bed. The resident told the therapist his hand had been like this for about 5 weeks. The Therapist asked the resident if he wanted to work with therapy to improve the mobility in the hand and the Resident stated: " Yes. " The OT stated he would recommend a double hand roll and would need to come back and measure the resident for a splint. An interview was conducted with the hospice aide that provided AM care for the resident regularly on 4/16/15 at 10:25AM. The Hospice Aide stated she had been working with Resident #11 for a long time. The Hospice Aide stated she noted the resident ' s left hand contracting but could not say how long but was a matter of weeks and not months. The Hospice Aide stated she spent about an hour with the resident in the morning during the week to give the resident a bath. The Hospice Aide stated she had not had a conversation with any of the staff regarding the resident ' s hand contracture. The DON stated in an interview on 4/16/15 at 10:34AM the NAs provide care every day and if a problem with range of motion was observed, the NAs were to report to the nurse and the nurse would make a referral to therapy and notify the physician. NA #2 stated in an interview on 4/16/15 at 10:44AM that she was frequently assigned to Resident #11. The NA stated after the resident came back from the hospital she saw the fingers of the left hand were bent and told Nurse #2 and she said OK. The NA stated she had not been assigned to the resident all week but when she did work with the resident she did range of motion with the left fingers. On 4/16/15 at 11:02AM Nurse #1 stated in an interview when the resident was re-admitted on [DATE] she saw the resident ' s left fingers curled a little bit but the resident was still able to pick up items and use the left hand. The Nurse stated she did not see the hand was contracted until she was asked about the resident ' s contracture on 4/16/15. The Nurse stated on 4/16/15 she looked at the resident ' s hand and asked him if he wanted a splint and the resident stated: " No. " The Nurse stated she looked around the room and did not see a splint. The Nurse stated she did not tell anyone about the contracture because the resident was on hospice and she knew he was not receiving any kind of therapy. The Nurse stated the NAs had not said anything to her regarding the resident ' s hand. Nurse #2 stated in an interview on 4/16/15 at 11:05AM that no one had said anything to her about a problem with the resident ' s left hand. The OT stated in an interview on 4/16/15 at 11:13AM that the resident had not been referred to therapy since being re-admitted to the facility on [DATE]. The OT provided a copy of the evaluation done on 4/16/15. The Occupational Therapy Plan of Care dated 4/16/15 revealed increased flexor tone in all MPs (metacarpophalangeal) on the left hand as a result of left [MEDICAL CONDITION] the past 3-5 weeks per patient report. Pain noted with passive range of motion. Under Therapy Necessity read: " Skilled OT is necessary to normalize muscle tone in order to maximize UE (upper extremity) function and allow the patient to perform bed mobility with the least amount of assistance and prevent contracture. " The treatment [DIAGNOSES REDACTED]. The DON stated in an interview on 4/16/15 at 11:18AM when the resident told Nurse #1 he did not want a splint, the nurse should have documented this and not done anything further. The DON stated the resident ' s family always said to do what the resident wanted to do. The DON stated anyone could put a hand rolled washcloth in the resident ' s hand and tell the nurse who would communicate this to the MDS Nurse who would revise the care plan and the care guide. The Administrator stated in an interview on 4/16/15 at 12:57PM that Nurse #1 should have made a referral to therapy to see what could be done for the resident ' s contracture even if the resident was on hospice.