Every finding on record at The Greens at Gastonia

Based on record review, observation, and resident and staff interviews, the facility failed to maintain residents' dignity when staff failed to knock before entering residents' rooms and when staff spoke negatively about a resident in the hall for 3 of 3 residents reviewed for dignity and respect (Resident #47, Resident #48 and Resident #90). The residents stated they felt very frustrated, angry, embarrassed, hurt and not worthy of respect or care. The findings included: a. Resident #47 was admitted on [DATE].Resident #47's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. An observation conducted during the initial tour on 6/22/26 at 10:45 AM revealed Nurse Aide (NA) #1 approaching the room of Resident #47, the door was closed, NA#1 proceeded to turn the door handle without knocking and entered the room.An interview with Resident #47 was conducted on 6/25/26 at 11:19 AM. Resident #47 reported the staff came into his room without knocking frequently. He stated he did not like it when they did this and became very frustrated. He reported he felt like he was entitled to have privacy. Resident #47 stated he had asked staff to knock before entering several times, but he had not made a complaint to management staff about staff not knocking.b. Resident #90 was admitted to the facility on [DATE].Resident #90 quarterly MDS assessment dated [DATE] revealed Resident #90 was cognitively intact.An observation conducted on 6/24/26 at 2:15 PM revealed NA #1 going into Resident #90's room. NA #1 approached the closed door of Resident #90's room, proceeded to turn the door handle without knocking and entered the room. An interview was conducted on 6/25/26 at 11:08 AM with Resident #90. He reported the staff came into his room several times a day without knocking. He reported that the staff had even come into the bathroom while he was in there, without knocking before. Resident #90 stated that when the staff comes into his room without knocking it makes him feel angry and like he has no privacy.An interview was conducted with Nurse Aide #1 at 2:07 PM on 6/25/26. She reported she was recently educated on privacy, including knocking on the resident's door and announcing yourself and waiting until the resident tell us to come in. She stated she felt like she didn't consistently knock on doors before entering resident rooms. She reported that she got caught up in her task and would forget to knock. She stated she did not remember if she knocked going into Resident #90 or Resident #47's room on 6/22/26 or 6/24/26.Resident #90 and Resident #47 did not reside in the same room.c. Resident #48 was admitted to the facility on [DATE].The quarterly minimum data set (MDS) dated [DATE] revealed Resident #48 was cognitively intact.An interview was conducted on 6/24/26 at 1:15 PM with Resident #48. Resident #48 revealed that back in February of 2026 she had told NA#2 that her lunch meal plate appeared to have coffee grounds on it. She reported NA #2 took the plate and told her she would have it replaced. Resident #48 reported that when NA#2 went out into the hall with the plate Nurse #5 asked her what was wrong with the plate and the NA #2 told him about Resident #48's concern. Resident #48 stated she heard Nurse #5 say to NA#2 in a sing-song tone, that she had H. I. V. and thinks she can complain about everything. Resident #48 indicated that Nurse #5 never used her name, but she knew he was talking about her, and she felt so embarrassed and hurt. Resident #48 reported that the comment made her feel like, that because of her diagnosis she was not worthy of his respect or care. An interview was conducted with NA #2 on 6/25/26 at 9:34 am. NA #2 reported that she remembered Resident #48 was concerned her lunch meal plate was dirty in February and she had offered to get her a new one. She stated that when she came out of the room with the plate, Nurse #5 asked her what was wrong with the plate. She stated she told him it was dirty and she was going to get Resident #48 another tray. NA #2 reported that Nurse #5 said to her that Resident #48 had H. I. V. and thought that gave her the right to complain about everything. NA #2 indicated Nurse #5 did not say Resident #48's name but they were standing just outside of Resident #48's room. NA #2 revealed that when she returned to Resident #48's room she was visibly upset and told NA #2 that she overheard what Nurse #5 said and it really hurt her. NA #2 reported she notified the Director of Nursing (DON).Nurse #5 was not available for interview and was no longer employed at the facility.An interview with the Director of Nursing (DON) was conducted on 6/25/26 at 6:50 PM. The DON reported that she expected her staff to knock on the door before entering. She reported that staff received training on residents' rights upon hire and annually and had recently received training specifically about knocking on room doors before entering. She explained that she was not sure why any staff would enter a resident's room without knocking and waiting for permission from residents who were cognitively able to give that permission. The DON revealed that she did not remember anyone reporting to her the incident involving Resident #48 and Nurse #5, regarding him speaking disrespectfully about Resident #48. She reported she expected all staff to treat all residents with respect and not discuss resident diagnoses with others and not to belittle a resident due to a diagnosis.An interview with the Administrator was conducted on 6/25/26 at 7:30 PM. The Administrator indicated that he expected all staff to knock on the door of a room, announce themselves, and wait for the residents' permission before entering a resident's room. He reported that staff received training on residents' rights and should know they were required to knock and wait for permission before entering a resident's room. The Administrator reported he had no knowledge of the incident involving Resident #48 and Nurse #5. He reported he expected all staff to always be professional and respectful.

Based on record review, resident, Resident Representative, staff, Consulting Pharmacist, and Medical Director interviews, the facility failed to obtain consent and inform the resident or Resident Representative in advance of the risks and benefits of psychotropic medications prior to the initiation or increase of the medication for 4 of 5 residents reviewed for unnecessary medications (Resident #15, Resident #47, Resident #27, Resident #1).The findings included:a. Resident #15 was admitted on [DATE] with diagnosis that included schizophrenia, psychophysical visual disturbance, Alzheimer's, Dementia with behavioral disturbance, anxiety disorder and other recurrent depression disorder.Resident #15's physician's orders revealed an active order dated 1/5/2026 mirtazapine (antidepressant medication that is also prescribed off-label for anxiety and appetite stimulant) 7.5 milligram (mg) tablet give 1 tablet by mouth at bedtime for anxiety/appetite.Resident #15's physician's orders revealed an order dated 1/5/2026 for olanzapine (antipsychotic medication) 10mg give 1 tablet by mouth two times a day for depression. This order was discontinued on 1/23/2026. Resident #15's physician's orders revealed an order dated 1/23/2026 for olanzapine 10mg give 1 tablet by mouth at bedtime for depression. This order was discontinued on 4/9/2026.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was severely cognitively impaired, and indicated Resident #15 received an antipsychotic and an antidepressant during the 7 day look back period.Resident #15's physician's orders revealed a discontinued order dated 2/28/2026 for buspirone hcl (antianxiety medication) 10mg give 1 tablet by mouth two times a day for anxiety. This order was discontinued on 5/21/2026.Resident #15's physician's orders revealed an active order dated 4/9/2026 for olanzapine 7.5mg give 1 tablet by mouth at bedtime for depression. Resident #15's physician's orders revealed an active order dated 5/21/2026 for buspirone hcl 10mg give 1 tablet by mouth three times a day for anxiety.Review of Resident #15's Medication Administration Record (MAR) from January to June of 2026 revealed mirtazapine, olanzapine and buspirone hcl was administered as ordered.A review of Resident #15's medical record revealed no information indicating if Resident #47 was informed in advance of the risks and benefits of mirtazapine, olanzapine and buspirone.An interview was conducted on 6/25/2026 at 11:10 AM with Resident #15's Resident Representative, who verified he had not been informed of any risks or benefits or side effects of mirtazapine, olanzapine or buspirone by the facility and had not signed any psychotropic consents for Resident #15.An interview with Medical Director #2, who was assigned to Resident #15, was conducted on 6/25/2026 at 10:42 AM. Medical Director #2 stated the facility was responsible for obtaining consent for psychotropic medications for residents who started and/or had an increase in dose for psychotropic medication. b. Resident #47 was admitted on [DATE] with diagnosis that included depression and generalized anxiety disorder.Resident #47's physician's orders revealed a discontinued order dated 10/29/2025 for trazodone (antidepressant medication that is also prescribed off label as a non-habit-forming sleep aid for insomnia) 50mg give one by mouth at bedtime for insomnia.Resident #47's physician's orders revealed a discontinued order dated 11/3/2025 for trazodone 100mg give one by mouth at bedtime for insomnia.Resident #47's quarterly MDS dated [DATE] revealed Resident #47 was cognitively intact and indicated antianxiety medication was administered during the 7 day look back period.Review of Resident #47's MAR from October 2025 through June 2026 revealed trazodone was administered as ordered.A review of Resident #47's medical record revealed no signed consent indicating Resident #47 was informed in advance of the risks and benefits of trazodone.An interview with Resident #47 was conducted on 6/24/2026 at 11:00 AM. Resident #47 stated he had not been informed of the risk or benefits of trazodone by anyone at the facility and had not signed a psychotropic medication consent.c. Resident #27 was admitted on [DATE] with diagnosis that included major depressive disorder, generalized anxiety disorder.Resident #27's physician's orders revealed an order dated 5/8/2025 for mirtazapine (antidepressant medication) 7.5mg give 1 tablet by mouth at bedtime for depression. This order was discontinued on 5/22/2025.Resident #27's physician's orders revealed an order dated 5/22/2025 for mirtazapine 15mg give 1 tablet by mouth at bedtime related to depression. This order was discontinued on 8/15/2025.Resident #27's physician's orders revealed an order dated 8/15/2025 for mirtazapine 15mg give 1 tablet by mouth at bedtime related to major depressive disorder. This order was discontinued on 9/3/2025.Resident #27's physician's orders revealed an active order dated 9/3/2025 for mirtazapine 15mg give one tablet by mouth at bedtime related to depression.Resident #27's annual MDS dated [DATE] revealed Resident #27 was cognitively intact and indicated she had received antidepressant and antianxiety medication during the 7 day look back period.Review Resident #27's MAR from 5/8/2025 through June 2026 revealed mirtazapine was administered as ordered.A review of Resident #27's medical record revealed no information indicating if Resident #47 was informed in advance of the risks and benefits of Mirtazapine.An interview was conducted on 6/25/2026 at 10:05 AM with Resident #27. Resident #27 stated no one from the facility had informed her of the risk and benefits of mirtazapine and she had not signed a psychotropic medication consent.d. Resident #1 was admitted on [DATE] with diagnosis that included depression, insomnia and anxiety.Resident #1's physician's orders revealed an order dated 4/24/2026 for fluoxetine (antidepressant medication) 10mg give 1 by mouth daily for depression, anxiety and sexually inappropriate behavior. This order was discontinued on 5/8/2026.Resident #1's physician's orders revealed an order dated 5/8/2026 for fluoxetine 20mg give 1 by mouth daily for depression/anxiety. This order was discontinued on 5/22/2026.Resident #1's physician's orders revealed an order dated 5/22/2026 for fluoxetine 40mg give 1 by mouth daily for depression. This order was discontinued on 6/19/2026.Resident #1's physician's orders revealed an active order dated 6/19/2026 for fluoxetine 60mg give 1 by mouth daily for depression/anxiety.Review of Resident #1's annual MDS dated 1/5/2026 revealed Resident #1 was cognitively intact and indicated he received an antidepressant during the 7 day look back period.Review of Resident #1's MAR from April to June 2026 indicated fluoxetine was administered as ordered.A review of Resident #1's medical record revealed no information indicating if Resident #47 was informed in advance of the risks and benefits of fluoxetine.An interview was conducted on 6/25/2026 at 2:00 PM with Resident #1, who stated he had not been informed of the risk and benefits of fluoxetine and had not signed a psychotropic medication consent. An interview was conducted with Nurse #1 on 6/24/2026 at 10:30 AM. Nurse #1 stated she thought the unit managers or supervisors completed the psychotropic medication consent forms.An interview was conducted with Unit Manager #2 on 6/24/2026 at 4:00 PM. Unit Manager #2 stated residents with orders for psychotropic medications needed a psychotropic consent form completed when they were admitted with orders for psychotropic medication and if a new psychotropic medication was started or the dose of a psychotropic medication was increased.A telephone interview was conducted on 6/25/2026 at 1:05 PM with the Psychiatric Nurse Practitioner (NP), who stated the facility was responsible for obtaining psychotropic medication consents for residents who started or had a dose increase of psychotropic medication.An interview was conducted with the Medical Director #1 on 6/25/2026 at 12:05 PM. Medical Director #1 revealed he did not complete psychotropic medication consents with the residents, and the facility was responsible for making sure they were completed per policy.A telephone interview with the Consulting Pharmacist on 6/25/2026 at 1:09 PM. The Consulting Pharmacist verified psychotropic medications required consent prior to being initiated and when there was a dose increase.An interview was conducted on 6/25/2026 at 11:29 AM with the Director of Nursing (DON) who stated a psychotropic consent form was required any time a resident started a psychotropic medication and when a psychotropic medication dose was increased. The DON revealed the floor nurses or unit manager should complete the consent when the order was received prior to administration of the first dose. The DON stated she was aware there was an issue with psychotropic consents not being complete, and the staff responsible to update consents had gone out on leave and the facility was still working on updating psychotropic medication consents.An interview was conducted on 6/25/2026 at 2:00 PM with the Administrator who stated he was not familiar with the exact process of psychotropic medication consents. The Administrator revealed the DON and nursing were responsible for psychotropic medication consents. The Administrator indicated he expected psychotropic medication consents to be completed by policy.

Based on record review, staff, Responsible Party, and Medical Director interviews, the facility failed to maintain accurate advanced directives throughout the medical record for 1 of 1 resident reviewed for advanced directives (Resident #103).The findings included:Resident #103 was admitted to the facility on [DATE].Review of Resident #103's comprehensive care plan initiated [DATE] indicated Resident #103 was a full code. Care plan goals listed as: Allow extra time for resident to discuss feelings regarding full code status, call 911 immediately as indicated, effectively communicate full code status wishes by placing in resident's chart, and or when resident must be transferred outside of the facility, Intercede rapidly and begin immediate resuscitative efforts utilizing all life-sustaining measures available if the residents heart stops beating or the resident stops breathing (Such as CPR, O2 administration etc.), notify family of residents condition promptly, obtain vital signs as ordered per physicians orders and as needed, notify provider as indicated.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #103 was severely cognitively impaired. Review of Resident #103's Physician's orders, revealed an order dated [DATE] that read Do Not Resuscitate- DNR (DNR). Review of the Code Book (a binder that contained paper copies of residents' advanced directives and code status) revealed Resident #103's paper medical record contained a signed Medical Orders for Scope of Treatment (MOST) form that indicated Resident #103's preference for DNR status in the event he had no pulse and was not breathing. The form was signed by Resident #103's Responsible Party and dated [DATE]. Review of the profile page of Resident #103's electronic health record revealed Resident #103's code status was listed as a DNR. An interview was conducted on [DATE] at 11:24 AM with Resident #103's Responsible Party who verified she had changed Resident #103's code status from a Full Code to a DNR on [DATE].An interview was conducted on [DATE] at 11:54 AM with Unit Manager #1 who revealed when a resident's code status was changed, she was responsible for entering the new order into the electronic medical record after all documentation was completed and signed. Unit Manager #1 did not recall who notified her of the change in Resident #103's code status. Unit Manager #1 confirmed the DNR form and MOST form were completed and signed on [DATE]. Unit Manager #1 stated she was not responsible for updating the residents care plan and revealed the MDS nurses updated the care plan. Unit Manager #1 stated that MDS nurses were notified of new orders for change in code status during the morning clinical meetings.An interview was conducted on [DATE] at 12:04 PM with MDS Nurse #1, who verified Resident #103's code status was listed as DNR, but the care plan indicated full code. MDS Nurse #1 stated changes or new orders for resident's code status were supposed to be communicated to MDS nurses in morning clinical meetings or by email. MDS Nurse #1 confirmed she was responsible for updating the residents care plan when their code status changed. MDS Nurse #1 stated Resident #103's care plan should have been updated after the new order for a DNR was received on [DATE]. MDS Nurse #1 was unsure of the exact reason Resident #103's care plan had not been updated. MDS Nurse #1 could not recall if Resident #103's new code status was discussed in the morning clinical meeting. An interview was conducted on [DATE] at 12:00 PM with the Director of Nursing (DON), who explained when a resident had a change in code status it was reported to the MDS nurses during the morning clinical meeting that was held Monday through Friday. The DON revealed the MDS nurses were responsible for updating the care plan when a resident had a change in code status. The DON could not recall if Resident #103's new code status had been discussed during the morning clinical meeting. The DON stated she expected a resident's code status to be consistent throughout the entire medical record.During an interview on [DATE] at 12:10 PM the Administrator indicated he was not familiar with the exact process that occurred when a resident had a change in code status. The Administrator stated he expected a resident's code status to be accurate and consistent throughout the entire medical record.An interview was conducted on [DATE] at 12:05 PM with the Medical Director who confirmed a resident's code status should be accurately documented throughout the entire medical record.

Based on observation, record review, resident, staff and Medical Doctor interviews, the facility failed to provide a treatment as ordered by the physician for a moisture associated skin issue for 1 of 3 residents reviewed for non-pressure skin treatments (Resident #48). The findings included:Resident #48 was admitted to the facility on [DATE] with diagnosis that included polyneuropathy (the malfunction or damage of multiple peripheral nerves throughout the body) generalized anxiety disorder, chronic obstructive pulmonary disorder, major depressive disorder. The quarterly minimum data set (MDS) dated [DATE] revealed Resident #48 was cognitively intact, incontinent of urine, and had moisture associated skin damage.A physician's order for Resident #48 dated 6/19/26 read, cleanse areas under abdominal folds with soap and water, pat dry. Apply interdry sheet (an antimicrobial, moisture-wicking fabric designed to manage moisture, friction and odor in skin folds) once daily.A review of the Treatment Administration Record (TAR) for June 2026 revealed documentation on 6/21/26 by Nurse #3 that Resident #48's interdry was applied.A review of the Treatment Administration Record (TAR) for June 2026 revealed documentation on 6/22/26 by Nurse #3 that Resident #48's interdry was applied.A review of the Treatment Administration Record (TAR) for June 2026 revealed documentation on 6/23/26 by Nurse #4 that Resident #48's interdry was applied.An interview was conducted with Resident #48 on 6/23/26 at 2:15PM. Resident #48 revealed that she had been prescribed interdry to help with moisture in her abdominal folds. She reported the hospital had sent interdry with her to the facility and it had been stored in her room, but she had ran out and had not received it for several days. She reported that the nurse aides had put a dry bath towel in her abdominal folds since she was out of the interdry. An observation of Resident #48's abdominal folds on 6/23/26 at 2:30 PM revealed that a bath towel had been placed in the abdominal fold.A second observation of Resident #48's abdominal folds on 6/23/26 at 4:15 PM with the Director of Nursing (DON) showed a bath towel had been placed in the abdominal folds and was now saturated with urine. During the observation the DON removed the towel from the abdominal fold and intact skin between the folds was observed.An interview was conducted with the Director of Nursing (DON) on 6/23/26 at 4:15 PM. The DON indicated she was not aware that Resident #48 was out of interdry and would have expected the nursing staff to make someone aware. She reported that the interdry had not been ordered but was available through the facility's vendor. She stated that after being made aware on 6/23/26 that Resident #48 did not have anymore, she had sent an employee to a sister facility to get some and made the supply clerk aware that interdry needed to be ordered. The DON stated that the nurses were aware that if there was a treatment on the TAR they do not sign it as completed unless they actually performed the treatment. The DON reported that putting a towel in Resident #48's abdominal folds was not an acceptable replacement for the interdry. An interview was conducted with the Treatment Nurse on 6/23/26 at 3:30 PM. The Treatment Nurse reported that she was not normally responsible for treatments such as placing or applying interdry, creams or powders. She stated she was, however, aware of the interdry order for Resident #48 only because she and Resident #48 had talked about it. She indicated she was not aware Resident #48 was out of the interdry. She stated the last time she was in Resident #48's room there was a box of interdry in there. An observation on 6/23/26 at 3:45 PM of the medication cart assigned to the hall where Resident #48 resided revealed no interdry was on the cart. An observation on 6/23/26 at 3:50 PM of the treatment cart revealed no interdry was on the cart. An observation on 6/23/26 at 3:55 PM of both medication storage rooms revealed no interdry in either room.An interview with Nurse #3 was conducted on 6/23/26 at 2:50 PM. Nurse #3 stated she had worked with Resident #48 on 6/21/26 and 6/22/26 and she did not know what interdry was. She reported she was newly hired at the facility and she felt she had signed the order as being completed on the TAR in error. Nurse #3 stated she did not apply interdry to Resident #48's abdominal folds.An interview with Nurse #4 was conducted on 6/23/26 at 3:00 PM. Nurse #4 stated she was not aware of an order for Resident #48 that included interdry. She stated she did not apply interdry to Resident #48's abdominal folds during her shift. Nurse #4 reported she must have signed the order as being completed on the TAR by accident.An interview with the Medical Doctor (MD) was conducted on 6/25/26 at 10:30 AM. The MD revealed that he would expect to be notified if supplies for a treatment were not available and that an order should not be signed off on the TAR as completed if it was not performed. He reported that a bath towel could serve as a temporary replacement for the interdry, if the interdry was not available but should not be used long term as there were much more appropriate substitutes for interdry. The MD reported that a bath towel should be moistened prior to applying it to the abdominal folds to avoid skin breakdown.An interview was conducted with the Administrator on 6/25/26 at 7:15 PM. The Administrator revealed he would expect the nursing staff to make a manager aware if supplies for treatment was not available. He stated that if a nurse did not perform a treatment, then it should not be signed off on the TAR.

Based on record review, Medical Doctor and staff interviews, the facility failed to maintain an accurate Treatment Administration Record (TAR) for 1 of 3 residents reviewed for medical record accuracy (Resident #48).Findings included: Resident #48 was admitted to the facility on [DATE] with diagnosis that included polyneuropathy (the malfunction or damage of multiple peripheral nerves throughout the body) generalized anxiety disorder, chronic obstructive pulmonary disorder, major depressive disorder. The quarterly minimum data set (MDS) dated [DATE] revealed Resident #48 was cognitively intact and had moisture associated skin damage. A physician's order for Resident #48 dated 6/19/26 read, cleanse areas under abdominal folds with soap and water, pat dry. Apply interdry sheet (an antimicrobial, moisture-wicking fabric designed to manage moisture, friction and odor in skin folds) once daily. A review of Resident #48's June 2026 Treatment Administration Record (TAR) revealed that interdry had been signed by staff each day from 6/20/26 through 6/22/26, indicating it the interdry was applied to Resident #48's abdominal fold on these days. An interview was conducted with Resident #48 on 6/23/26 at 2:15PM. Resident #48 revealed that she had been prescribed interdry to help with moisture in her abdominal folds. She reported the hospital had sent interdry with her to the facility and it had been stored in her room, but she had ran out and had not received it for several days. She reported that the nurse aides had put a dry bath towel in her abdominal folds since she was out of the interdry. An observation of Resident #48's abdominal folds on 6/23/26 at 2:30 PM revealed that a bath towel had been placed in the folds. A second observation of Resident #48's abdominal folds on 6/23/26 at 4:15 PM with the Director of Nursing (DON) showed a bath towel had been placed in the abdominal folds and was now saturated with urine. An interview was conducted with the Director of Nursing (DON) on 6/23/26 at 4:15 PM. The DON stated that the nurses were aware that if there was a treatment on the TAR they do not sign it as completed unless they actually performed the treatment. An interview with Nurse #3 was conducted on 6/23/26 at 3:00 PM. Nurse #3 stated she had worked with Resident #48 on 6/21/26 and 6/22/26 and she did not know what interdry was. She reported she was newly hired at the facility and she felt she had signed the order as being completed on the TAR in error. Nurse #3 stated she did not apply interdry to Resident #48's abdominal folds. An interview with Nurse #4 was conducted on 6/23/26 at 3:30 PM. Nurse #4 stated she was not aware of an order for Resident #48 that included interdry. She stated she did not apply interdry to Resident #48's abdominal folds during her shift. Nurse #4 reported she must have signed the order as being completed on the TAR by accident. An interview with the Medical Doctor (MD) was conducted on 6/25/26 at 10:30 AM. The MD revealed that he would expect that an order would not be signed off on the TAR as completed if it was not performed. An interview was conducted with the Administrator on 6/25/26 at 7:15 PM. The Administrator revealed he would expect the nursing staff to only sign off on the TAR on treatments that were actually performed.

Based on observations, record review, and staff interviews, the facility failed to follow their Hand Hygiene policy when Nurse #1 did not perform hand hygiene before each donning of clean gloves during catheter care and failed to perform hand hygiene between residents during medication pass. This deficient practice affected 3 of 7 residents reviewed for infection control and included 1 of 7 staff observed for infection control. (Resident #112, #121, #135). The findings included:Review of the facility's policy and procedure entitled Hand Hygiene read in part:Hand hygiene continues to be the primary means to prevent the spread of healthcare-associated infections. The following is a list of some situations that require hand hygiene:Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident);After contact with a resident's mucous membranes and body fluids or excretions;After handling soiled or used linens, dressings, bedpans, catheters, and urinals;After removing gloves or aprons; andAfter completing duty. An observation of catheter care was made on 6/24/26 at 11:15 AM with Resident #112 and Nurse #1. Nurse #1 was observed cleaning the bedside table and placing catheter supplies on a clean paper towel after the surface dried. Nurse #1 donned a clean gown and sanitized her hands and donned clean gloves. She then removed the old dressing from the suprapubic catheter and threw it away. Nurse #1 then doffed her gloves and without sanitizing her hands, donned a clean pair of gloves and proceeded to clean the suprapubic area and replaced the dressing with clean gauze and secured with tape. Nurse #1 then doffed her gown and gloves, collected her supplies and trash, wiped down the table and left the resident's room without performing hand hygiene. An observation was made during medication administration on 6/24/26 at 8:15 AM. During the observation Nurse #1 was observed entering the room of Resident #135 with his medications. She did not perform hand hygiene nor did she don gloves before removing Resident #135's straw from his cup and placing it into the cup of water she was providing to be used while taking his medications. Nurse #1 then poured Resident #135's medications into her ungloved hand and Resident #135 took the medications from her hand, one by one, and placed them in his mouth. Nurse #1 then removed Resident #135's straw from the water cup and returned it to the cup in his room. Nurse #1 then returned to the medication cart and pulled Resident #121's medications without performing hand hygiene. She then administered Resident #121's medications and returned to her medication cart without performing hand hygiene. An interview was conducted on 6/25/26 at 2:33 PM with Nurse #1. She revealed she was not aware that she had not sanitized her hands after she had doffed her gloves during catheter care. Nurse #1 also reported that she also was not aware that she did not sanitize her hands after touching the used straw of Resident #135's and assisting him with his medications during medication pass. She also stated she didn't realize she did not perform hand hygiene before providing medications to Resident #121. Nurse #1 stated she knew she was supposed to always sanitize her hands when she removed her gloves and before putting on clean gloves. She also reported she was aware she should have performed hand hygiene between residents during her medication pass. Nurse #1 stated she received education on infection prevention several times throughout the year and is unsure why she did not perform hand hygiene during these times. An interview on 6/24/26 at 11:15 AM with the Infection Preventionist (IP) revealed she was not aware of the errors made by Nurse #1 during catheter care or medication pass. She stated her expectation was that Nurse #1 would have sanitized her hands every time she removed her gloves and before putting on clean gloves during catheter care and that she would have sanitized her hands between residents during medication pass. The IP further stated staff received education on infection control annually and multiple times during the year. An interview on 6/25/26 at 5:15 PM with the Director of Nursing (DON) revealed she was not aware of Nurse #1's errors during catheter care or medication pass. The DON stated it was her expectation that all staff follow infection control best practices to prevent the spread of infection. She further stated staff receive education on infection control annually as well as multiple times throughout the year. An interview on 6/25/26 at 7:30 PM with the Administrator revealed he would expect Nurse #1 to follow the Hand Hygiene policy at all times. The Administrator stated that all staff had been provided education about infection control and hand hygiene frequently.

Based on record reviews, resident, staff, Nurse Practitioner (NP), and physician interviews, the facility failed to clarify and/or implement wound care orders as specified in the hospital discharge summary. In addition, the resident was seen by a Wound Care NP four days after admission and the wound care orders were not implemented until two days later. As a result, the resident was not provided wound care to three abdominal surgical wounds until six days after admission to the facility. The deficient practice occurred for 1 of 2 residents reviewed for wound care (Resident #1).The findings included:Resident #1's hospital Discharge summary dated [DATE] revealed the following wound care orders: May wash surgical incisions daily with soap and water using a fresh washcloth each time.Resident #1 was admitted to the facility on [DATE] with diagnoses which included laparoscopic incarcerated ventral hernia repair (a medical emergency where abdominal tissues (like the intestine) become trapped in a hernia sac and cannot be pushed back into the abdomen) and diabetes mellitus. The facility's admission nursing note dated 10/17/2025 at 2:00 PM by Nurse #1 revealed Resident #1 arrived at the facility via wheelchair. Resident #1 was alert and oriented and had three surgical incisions to her abdomen.Multiple unsuccessful attempts were made to contact and interview Nurse #1 (agency) who admitted Resident #1 on 10/17/2025.The care plan dated 10/18/2025 revealed Resident #1 was at risk for pressure ulcer development related to disease processes, impaired mobility, and the presence of an abdominal surgical wound. The interventions included to provide surgical wound care as ordered.Review of the Electronic Medical Record revealed Resident #1 was her own responsible party.Review of the Physician's admission visit note dated 10/18/2025 at 8:00 AM revealed Resident #1 had intact dressings to her right upper abdomen, lower mid-abdomen, and right lower abdomen.The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's cognition was moderately impaired. Resident #1 had no behaviors or refusals of care. The MDS also indicated Resident #1 had a surgical wound and was receiving surgical wound care.Review of the previous Wound Care NP's visit note dated 10/21/2025 revealed the following wound care orders: Clean abdominal surgical incisions with wound cleanser and apply a bordered dressing daily. Review of the Treatment Administration Record (TAR) dated October 2025 revealed Resident #1 had no wound care orders entered on the TAR until 10/23/2025 which specified to clean abdominal surgical incisions with wound cleanser and apply a bordered dressing daily. Review of the October and November 2025 TARs revealed the treatment was completed daily until 11/10/2025 when the Wound Care NP discontinued the order.Review of the Electronic Medical Record revealed Resident #1 was discharged on 11/17/2025. Resident #1 was interviewed via telephone on 5/5/2026 at 10:04 AM. She stated her abdominal surgical wound dressing changes were not done for about a week after she was admitted to the facility. Resident #1 explained that she had an incontinent episode the day after she was admitted to the facility around 9:00 PM and she soiled her abdominal dressings. Resident #1 further explained that she asked a nurse to change her abdominal dressings and the nurse refused (she could not recall the nurse's name). Resident #1 explained that she removed her abdominal dressings and cleaned the incisions with soap and water and left the incisions open to air and it was several days before she received any type of wound care for her abdominal incisions. Resident #1 also stated that her surgical incisions healed without any issues.An interview was conducted with Nursing Assistant (NA) #1 on 05/05/2026 at 2:19 PM who was assigned to care for Resident #1 on 10/18/2025 on the 7:00 am to 3:00 pm shift. NA #1 stated that she did not recall Resident #1 and did not remember anything about her.An interview was conducted with NA #2 on 05/06/2026 at 6:40 AM who was assigned to care for Resident #1 on 10/17/2025 and 10/18/2025 on the 11:00 pm to 7:00 am shift. NA #2 stated that she did not recall Resident #1.On 05/06/2026 at 8:10 AM an interview was conducted with NA #3 who was assigned to Resident #1 on 10/17/2025 and 10/18/2025 on the 3:00 pm to 11:00 pm shift. NA #2 stated that she remembered Resident #1 and that she was independent with her activities of daily living, but she did not remember anything about her incisions or her having an incontinent stool.Multiple unsuccessful attempts were made to interview Nurse #3 (agency) who was assigned to Resident #1 on 10/17/2025 on the 3:00 pm to 11:00 pm shift.On 05/06/2026 at 8:20 AM a telephone interview was conducted with Nursing Supervisor #1 who stated that she remembered Resident #1 but had no knowledge of her surgical incisions or her wound care orders.Multiple unsuccessful attempts were made to interview Nurse #4 (agency) who was assigned to Resident #1 on 10/18/2025 from 7:00 am to 11:00 pm.An interview was conducted with Nurse #2 on 05/06/2025 at 6:45 AM who was assigned to Resident #1 on 10/22/2025 on the 11:00 pm to 7:00 am shift. Nurse #2 stated that she did not remember Resident #1.On 05/06/2026 at 8:25 AM a telephone interview was conducted with Nursing Supervisor #2 who stated that she recalled Resident #1 and remembered talking to Resident #1's family member about her call bell on Sunday 10/19/2025. Nursing Supervisor #2 stated that she went to Resident #1's room and checked to see if her call bell was functioning properly and she also looked at her abdominal incisions which were open to air and clean and dry. Nursing Supervisor #2 stated that she did not recall if Resident #1 had any wound care orders, but she did not notice anything abnormal with her abdominal incisions.On 05/06/2026 at 9:20 AM an interview was conducted with Unit Manager #1 who explained that the facility has had 3 different Wound Nurses in the past 6 months. He also stated that the facility currently had a dedicated Wound Care Nurse working Monday-Friday. Unit Manager #1 also stated that if the facility had an extra nurse scheduled for the weekend, that nurse would be assigned to perform wound care, if not, the hall nurses were responsible for wound care on their assigned units. The Unit Manager #1 also stated that he did not recall Resident #1.On 05/06/026 at 9:34 AM an interview was conducted with the Wound Nurse. The Wound Nurse stated that she had only been in her position for two weeks and did not provide care for Resident #1. Multiple unsuccessful attempts were made to contact and interview the previous Wound Care Nurse who was employed by the facility at the time of Resident #1's stay.Multiple unsuccessful attempts were made to interview the previous Wound Care NP who initiated Resident #1's wound care orders.An interview was conducted with the Director of Nursing (DON) on 05/06/2026 at 11:00 AM who indicated she was not aware that Resident #1's wound care orders were not set up on the day of her admission on [DATE] as specified on her hospital discharge summary or on 10/21/2025 when the Wound Care NP provided new wound care orders. The DON verified that Resident #1's hospital discharge summary included wound care orders to wash the abdominal incisions daily with soap and water. The DON also verified that the Wound Care NP's orders dated 10/21/2025 were not entered into the computer system and initiated by the previous Wound Care Nurse until 10/23/2025. The DON reviewed Resident #1's TAR and confirmed that no surgical wound care was documented for Resident #1 until 10/23/2025. The DON stated that the discharge summary wound care orders and the Wound Care NP's treatment orders must have been overlooked and should have been initiated when the orders were written. She explained that the nursing staff would not know to complete the wound care unless the order was entered into the computer system. The DON stated that she expected all wound care orders to be entered into the computer system so the orders would flow to the TAR, and the nursing staff would know the resident had wound care orders. The DON further explained that she expected all residents' wound care to be completed as ordered. The DON further explained that Nurse #1 should have entered or discussed the wound care orders with the physician and the previous Wound Care Nurse should have entered the orders from the Wound Care NP on 10/21/2025.Multiple unsuccessful attempts were made to interview the facility's previous NP.A telephone interview was conducted with the facility NP on 05/06/2026 at 12:32 PM. The NP stated that he was not familiar with Resident #1. The NP further stated that he expected the facility staff to follow all wound care orders as written. An interview was conducted with the facility Physician on 05/06/2026 at 12:52 PM who stated he was not aware Resident #1 had not received wound care during the first week of her admission to the facility. He stated that he expected the nursing staff to follow all orders for dressing changes and wound care.

Based on observation, record review, and staff interviews, the facility failed to follow their Infection Control policies and procedures for Hand Hygiene when the Wound Care Nurse failed to doff her gloves, sanitize her hands, and don clean gloves after cleaning a sacral wound. With the same gloves on after cleaning the sacral wound with wound cleanser the Wound Care Nurse applied the treatment to the sacral wound for Resident #5 with a sacral pressure ulcer who was on Enhanced Barrier Precautions (EBP). The deficient practice occurred for 1 of 7 staff observed for infection control practices (Wound Care Nurse).The findings included:Review of the facilities Hand Hygiene policy and procedure which is part of the Infection Control policies and procedures last revised 08/2015 revealed the following:Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection.Policy Interpretation and Implementation:2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations:b. Before and after direct contact with resident;g. Before handling clean or soiled dressings, gauze pads, etc.;h. Before moving from a contaminated body site to a clean body site during residentcare;i. After contact with a resident's intact skin;j. After contact with blood or bodily fluids;k. After handling used dressings, contaminated equipment, etc.; andm. After removing glovesAn observation on 05/05/26 at 11:30 AM of sacral wound care on Resident #5 was made with the Wound Care Nurse and Wound Nurse Practitioner (NP). The Wound Care Nurse had already cleaned the overbed table and placed a barrier on it with her wound care supplies on top of the barrier. The Wound Care Nurse began by washing her hands with soap and water and donning clean gloves, and a gown. She proceeded by removing the old dressing using wound cleanser to loosen the edges of the old dressing, removed it and discarded it in the trash. The Wound Care Nurse doffed her gloves, washed her hands with soap and water and donned clean gloves. The Wound Care NP with gloves and gown on measured the wound and with the permission of the resident debrided the wound. After the debridement was completed the Wound Care Nurse cleaned the wound with wound cleanser and gauze. After cleaning the wound, and without doffing her gloves, sanitizing her hands, and donning new gloves, the Wound Care Nurse cut the calcium alginate (highly absorbent wound dressing) and placed it on the wound and covered the wound with a bordered gauze dressing. She gathered her supplies along with the trash, doffed her PPE, washed her hands with soap and water and left Resident #5's room.An interview on 05/06/26 at 9:34 AM with the Wound Care Nurse revealed she had been doing the wounds at the facility for a short period. The Wound Care Nurse stated she had been making rounds weekly with the Wound Care NP and doing the wound care in the facility. She further stated she thought the wound care on Resident #5 had gone well on 05/05/26. When asked about cleansing the wound and then applying the treatment, the Wound Care Nurse agreed that she should have doffed her gloves, sanitized her hands, and donned clean gloves prior to applying the treatment to the wound. She stated she didn't know why she had left that step out but said she should have sanitized her hands and changed her gloves prior to applying the treatment to Resident #5's wound.The Infection Preventionist was not available for interview.An interview on 05/06/26 at 1:46 PM with the Director of Nursing (DON) revealed it was her expectation that the Wound Care Nurse follow the Hand Hygiene policy and procedure. The DON stated she should have doffed her gloves, sanitized her hands and donned clean gloves after she cleaned the wound and before applying the treatment to Resident #5's sacral wound.

Based on observations, record reviews, and Nurse Practitioner, resident, and staff interviews, the facility failed to provide effective supervision for Resident #3 who had dementia with severe cognitive impairment, hemiparesis (mild or moderate weakness) of the dominant right side due to a stroke, and a history of smoking. A smoking assessent completed on 12/20/24 noted Resident #3 had limited range of motion and unclear speech response but was determined as having no issues with her ability to smoke safely and was determined to be safe to smoke unsupervised. On 3/19/25, Resident #3 was smoking unsupervised in the designated smoking area and caught her hair on fire. Resident #3 patted her hair with her right hand to put out the fire. Resident #3's hair was singed on her right side at least one inch starting from her hairline at her right ear through her hairline to the center part of her hair. Resident #3's right eye lid was blistered, and the palm of her right hand and behind her right ear also received mild burns and all were treated with a topical antibiotic cream. The smoking assessment completed 3/19/25 determined Resident #3 required staff supervision with smoking due to being unable to safely light smoking materials, hold smoking materials safely, and unable to call for emergency assistance. On Sunday 4/20/25 Resident #3 exited the front entrance of the building in her wheelchair and self- propelled herself 151 feet from the entrance of the facility through the parking lot to the parking lot entrance/exit area and was headed toward the main road without staff knowledge. The main road in front of the facility and was four lanes with a speed limit of 35 miles per hour. A facility visitor who was leaving the parking lot telephoned the Weekend Nurse Supervisor around 7:00 PM and stated a resident was in her wheelchair outside at the parking lot entrance/exit and was wheeling herself towards the main road. The Weekend Nurse Supervisor notified Unit Manager #3 and they both responded to the parking lot where Resident #3 was found at the parking lot's entrance/exit area seated in her wheelchair facing the facility with her back towards the main road and self-propelling herself backwards up the exit incline towards the main road. Resident #3 did not have smoking material in her possession but told the staff she was in the parking lot because she wanted to smoke. This deficient practice had a high likelihood of causing serious harm or injury to Resident #3 and affected 1 of 3 residents reviewed for supervision to prevent accidents (Resident #3). Immediate jeopardy began on 3/19/25 when Resident #3 was smoking unsupervised and lit her hair on fire and again on 4/20/25 when Resident #3 exited the facility unsupervised and without staff knowledge. The immediate jeopardy was removed on 5/01/25 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses that included stroke, expressive aphasia (partial loss of the ability to produce language), and hemiparesis (mild or moderate weakness) of the dominant right side, seizure disorder, and muscle weakness. Resident #3 was also diagnosed with dementia in 2015 and anxiety disorder, depression, and bipolar disease in 2018. Resident #3's quarterly smoking safety assessment completed by the previous Administrator dated 7/15/24 revealed Resident #3 was a smoker with a limited range of motion, weak grasps, diminished reflex response, and unclear speech response. Under the direct smoking observation section, Resident #3 was assessed as being unable to hold smoking materials safely and respond quickly to fallen ashes. Therefore, the smoking requirement for Resident #3's safety was for her to be a supervised smoker, wear a smoking apron, and smoking materials to be stored by the facility. The revised care plan dated 7/15/24 revealed Resident #3 was a smoker with a goal that she would not suffer any injuries from unsafe smoking practices through next review date. Interventions included Resident #3 could utilize cigarettes and smoke supervised, wear a smoking apron to protect her clothing, and had been instructed on smoking risks and hazards. Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. Resident #3 was also assessed for use of tobacco, being ambulatory with assistance of a wheelchair, required substantial assistance for transfers, functional limitation of range of motion with impairments to the upper and lower extremities on one side, and no change in behaviors were noted. Resident #3's quarterly smoking safety assessment completed by the MDS Coordinator #2 dated 12/30/24 revealed Resident #3 was a smoker with limited range of motion and unclear speech response. Under the direct smoking observation section, Resident #3 was assessed as having no issues with her ability to smoke safely. Therefore, the smoking requirement for Resident #3's safety was changed for her to become an unsupervised smoker, no smoking apron required, and smoking materials continued to be stored by the facility. Care Plan updated to show change in smoking status from supervised to unsupervised. An interview with the MDS Coordinator #2 on 4/29/25 at 2:06 PM revealed she was familiar with Resident #3 and had completed her smoking evaluation on 12/30/24. She stated she had completed Resident #3's to the best of her knowledge and understanding of the questions. During her observation of Resident #3 smoking she felt Resident #3 was able to light, smoke, and dispose of her cigarette properly, and that was why she made her an unsupervised smoker. She revealed she was aware of Resident #3 being cognitively impaired and of her limited range of motion but felt that she was able to handle and smoke a cigarette safely. When asked if there had been any improvements or changes with Resident #3's cognition, functional abilities, or diagnosis since her last smoking assessment on 7/15/24, the MDS Coordinator #2 stated no but that she believed that Resident #3 was able to hold a cigarette and smoke it safely. The revised care plan dated 12/30/24 revealed Resident #3 was a smoker with a goal that she would not suffer any injuries from unsafe smoking practices through next review date. Interventions included Resident #3 could utilize cigarettes and smoke unsupervised, observe clothing and skin for signs of cigarette burns, and had been instructed on smoking risks and hazards. Resident #3's annual MDS assessment dated [DATE] revealed she was severely cognitively impaired. Resident #3 was also assessed for use of tobacco, being ambulatory with assistance of a wheelchair, required partial assistance for transfers, functional limitation of range of motion with impairments to the upper and lower extremities on one side, and no change in behaviors were noted. Nursing progress note written by Nurse #3 dated 3/19/25 revealed Resident #3 was outside smoking when her hair caught fire. Hair to the right of her head was singed off. Ear and hand to right side noted red. Provider and Responsible Person was updated. The Medical Director responded with the following feedback: Continue to monitor any changes at this time. Resident #3's quarterly smoking assessment completed by Nurse #3 dated 3/19/25 revealed Resident #3 was a smoker with problematic short- and long-term memory, limited range of motion, and unclear speech. Under the direct smoking observations sections, Resident #3 was assessed as being unable to safely light smoking materials, hold smoking materials safely, and unable to call for emergency assistance. Therefore, the smoking requirement for Resident #3's safety was for her to become a supervised smoker, wear a smoking apron, and smoking materials to be stored by the facility. A telephone interview with Nursing Assistant (NA) #7 on 4/29/25 at 3:11 PM revealed she was familiar with Resident #3. She stated on 3/19/25 she had gone into another resident's room to check on them and was looking out of their window to the smoking area and she observed Resident #3 outside at the smoking area patting on the side of her head. She revealed she left the other resident's room, went over to the door that leads out to the smoking area, and saw Resident #3 trying to open the door to come back inside the facility. NA #7 stated she opened the door for Resident #3 to come in and immediately noticed the smell of something burning and when she looked at Resident #3's hair she could tell it had been singed and the right side of her face at her hairline was red. She revealed she immediately assisted Resident #3 over to the nurse's desk and informed Nurse #3 what happened and then went to get the DON. She revealed Nurse #3, and the DON began treating Resident #3 and she went back to her residents. An interview with Nurse #3 on 4/29/25 at 12:34 PM revealed he was familiar with Resident #3. He stated he was standing at the nurse's desk on 3/19/25 when NA #7 brought Resident #3 over to him stating she believed Resident #3 had burned her hair while smoking. He revealed when he began to assess Resident #3, he observed that she had singed her hair starting from her hairline at her right ear up through the hairline at the center part of her hair. He stated he also observed that she had redness behind her right ear, on her face at her hairline, and to the palm of her right hand. Nurse #3 revealed he asked Resident #3 what happened, and she stated she was smoking and her hair caught fire, and she put it out with her hand. He stated he notified the physician who told him to monitor, made a note for the NP to assess Resident #3 for burns, documented in the medical chart, and completed a new smoking assessment for Resident #3 to be a supervised smoker. He revealed after he finished assessing Resident #3, the Director of Nursing (DON) came and took Resident #3 back to her room. Previous infection control nurse progress note dated 3/19/25 revealed the Nurse Practitioner (NP) notified of blistered area (second-degree burn) to right eyelid. New order to apply [a topical antibiotic cream used to treat and prevent infection of serious burns] to area twice a day and Tylenol 650 milligrams (MG) every 8 hours as needed for pain. Resident #3 to be evaluated by NP upon next round. Resident #3 was made aware. NP order for Resident #3 dated 3/19/25 revealed Tylenol Oral Tablet 325 MG (Acetaminophen) give 2 tablets by mouth every 8 hours as needed for pain for 3 Days and apply [topical antibiotic cream] to right upper eyelid twice a day. An NP progress note dated 3/20/25 revealed nursing staff reported Resident #3 was smoking outside and burned her right hand and behind her right ear. Resident #3 was a [AGE] year-old female seen per nursing request for burns to right hand and behind right ear due to smoking. Nursing staff requested a visit for initial evaluation and treatment of burns. The risk of complication was moderate. Burn of unspecified degree of right hand, unspecified site, initial encounter: right hand burn was mild, only redness, no blistering, will start antibiotic cream to area twice a day. Burn of unspecified degree of head, face, and neck, unspecified site, initial encounter: Burn area behind left ear was mild, only redness noted, no blistering, will start antibiotic cream to area twice a day. NP order for Resident #3 dated 3/20/25 revealed clean areas to right upper and lower eyelids, right ear, right face, right forehead and right hand with normal saline (NS) and apply [topical antibiotic cream] twice a day for burns. Resident #3's March 2025 Medication Administration Record revealed she did not require the use of her as needed pain medication. Resident #3 was observed on 4/29/25 at 10:30 AM outside smoking in the designated smoking area. The designated smoking area was a cemented area located inside the fenced courtyard, had a permanent shade to protect from the weather, tables, chairs, ash trays, and fire extinguisher available, and the area was accessible through a door in the dining room. Resident #3 was seated in her wheelchair wearing her smoking apron and using a smoking device to assist with smoking. The smoking device was an ash tray permanently mounted onto a flat wooden board, a long rubber tubing was attached to the ash tray by an adaptor on one end to hold the cigarette and allow ashes to fall into the ashtray safely, and a mouthpiece was attached at the other end of the tubing for Resident #3 to smoke safely. Hospitality Aide #1 was outside with Resident #3 supervising her while smoking. Resident #3 was observed to be able to smoke safely while using the device. When asked Resident #3 how she liked smoking with the device she kept frowning and shaking her head No. An interview and observation with Resident #3 on 4/29/25 at 11:30 AM revealed she was outside smoking unsupervised in the designated smoking area on 3/19/25 and her hair caught fire. She demonstrated she used the palm of her hand to pat out the fire. Observation of Resident #3's hair showed where at least 1 inch of the hair on the right side of head starting from the ear to the center part of head was singed off and was starting to grow back. Observations of Resident #3's palm of her right hand, behind her right ear, and top of her right eyelid revealed no signs of redness, mild burns, or scarring. An interview with Hospitality Aide #1 on 4/29/25 at 10:40 AM revealed he was responsible for taking supervised smokers outside to smoke during their scheduled smoking times, apply their smoking aprons, provide them with their smoking materials from the locked box that was kept at the nurse's station. He stated there was a list of the supervised and unsupervised smokers kept at each nurse's desk, so he was aware of who smoked and if they were supervised or unsupervised. He revealed all smoking materials were kept inside the locked box located at the nurse's desk and residents who were unsupervised smokers would have to request their smoking materials prior to smoking and return their materials when they are finished. Hospitality Aide #1 stated supervised smokers were not allowed to have access to their smoking materials, staff provided them with their smoking materials, light their cigarettes for them, and then place their materials back into the locked box. He revealed supervised smokers have designated smoking times at 10:30 AM, 1:30 PM, and 6:30 PM. An interview with the Nurse Practitioner (NP) on 4/29/25 at 11:00 AM revealed she was familiar with Resident #3. She stated she was notified by telephone on 3/19/25 of Resident #3's smoking incident where her hair caught fire causing some redness to the palm of her right hand and behind her right ear and a blister to her right eyelid. She revealed she ordered on 3/19/25 for a medicated cream to be applied to her right eyelid and an order for as needed pain medication. The NP stated she assessed Resident #3 in person on 3/20/25 and noted mild second-degree burns like a bad sunburn to the palm of her right hand and behind her left ear and continued the order for the medicated cream to the right eyelid to include the right hand and behind the right ear. She revealed she did not recall Resident #3 complaining of any pain from those areas, but she did have as needed pain medications ordered just in case. She stated she was not familiar with Resident #3's smoking abilities but would assume that based on her diagnosis and the fact that she does have some good and some bad days would most likely contribute to her inability to complete certain tasks such as smoking safely. An interview with the Administrator and DON on 4/29/25 at 2:40 PM revealed they were familiar with Resident #3. The Administrator stated she was on leave when the smoking incident with Resident #3 occurred and was notified of the incident when she returned. The DON stated she was working at the facility on 3/19/25 when the smoking incident with Resident #3 occurred, she was notified by NA #7 that Resident #3 had caught her hair on fire while outside smoking. She revealed she went to the nurse station where Nurse #3 was assessing Resident #3 for injuries and observed the hair next to her hairline on the right side had been singed off and she did have some redness on her face, behind her ear, and to the palm of her right hand. The DON stated that after Nurse #3 completed his assessment, she assisted Resident #3 back to her room and asked her what happened, and Resident #3 stated that she was outside smoking, caught her hair on fire and put it out with her hand. She revealed Resident #3 did have right sided weakness with limited range of motion and because of that would sometimes lean more to her right side. The DON stated she had assumed that what caused the incident was Resident #3 had her hand that was holding her cigarette up and as she leaned, she caught her hair on fire. She revealed Resident #3 was an unsupervised smoker prior to the incident. The DON stated an updated smoking assessment was completed on 3/19/25 and Resident #3 was now a supervised smoker, wore a smoking apron, and used a smoking device. Resident #3's wandering assessment dated [DATE] revealed no history of wandering or exit seeking behaviors and no interventions needed. Resident #3's quarterly MDS assessment dated [DATE] revealed she was severely cognitively impaired. Resident #34 was also assessed as being ambulatory with assistance of a wheelchair, functional limitation of range of motion with impairments to the upper and lower extremities on one side, with no history of wandering or exit seeking behaviors. Nursing progress note written by Unit Manager #3 dated 4/20/25 revealed Resident #3 went outside into the front parking lot because She wanted to go smoke, and believed if she went out of the front door staff would come quicker. Resident #3 stated she was not trying to leave the building. A telephone interview with the Weekend Nurse Supervisor on 4/29/25 at 1:19 PM revealed she was familiar with Resident #3. She stated she was working on the evening of 4/20/25 and sometime between 7:00 PM and 7:15 PM she received a telephone call from a visitor who was leaving the facility parking lot (she could not recall the visitor's name) that a resident was out in the parking lot at the entrance/exit area and headed towards the road. She revealed she immediately went to get Unit Manager #3 and when they went outside to the parking lot, they found Resident #3 seated in her wheelchair at the entrance and exit area of the parking lot. Resident #3 was inside her wheelchair facing the facility with her back facing the road and was trying to wheel herself backwards up the entrance/exit incline towards the main road. The Weekend Nurse Supervisor stated she and Unit Manager #3 asked Resident #3 what she was doing out in the parking lot, and she stated she was going to smoke. She revealed she checked, and Resident #3 did not have any smoking materials on her and when asked if she was trying to leave the facility, Resident #3 kept saying she just wanted to go smoke. Weekend Nurse Supervisor stated Resident #3 was a supervised smoker and she had just taken her out to smoke in the designated smoking area for the last scheduled smoking time around 6:30 PM. She revealed after Resident #3 smoked her normal two cigarettes; she assisted Resident #3 back inside the facility which was probably around 6:45 PM and she went back to the hall she was assigned, and Resident #3 was wheeling herself down the hall back towards her room. Weekend Nurse Supervisor stated she was not aware of Resident #3 asking any staff between the time she came back inside from smoking at 6:30 PM and the time she was found outside to go smoke. She stated Unit Manager #3 called the Administrator who advised to take Resident #3 back inside the facility, assess her for any injuries, and then take her to smoke. The Weekend Nurse Supervisor revealed Unit Manager #3 assessed Resident #3 with no injuries noted and then she took her out to smoke with no further issues. She stated to her knowledge Resident #3 had never displayed any wandering or exit-seeking behaviors and she felt this was an isolated incident where Resident #3 wanted to go back out to smoke and that was her way of getting staff's attention so they would take her to go smoke. An interview with Unit Manager #3 on 4/29/25 at 11:42 AM revealed she was familiar with Resident #3. She stated she was working on the evening of 4/20/25 and sometime between 7:00 PM and 7:15 PM the Weekend Nurse Supervisor came to her stating Resident #3 was in the parking lot unattended. She revealed she and the Weekend Nurse Supervisor went outside to the parking lot and found Resident #3 in the parking lot at the bottom of the entrance and exit incline. Resident #3 was seated inside her wheelchair, the wheelchair was turned backwards with her back towards to road, and she was attempting to wheel herself up the incline towards the road. Unit Manager #3 stated she and the Weekend Nurse Supervisor asked Resident #3 why she was outside in the parking lot and where she was going and Resident #3 stated that she was going to smoke. She revealed Resident #3 continued to say that she was going to smoke and when asked if she was trying to leave the facility, Resident #3 shook her head No and said she was not leaving she just wanted to go smoke. The Unit Manager stated she called the Administrator and informed her of Resident #3 being out in the parking lot and the Administrator instructed her and the Weekend Nurse Supervisor to take Resident #3 back inside the facility, assess her for any injuries, and then take her out to smoke. Unit Manager #3 revealed she completed Resident #3's assessment with no injuries noted, the Weekend Nurse Supervisor took Resident #3 out to smoke, and there were no further issues the rest of the evening. She stated to her knowledge Resident #3 had never had any wandering behaviors before and she truly felt that she was just trying to get nursing staff's attention so they would take her out to smoke. An interview with Resident #3 on 4/29/25 at 11:30 AM revealed on the evening of 4/20/25 she exited the facility to the parking lot and was heading towards the road to smoke when staff came and stopped her. She stated she did not have any smoking materials on her, she wanted to go smoke. When asked where she was going to get the smoking materials needed to smoke, Resident #3 stated she would get them at the road. When asked if she was trying to leave the facility, Resident #3 stated, No that she just wanted to go outside and smoke. When asked if she had gone outside to smoke during the last smoking time at 6:30 PM, Resident #3 stated Yes but she just wanted to go smoke. When asked if she had told staff she wanted to go back outside to smoke again, Resident #3 shook her head No. When asked if she was aware of the concerns with her going outside in the parking lot towards the road in her wheelchair by herself, Resident #3 shook her head No and stated again that she was just trying to go smoke. Attempted contact with NA #8 who was scheduled with Resident #3 on the evening of 4/20/25 was unsuccessful. Attempted contact with NA #9 who was scheduled with Resident #3 on the evening of 4/20/25 was unsuccessful. Observation of the facility and route taken by Resident #3 on 4/29/25 at 3:15 PM revealed the facility was a single-story building facing a main four lane road with a speed limit of 35 miles per hour, surrounded by multiple businesses, and within one mile of a hospital. The entrance to the facility was covered, open, with no sidewalks, and accessible from the front parking lot off from the main road. The route taken by Resident #3 as described by Unit Manager #3 and the Weekend Nurse Supervisor revealed Resident #3 was seated in her wheelchair and wheeled herself outside through the unlocked doors located at the front entrance of the facility, went into the front parking lot, took a right towards the parking lot entrance, and was found at the bottom of the incline at the parking lot entrance with her wheelchair turned backwards and wheeling herself towards the road. The estimated length from the front door entrance to the incline at the entrance parking lot was 151 feet, the incline at entrance of the parking lot was a slope of 10 inches, and starting from the bottom of the incline to the top of the incline located at the main road was 56 feet. Per weather.com the weather at the facility on 4/20/25 was sunny and clear, temperature was 78 degrees, and sunset was at 7:50 PM. An interview was conducted with the NP on 4/29/25 at 11:00 AM revealed she was familiar with Resident #3. She stated she was not aware of the incident on 4/20/25 with Resident #3 leaving out of the facility and attempting to go towards the road. She revealed to her knowledge Resident #3 did not have a history of wandering but she still would have liked to have been informed of the incident so she could have assessed if this was an isolated incident related to wanting to go smoke, or a new behavior brought on by a change with her medical conditions. She stated Resident #3 does require a wheelchair for mobility, had right sided weakness with limited range of motion, and diagnosis of dementia, seizures, and expressive aphasia which could put her at risk of accidents in general. The NP revealed Resident #3, being out in the parking lot and attempting to ambulate herself towards the main road could certainly have put her at more of a risk of having a fall or being hit by a car. An interview with the Administrator on 4/29/25 at 2:40 PM revealed she was familiar with Resident #3. The Administrator stated on the evening of 4/20/25 sometime after 7:00 PM she received a telephone call from Unit Manager #3 stating that Resident #3 was found outside the facility, on the sidewalk not far from the front porch. She stated Unit Manager #3 reported that when they found Resident #3 and asked her what she was doing outside that she told them that she was not trying to leave the facility, that she just wanted to go smoke. The Administrator revealed that she instructed Unit Manager #3 to take Resident #3 back inside and assess her for any injuries and then assist Resident #3 with going to smoke. She stated they did not implement any 15-minute checks just continued normal rounds because at that time they did not feel Resident #3 had tried to elope or that she was an elopement risk, she was just trying to get the staff's attention to go smoke. The Administrator revealed to her knowledge Resident #3 had never had any history with wandering or displayed any exit seeking behaviors and prior to this incident had gone out to the front porch to sit with no issues. She stated although she was never told Resident #3 was further out into the parking lot headed towards the road, she did not believe Resident #3 was ever trying to leave the facility, this was an isolated incident, and did not feel Resident #3 was ever an elopement risk. She revealed Resident #3 had been taken out to smoke during the designated smoking time at 6:30 PM, and she was not aware of her asking staff to go back outside again to smoke prior to exiting out of the front of the facility. The Administrator stated she was not aware of Resident #3 not liking the assigned smoking device and they would be reassessing Resident #3's smoking ability to see if there was another option for her to be able to smoke safely without using the smoking device. The Administrator was notified of immediate jeopardy on 4/30/25 at 5:20 PM. The facility provided the following plan for immediate jeopardy (IJ) removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Facility failed to have effective systems in place to ensure all residents are being appropriately assessed for the correct level of supervision required for smoking to prevent accidents. Facility failed to have effective systems in place to ensure severely cognitively impaired residents are not leaving the building unsupervised to prevent accidents. On 12/30/24 a smoking assessment was completed for resident by MDS. The smoking assessment found resident able to smoke unsupervised. Resident had been previously assessed as requiring supervision while smoking due to being unable to hold smoking materials safely or respond to fallen ashes quickly. On 3/19/25 Resident was assessed by licensed nurse with injuries noted to the right forehead, right ear, and right hand pursuant to a smoking incident. The Medical Director was notified by the Director of Nursing with treatment orders obtained. The facility initiated a therapy referral for positioning while in wheelchair on 3/19/25. Therapy followed resident with plan of treatment. The Responsible Person was notified of incident, follow up treatment plan and change in supervision with smoking with resident's consent. Resident's smoking assessment was re-evaluated by charge nurse on 3/19/25 and resident was notified that she was now a supervised smoker, resident verbalized understanding and in agreement. Despite some cognitive impairment she is oriented and conversant. Resident has expressive aphasia and able to communicate needs with some delayed verbalization. Staff notified of change in supervision with smoking and residents' apparatus by the Director of Nursing. Director of Nursing updated smoking binder that is in nurse's stations, front office and therapy department. On 3/19/25 the facility ordered resident #3 a smoking adaptive apparatus to hold her cigarette. Being a supervised smoker, staff will light her cigarettes. Resident's care plan/ kardex updated to reflect that her hair is pulled back per resident acceptance. Smoking apron available per residents' acceptance. Resident has dementia and expressive aphasia and has ability to communicate needs and preferences, and facility will honor that per her rights while providing supervision to promote safety. On 4/20/25 resident was witnessed by a family member in the parking lot approximately 20 feet from the road. The family stayed with the resident and notified the facility that resident was outside and safe as staff were not aware. The resident was witnessed less than 15 minutes prior to at the nurse's station. On 4/20/25 the Unit Manager assessed resident and there was no physical injuries and resident was not in any mental distress. Resident expressed she was not leaving and only wanted a cigarette. The Unit Manager assessed resident for wandering tendencies and resident did not present as a risk as she wanted to go outside and have a cigarette. Resident was provided with a cigarette in designated smoking area. Residents' preference for smoking times to be honored per request with staff supervision. On 4/29/25 facility made aware that resident did not prefer the smoking apparatus and discontinued the apparatus on 4/30/25. Resident can safely hold a cigarette with supervision. Residents that smoke may have potential of being affected by deficient practice, therefore skin assessments were completed on all residents who smoke to ensure no burns identified from smoking. Assessments were completed by licensed nurses on 3/19/25. No areas of burns were identified. The Director of Nursing and licensed nurses re-assessed all residents who wish to smoke for need of supervision and/or adaptive equipment, no additional residents were noted. Assessments were completed on 3/19/25. On 3/19/25 The Director of nursing and licensed nurses reviewed care plans and Kardex's for all supervised and unsupervised smokers to ensure up to date and accurate with no additional concerns noted. On 4/20/25 the charge nurse completed a resident headcount to ensure that all residents were accounted for. There were no concerns with any other residents. On 4/21/25 Social Ser [TRUNCATED]

Based on record review, resident, and staff interviews, the facility failed to protect the resident's (Resident #76) right to be free from misappropriation of property when Hospitality Aide #1 used Resident #76's debit card to withdraw cash from an Automatic Teller Machine (ATM) and purchase various items from several stores without Resident #76's permission or knowledge. Hospitality Aide #1 was alleged to have spent approximately $628.75 on November 29, 2024. Resident #76 stated it made me real sad that she took advantage of me. He indicated he trusted Hospitality Aide #1 as she had been kind to him and was upset she stole his money. This deficient practice occurred for 1 of 3 residents (Resident #76) reviewed for abuse, neglect, and misappropriation of resident property. The findings included: Resident #76 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #76 was cognitively intact. A review of the facility's reportable incidents revealed an initial allegation report dated 12/3/24 indicating the facility became aware on 12/3/24 that money from Resident #76's personal bank account was missing. The report revealed Resident #76 gave Hospitality Aide #1 permission to purchase cigarettes with his debit card, but did not authorize additional purchases. The report indicated there was reasonable suspicion of a crime, and the alleged misappropriation of resident property was reported to law enforcement on 12/3/24. Hospitality Aide #1' statement indicated she used Resident #76's debit card to purchase items for herself, as well as withdrew cash at the ATM. A review of Resident #76's bank account record dated 12/20/24 revealed there were various transactions at local businesses, an ATM cash withdrawal, and an out of network ATM fee. The unauthorized transactions totaled approximately $628.75 and posted to his bank account on 12/2/24. A review of the police department incident report indicated a report was filed on 12/3/24 at 11:42 AM concerning Resident #76 and stolen money from his bank account. An interview with Resident #76 was conducted on 4/10/25 at 3:13 PM. He stated, it made me real sad that she took advantage of me. Resident #76 stated he gave Hospitality Aide #1 his debit card to purchase cigarettes but did not authorize any of the other charges made on 11/29/24. He indicated Hospitality Aide #1 purchased him cigarettes with his debit card many times before, probably once a week for many months. A second interview with Resident #76 on 4/10/25 at 3:51 PM revealed Hospitality Aide #1 returned his debit card and brought him cigarettes after purchasing them on 11/29/24. He indicated a police report was completed, and charges were filed. Resident #76 indicated he was sad about the incident and hoped it was not Hospitality Aide #1 who took his money as she had been very kind to him and took good care of him. Resident #76 stated the Administrator had recently been purchasing cigarettes for him as Hospitality Aide #1 was no longer purchasing them for him. A third interview with Resident #76 on 4/10/25 at 9:06 AM revealed he had not been reimbursed yet for the stolen money and did not understand why it was taking so long for the facility to pay him back. Multiple attempts were made to contact Hospitality Aide #1 and were unsuccessful. A phone interview with the Former Business Office Manager (BOM) conducted on 4/14/25 at 9:17 AM. She revealed she was the BOM at the facility until the middle of March 2025. She explained Resident #76 came to her office to make a payment on his account. The debit card declined when we ran it for the full amount. The former BOM stated she assisted Resident #76 with calling his bank to hear his account balance and found out the unauthorized charges to include an ATM withdraw. She asked Resident #76 if he gave his card to someone, and he stated he had given it to Hospitality Aide #1 to buy him cigarettes. The Former BOM stated Resident #76 did not give permission for other charges. She stated she spoke with the facility's corporate team when this happened as she felt the facility should write off the balance for Resident #76. She was not aware of any efforts to reimburse Resident #76 but indicated she brought up the topic in her corporate meetings often. The Former BOM stated she was not aware of any efforts to purchase him anything such as cigarettes to reimburse him for the money that was stolen. She stated the cigarettes that were purchased for him were paid for with Resident #76's money. The Former BOM indicated when she left her position in March 2025, Resident #76 had not been reimbursed with cash or cigarettes. A phone interview was conducted with the Former Administrator on 4/10/25 at 10:30 AM revealed Resident #76 took his debit card to the former Business Office Manager (BOM) at the beginning of December to pay his patient monthly liability (PML). The full amount of his PML would not go through when the card was processed. The Former BOM called the bank with Resident #76 and found the card had been used many times at various stores and one cash withdrawal at an ATM. The Former Administrator stated that Hospitality Aide #1 was terminated, as she stated she used Resident #76's debit card on various purchases and an ATM withdrawal without his permission. She stated a police report was filed, and charges were filed. The Former Administrator was not aware of any efforts made to reimburse Resident #76. She was unaware if the facility started a reimbursement process after she left her position at the end of February 2025. An interview with the Administrator on 4/10/25 at 5:11 PM revealed she was made aware of the incident with Resident #76's debit card when she came to the facility in March. She stated she understood the Former Administrator investigated the stolen money incident and reported the incident to the State Survey Agency. The Administrator stated she discussed with Resident #76 the idea of reimbursing him for the money owed to him with cigarettes purchased on the corporate credit card for seven or eight months or however long it took to make up the stolen money. The Administrator stated she spoke to Resident #76 about the reimbursement plan the week before last when he ran out of cigarettes. The facility presented a plan of correction that was not accepted by the State Survey Agency. The facility indicated they started reimbursing Resident #76 with cigarettes after the incident, starting on 12/9/24. The facility failed to provide a timeline of cigarettes purchased for Resident #76 after the purchase of cigarettes on 12/9/24. The next receipts for cigarettes and a toiletry item submitted to the State Survey Agency were dated 4/9/25. An interview with the Former BOM on 4/14/25 at 9:17 AM revealed there was no plan for reimbursing Resident #76 when she left the facility in the middle of March and his cigarettes were purchased with his money, not the facility's. An interview with the Former Administrator on 4/14/25 revealed Resident #76 always relied on the facility to buy cigarettes, but there was no plan in place to purchase cigarettes continuously for reimbursement or any other kind of cash reimbursement. She indicated the facility bought Resident #76 cigarettes one time after the incident because he didn't have any to smoke. The Former Administrator stated it was a singular purchase and was not part of any reimbursement plan.

Based on observations, record reviews, staff, Pharmacist, and Medical Director interviews, the facility failed to have an effective system in place to ensure a new physician order for an as needed pain medication was available to administer for 1 of 5 residents (Resident #2) reviewed for pharmacy services. Resident #2 received a new order for her as needed pain medication in January 2025. Resident #2 received seven wrong dosages in March 2025 and two wrong dosages in April 2025 of her as needed pain medication due to the pharmacy not having received the new order from January 2025 and the correct dosages not being sent to the facility. The findings included: Resident #2 was initially admitted to the facility on [DATE] and readmitted from the hospital on 1/13/2025. Resident #2 had diagnoses that included chronic diastolic congestive heart failure, Type 2 diabetes Mellitus with diabetic polyneuropathy (a condition where nerve damage occurs due to persistently high blood sugar levels), intervertebral disc degeneration lumbar region without mention of lumbar back pain or lower extremity pain. Record review indicated Resident #2 resided on the 300-hall during the months of March and April 2025. Resident #2's physician order dated 2/24/2024 prescribed Tramadol HCL Oral Tablet 75 milligrams (mg) (narcotic medication for pain) give one tablet and a half by mouth every 6 hours as needed for pain was discontinued. Resident #2 was transferred to the hospital on 1/10/2025 and admitted with COVID-19 and respiratory failure. Resident #2 was discharged back to the facility on [DATE]. Resident #2's hospital discharge summary dated 1/13/2025 revealed a new order for Tramadol HCL 50 mg give one tablet by mouth every six hours as needed for pain. The facility physician order dated 1/13/25 revealed Resident #2 was to receive Tramadol HCL Oral Tablet 50 mg. Give one tablet by mouth every six hours as needed for pain. Review of Resident #2's tramadol order dated 1/13/2025 indicated the order from the provider was written at 1:32pm by a previous Nurse Practitioner and entered by Nurse #10 on 1/13/2025 at 3:5pm. Resident #2's Medication Administration Record (MAR) was reviewed from 1/13/2025 through April 2025 and revealed an active order that read Tramadol HCL Oral Tablet 50mg. Give one tablet by mouth every six hours as needed for pain. During a telephone interview on 4/11/2025 at 5:18 pm Nurse #10 stated she did not remember entering any orders into the electronic medical record for Resident #2 on 1/13/25, but she did remember she verified some orders. Nurse #10 stated orders were entered by the supervisor. Nurse #10 stated she knew narcotic orders had to be faxed from the pharmacy and that when a resident was admitted she would fax the prescriptions that came from the hospital. Nurse #10 was not aware that if a resident had a new order for a different dose of narcotic that a new prescription would have to be sent even though the new order was in the medication profile in the electronic record. The 300-hall medication cart controlled medication declining sheet revealed Resident #2 was administered the discontinued dose of Tramadol HCL 75 mg give 1 tablet by mouth every 6 hours as needed on 3/6/2025 (Nurse #11), 3/8/2025, 3/11/2025 (Nurse #6), 3/12/2025, 3/16/2025 (Nurse #7), 3/17/2025, 3/19/2025 (Nurse #6), 4/5/2025 (Nurse #8) and 4/6/2025 (Nurse #9). Observation of the 300-hall medication cart narcotic box on 4/9/2025 at 5:30pm revealed three blister packs labeled Tramadol HCL for Resident #2 each unpunctured blister contained 75mg of Tramadol HCL. During a telephone interview on 4/10/2025 at 2:58 pm Nurse #11 stated that maybe she didn't read the label correctly. Nurse #11 stated if she signed that she gave tramadol HCL to Resident #2, then she probably gave the 75mg in the blister pack. Nurse #11 stated she thought the correct dose of medication would be in the narcotic drawer. Nurse #11 documented on 3/6/2025 she administered as needed tramadol HCL to Resident #2. During an interview on 4/10/2025 at 11:21am Nurse #6 reviewed Residents #2's order on the MAR and Resident #2's controlled medication declining sheet and verified Resident #2 had an order for tramadol HCL 50mg by mouth every 6 hours as needed for pain. Nurse #6 stated she administered tramadol HCL 75 mg to Resident #2 on 3/11/2025 and 3/19/2025. During a telephone interview on 4/11/2025 at 12:13pm Nurse #7 stated she had been at the facility since July 2023. Nurse #7 stated she did not specifically remember if she administered Resident #2 a PRN on 3/16/2025, but if she signed out it was administered then tramadol HCL 75mg was probably administered. Nurse #7 stated if she had wasted the half tablet it would have been signed with another person as wasted. Nurse #7 stated if there are new orders it usually gets reported from shift to shift, and that if a new dosage of a narcotic was ordered a new script would need to be sent to the pharmacy so the medication would be received. Nurse #7 stated you can ask the provider when they are in the facility to write a script or ask the on-call provider to send an electronic script if it is needed. Nurse #7 stated if a new dose of a narcotic is ordered the discontinued dose can be pulled out, signed with a witness and placed in the return bag to be sent back to pharmacy. Nurse #7 stated it was possible since the dosage on the medication blister pack read 50mg, and the instructions above it were smaller, it was possible the wrong dose was administered. Nurse #7 stated third shift returns most of the narcotics, but she knew other nurses were able to send back medications. During a telephone interview on 4/11/2025 at 12:02pm Nurse #8 stated she was an agency nurse and thought she recalled Resident #2 and had only worked at the facility for one shift on 4/5/2025. Nurse #8 stated if tramadol HCL 75mg was in the blister pack in the medication cart, that is what she administered to Resident #2. Nurse #8 stated she had not received any education regarding returning narcotics to the pharmacy, or that a script was required to receive medication for new narcotic orders. During a telephone interview on 4/11/2025 at 11:48 am Nurse #9 stated she had worked as an agency nurse at the facility off and on since June 2024, and that she worked on different halls. Nurse #9 stated she had not received any education regarding returning narcotics to the pharmacy, and that usually the supervisor on the weekend would take care of sending narcotics back to the pharmacy. Nurse # 9 verified worked with Resident #2 on 4/6/2025 and administered the incorrect dose of tramadol to Resident #2. During an interview on 4/10/2025 at 10:50am Nurse #5 stated she used to be a unit manager but now worked as a floor nurse. Nurse #5 stated if a provider wrote to change the dosage of a medication a script would need to be sent to pharmacy. Nurse #5 stated if the wrong medication was in the drawer the provider could be notified to see what to administer until the correct medication arrived. Nurse #5 stated she would send back the old dose of medication and make sure the pharmacy had the correct script for the new order. During an interview on 4/10/2025 at 11:50 am Unit Manager #2 stated she was new to the facility and did not know if a certain shift was responsible for returning discontinued narcotics to the pharmacy. Unit Manager #2 stated if a resident received a new order for a new dose of a narcotic, then she would send back the discontinued dose and request a new dose from the pharmacy. During an interview on 04/10/25 at 10:14 AM the Unit Manager #1 stated if a resident received an order for a new dose of a narcotic, a new prescription would have to be sent to the pharmacy either faxed by the nurse or sent electronically from the provider. During a telephone interview on 4/10/2025 at 10:19 AM Pharmacist #1 stated the pharmacy had not received any requests for tramadol HCL 50 mg for Resident #2. They would need a prescription to dispense and no prescription for tramadol HCL 50 mg had been received for Resident #2. Pharmacist #1 verified tramadol HCL 50 mg was active in Resident #2's medication profile in the electronic health record. Pharmacist #1 stated she was not familiar with the facility's policy on sending back narcotics when there was a dose change, or if they would continue to use the old pack and waste the extra medication. Pharmacist #1 stated if a new script had been sent for tramadol HCL 50 mg, a new blister pack would have been sent. The Medical Director was interviewed on 4/10/2025 at 12:37 pm and stated he expected discontinued medications to be sent back to the pharmacy and to send in an order to receive blister packs with the correct dosage. The Medical Director expected residents to receive their medications as ordered. During an interview on 4/10/2025 at 11:57 am the Director of Nursing (DON) verified Resident #2 had an active order for tramadol HCL 50 mg one tab by mouth every 6 hours as needed for pain, written on 1/13/2025, and that Resident #2's medication blister packs of tramadol HCL contained 75 mg in each blister pack. The DON verified a new prescription for Tramadol HCL 50mg should have been sent to the pharmacy on 1/13/2025 so Resident #2's new dosage of Tramadol HCL would be sent to the facility. The DON stated when a new order for a narcotic was received normally a written prescription would be faxed to the pharmacy by the nurse, or the provider would send an electronic prescription. During an interview on 4/10/2025 at 3:30pm the Administrator stated she expected a resident's medication to be available and administered as ordered. The Administrator stated she would expect staff to document accurately and honestly on the Medication Administration Record.

Based on record review, and family member and staff interviews, the facility failed to ensure a dependent resident (Resident #158) had a functioning call light to call staff for assistance with care. Resident #158 told her family member it made her feel helpless not being able to call for assistance. A reasonable person would expect to have their call light function so they could call staff for assistance with care when needed. This deficient practice affected 1 of 3 residents reviewed for dignity and respect (Resident #158). The findings included: Resident #158 was admitted to the facility on [DATE]. Review of Resident #158's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired but could make her needs known. Resident #158 required substantial/maximal assistance to dependence for all activities of daily living (ADL) care except eating in which she required setup. Resident #158 was incontinent of bowel and bladder and required staff assistance with toileting hygiene. Review of Resident #158's care plan dated 01/25/25 revealed a focus area for Resident # 158 requiring assistance for ADL care related to limited mobility. The goal was for the resident's ADL care needs to be anticipated and met throughout the next review period. The interventions included in part: - Provide resident with assistance for eating, dressing, toileting, transfers, bathing, oral hygiene, personal hygiene, and bed mobility as needed. Review of a grievance form completed on 12/28/24 by the former Administrator revealed a family member had filed a grievance regarding Resident #158's call light issue. The grievance was assigned to the Administrator, and a meeting was held with the family member of Resident #158, the former Administrator, the Regional Director of Operations and the Regional Director of Clinical Services. According to the grievance a self-imposed plan of correction was initiated and 100% audit of all call lights was done to ensure proper working call lights for all residents, timeline of care was completed for Resident #158 to ensure there were no issues with care and all staff received training on call light protocols and audits were completed to ensure working call lights throughout the facility for all residents. Written notification was provided to the family member of Resident #158 and a one-to-one discussion was provided with the family member and staff. An interview on 04/08/25 at 10:21 AM with the former Administrator revealed she recalled Resident #158's call light being tampered with by using a temperature probe and unplugging the call light so the resident could not call staff for assistance. The former Administrator stated it had happened, but they were unable to determine when it had happened or who had done it. A telephone interview on 04/07/25 at 2:42 PM with the family member revealed she had visited Resident #158 on 12/28/24 and when she arrived at the facility the resident's call light was not working. The family member stated she looked at the call light on the wall and it was unplugged and a temperature probe had been placed in the plug to prevent the call light from alarming. The family member reported the incident to the former Administrator who completed a grievance. The family member stated Resident #158 told her it made the resident feel helpless not being able to call for assistance with care when her call light was not working. The family member further stated the call light had been working on 12/27/25 when she had visited the resident during the day. An interview on 04/08/25 at 2:23 PM with Nurse Aide (NA) #3 who was assigned to care for Resident #158 during the 7:00 AM to 3:00 PM shift on 12/28/24 stated she noticed the call light was not plugged in when she was making rounds around 10:00 AM on the resident. NA #3 stated she thought maintenance had put something in the plug because they were working on the call light so she gave Resident #158 the call light from the empty bed next to her bed after she tested it and it worked. She further stated it wasn't until later that day when the family member visited the resident that the family member told her Resident #158's call light was not working because someone had tampered with the call light. NA #3 further indicated she had no idea how long the call light had not been working when she found it that morning on 12/28/24. According to NA #3 Resident #158 was able to use her call light to call for assistance when she needed care. An interview on 04/09/25 at 11:18 AM with NA #5 revealed she recalled taking care of Resident #158. She stated the resident was very pleasant and she was able to use her call light to alert staff of her care needs. NA #5 stated at times Resident #158 rang her call light even when she didn't need assistance or care. An interview on 04/10/25 at 4:15 PM with Unit Manager #1 revealed she recalled Resident #158 and stated she was familiar with the issue with her call light being tampered with and not working. Unit Manager #1 stated Resident #158 was able to use her call light to alert staff when she needed care. She further stated they were never able to determine who tampered with Resident #158's call light. A telephone interview was attempted multiple times with the nurse assigned to care for Resident #158 on the 7:00 AM to 3:00 PM shift on 12/28/24 without success. An interview on 04/10/25 at 5:07 PM with the Director of Nursing and Administrator revealed it was their expectation that all residents had functioning call lights to allow them to call staff for assistance with care.

Based on observations, record reviews, resident and staff interviews, the facility failed to stop a resident who had been assessed and determined clinically unsafe to self-medicate from self-medicating medications for 1 of 1 resident reviewed for self-administration of medication (Resident # 99). The findings included: Resident #99 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia. Review of the self-administration of medication assessment dated [DATE] revealed Resident #99 had been assessed by the interdisciplinary team and determined he was clinically unsafe to self-medicate. The physician's order dated 01/14/25 revealed Resident #99 had an order to inhale 2 puffs of Budesonide-Formoterol (Symbicort) inhalation aerosol 80-4.5 micrograms (mcg) per actuation two times daily for shortness of breath. There was no order for the albuterol. Further review of Resident #99's physician orders since his admission on 01/14/25 revealed no medications were ordered to be left in his room for him to self-medicate. Review of Resident #99's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #99 was coded with intact cognition and adequate vision. During the initial encounter with Resident #99 on 04/07/25 at 12:53 PM, the Surveyor asked Resident #99 if he kept any medication in his room. Resident #99 showed the Surveyor an opened Symbicort inhaler and an opened albuterol inhaler in the drawer of his bedside table. The manufacturer's expiration dates and opening dates for both inhalers were invisible during the observation. Resident #99 stated a few nursing staff were aware of his Symbicort and let him keep it in his room. However, he could not recall the names of these staff. On the other hand, none of the staff knew that he had an albuterol inhaler in his room. He explained he had breathing problems at times and needed to keep an albuterol inhaler with him in case he needed it as a rescue inhaler. He added he had used the inhalers a few times since admission. On 04/07/25 at 2:35 PM, a joint observation was conducted with Nurse Aide #2 (NA), Nurse #2, and Unit Manager #2 (UM). Resident #99 showed nursing staff the inhalers stored in the drawer of his bedside table. When the Surveyor asked Resident #99 in front of the nursing staff if he had ever used any of the 2 inhalers while in the facility, he confirmed he had used both inhalers but could not recall the exact dates. During an interview conducted on 04/07/25 at 2:38 PM, NA #2 stated she had provided care for Resident #99 but did not notice he had medications in his room. Otherwise, she would report the incident to the nurse. An interview was conducted with Nurse #2 on 04/07/25 at 2:41 PM. She stated she was not aware of the 2 inhalers in Resident #99's room. Resident #99 was not allowed to keep medications in his room unless he was assessed as being able to self-medicate. Nurse #2 added Resident #99 had a physician's order to receive Symbicort inhaler but not the albuterol inhaler. During an interview conducted on 04/07/25 at 2:48 PM, UM #2 stated the medications were most likely brought in by Resident #99's family. The Symbicort inhaler should be stored in the medication cart and albuterol should be returned to Resident #99's family unless he was assessed as being able to self-medicate and had a physician's order to self-medicate both inhalers. An interview was conducted with the Director of Nursing (DON) on 04/08/25 at 2:55 PM. She explained the facility would not search for any resident's drawer without reasons and that was why nursing staff were not aware of the inhalers in the drawer of bedside table in Resident #99's room. She clarified that if the inhalers were visible to the nursing staff in Resident #99's room, she expected them to remove both inhalers as indicated. On 04/10/25 at 5:29 PM, an interview was conducted with the Administrator. She expected residents who had been assessed by the interdisciplinary team and determined to be unsafe or clinically inappropriate to self-medicate to remain free of medications in their room.

Based on record reviews and staff interviews, the facility failed to ensure a call light was plugged in and in working order for 1 of 5 dependent residents who were reviewed for reasonable accommodation of needs (Resident #158). The findings included: Resident #158 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II, hypertension and dementia. The resident was discharged to the hospital on 02/01/25. Resident #158's quarterly MDS assessment dated [DATE] revealed she was severely cognitively impaired but was sometimes able to make her needs known. The assessment indicated Resident #158 required minimal to maximal assistance with activities of daily living and was always incontinent of bowel and bladder. Resident #158's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired but was sometimes able to make her needs known. The assessment indicated Resident #158 required substantial to maximal assistance with activities of daily living and was always incontinent of bowel and bladder. Review of a grievance form completed on 12/28/24 by the former Administrator revealed a family member had filed a grievance regarding Resident #158's call light issue. The grievance was assigned to the Administrator and a meeting was held with the family member of Resident #158, the former Administrator, the Regional Director of Operations and the Regional Director of Clinical Services. According to the grievance a self-imposed plan of correction was initiated and 100% audit of all call lights was done to ensure proper working call lights for all residents, timeline of care was completed for Resident #158 to ensure there were no issues with care and all staff received training on call light protocols and audits were completed to ensure working call lights throughout the facility for all residents. Written notification was provided to the family member of Resident #158 and a one-to-one discussion was provided with the family member and staff. A telephone interview on 04/07/25 at 2:42 PM with the family member revealed she had visited Resident #158 on 12/28/24 and when she arrived at the facility the resident's call light was not working. The family member stated she looked at the call light on the wall and it was unplugged and a temperature probe cover had been placed in the plug to prevent the call light from alarming. The family member reported the incident to the former Administrator who completed a grievance. The family member stated Resident #158 told her it made the resident feel helpless not being able to call for assistance with care when her call light was not working. The family member further stated the call light had been working on 12/27/25 when she had visited the resident during the day. A telephone interview on 04/08/25 at 10:21 AM with the former Administrator revealed she recalled Resident #158's call light being tampered with by using a temperature probe cover and unplugging the call light so the resident was not able to call staff for assistance. She stated the resident could call staff for assistance by using her call light but on 12/28/24 it had been tampered with and was not working. The former Administrator further stated they were not able to determine who had tampered with the call light but said once they found out they had fixed the call light so that it worked for the resident. An interview on 04/08/25 at 2:23 PM with Nurse Aide (NA) #3 who was assigned to care for Resident #158 during the 7:00 AM to 3:00 PM shift on 12/28/24 stated she noticed the call light was not plugged in when she was making rounds around 10:00 AM on the resident. NA #3 stated she thought maintenance had put something in the plug because they were working on the call light so she gave Resident #158 the call light from the empty bed next to her bed after she tested it and confirmed it worked. She further stated it wasn't until later that day when the family member visited the resident that the family member told her Resident #158's call light was not working because someone had tampered with the call light. NA #3 further indicated she had no idea how long the call light had not been working when she found it that morning on 12/28/24. According to NA #3 Resident #158 was able to use her call light to call for assistance when she needed care. An interview on 04/09/25 at 11:18 AM with NA #5 revealed she recalled taking care of Resident #158. She stated the resident was very pleasant and she was able to use her call light to alert staff of her care needs. NA #5 stated at times Resident #158 rang her call light even when she didn't need assistance or care. An interview on 04/10/25 at 4:15 PM with Unit Manager #1 revealed she recalled Resident #158 and stated she was familiar with the issue with her call light being tampered with and not working. Unit Manager #1 stated Resident #158 was able to use her call light to alert staff when she needed care. She further stated they were never able to determine who tampered with Resident #158's call light. A telephone interview was attempted multiple times with the nurse assigned to care for Resident #158 on the 7:00 AM to 3:00 PM shift on 12/28/24 without success. An interview on 04/10/25 at 5:07 PM with the Director of Nursing and Administrator revealed it was their expectation that all residents had functioning call lights to allow them to call staff for assistance with care. The Administrator stated that there had been no further issues with resident call lights and that audits continued and no issues were found with call lights being tampered with or not functioning properly. She stated the call light audits were reviewed at each Quality Assurance and Performance Improvement (QAPI) meeting. The facility provided the following corrective action plan: Address how corrective actions will be accomplished for those residents who have been affected by the deficient practice: On 12/28/24 facility identified concern regarding functioning call light not being available to one resident. The Director of Nursing (DON) and Social Worker (SW) immediately completed physical and psychosocial assessment on affected resident with no negative findings. Call light was immediately made functional. How will the facility identify other residents having the potential to be affected by the same deficient practice: On 12/28/24 the facility initiated an audit by the Assistant Director of Nursing (ADON), Unit Managers (UMs) and Nursing Assistants (NAs) of all residents call lights and areas equipped with call lights to ensure they were within reach and functioning appropriately. No additional issues with call lights were noted. No additional residents were affected. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur: On 12/28/24 the weekend supervisor initiated in-service education to all staff regarding ensuring call lights are within reach of resident and properly functioning. Education of staff to continue upon return to work. Education for newly hired staff will be provided by DON, ADON or Unit Manager upon hire, prior to receiving assignment. How will the facility monitor its corrective actions to ensure that the deficient practice will not recur: The Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers (Ums) and/or Caring Angel will audit five residents, five days a week times four weeks, then three residents five days a week times four weeks to ensure residents call lights are within reach and properly functioning. These audits will be conducted on all three shifts. Results of this monitoring will be brought before the Quality Assurance and Performance Improvement Committee quarterly with the QAPI committee responsible for ongoing compliance. Compliance Date: 12/29/24. The corrective action plan was validated on 04/10/25. During the onsite validation on 04/10/25, call lights were tested and were functioning properly. Observations of call lights ringing and lighting up outside residents doors were completed. Staff interviews with Nurse Aides (NAs), Caring Angels, Unit Managers, and the DON revealed staff had received education on checking call lights to ensure they were functioning and within reach of the residents. Interviews with residents throughout the survey revealed their call lights were functioning and they were able to call staff for care needs. Audits of call lights being monitored were reviewed without any issues. The Administrator was interviewed and stated the results of the call light audits were discussed in each QAPI meeting. The corrective action plan's completion date of 12/29/24 was validated.

Based on record review and staff interviews, the facility failed to have advance directives accurate throughout the medical record for 2 of 4 residents (Resident #68 and Resident #48) reviewed for advance directives. The findings included: 1.Resident #68 was admitted to the facility on [DATE]. Resident #68's care plan initiated on 12/18/24 indicated Resident #68's health directive was a full code. Interventions included to intercede rapidly and begin immediate resuscitative efforts utilizing all life-sustaining measures available if the resident's heart stops beating, or the resident stops breathing. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #68 was severely cognitively impaired. A review of Resident #68's medical record indicated a physician's order dated 2/28/25 for Do Not Resuscitate (DNR). The advance directive binder at the nurses' station indicated a DNR form for Resident #68 which was signed by the Medical Director on 2/24/25. An interview with Nurse #1 on 4/8/25 at 10:34 AM revealed she just started taking care of Resident #68 after he was transferred from another hall today. Nurse #1 stated that she would check Resident #68's chart to find out if he was full code or DNR by looking at the current code status order. After reviewing Resident #68's care plan during the interview, Nurse #1 stated that it could cause confusion because Resident #68's care plan indicated he was a full code while he had a DNR form dated 2/24/25 in the advance directive binder. She further stated that the supervisor and the Social Worker were both responsible for the advance directives. An interview with Unit Manager #1 on 4/8/25 at 10:43 AM revealed Resident #68's care plan was supposed to have been updated, but she wasn't sure who should have done it. An interview with Minimum Data Set (MDS) Coordinator #1 on 4/8/25 at 10:46 AM revealed the Social Worker was responsible for revising the care plans regarding the advance directives. An interview with Social Services Director (SSD) on 4/8/25 at 10:49 AM revealed she was one of the Social Workers who worked at the facility. The SSD stated that she was not aware that Resident #68's code status had been changed from full code to DNR. The SSD stated that the reason for this was that she was out on leave in February 2025, and they had another different Social Worker at that time who had quit. The SSD further stated that the Social Workers usually discussed the advance directives with the residents and their representatives whenever they wanted to update their advance directive, and they would update the care plan as well. An interview with the Administrator on 4/10/25 at 5:23 PM revealed both the Social Workers and the MDS Coordinator were responsible for updating the care plans to indicate a change in the advance directives. 2.Resident #48 was admitted to the facility on [DATE]. Resident #48's care plan last revised on 9/11/23 indicated Resident #48's health directive was a full code. Interventions included to intercede rapidly and begin immediate resuscitative efforts utilizing all life-sustaining measures available if the resident's heart stops beating, or the resident stops breathing. The modification of quarterly Minimum Data Set assessment dated [DATE] indicated Resident #48 was moderately cognitively impaired. A review of Resident #48's medical record indicated a physician's order dated 4/3/25 for Do Not Resuscitate (DNR). The advance directive binder at the nurses' station indicated a DNR form for Resident #48 which was signed by the Medical Director on 4/3/25. An interview with the Social Services Director (SSD) on 4/8/25 at 11:17 AM revealed Resident #48's code status must have changed after he came back to the facility from the hospital, and they didn't catch that it had changed. The SSD stated she didn't attend Resident #48's most recent care plan meeting, and that the Social Services Assistant told her that she didn't know that she was supposed to update the care plans when there was a change in advanced directives. An interview with Minimum Data Set (MDS) Coordinator #1 on 4/8/25 at 11:24 AM revealed Resident #48's code status changed when they discussed this with his responsible party during his care plan meeting on 4/3/25. MDS Coordinator #1 stated that the Social Services Assistant attended the care plan meeting. An interview with the Social Services Assistant on 4/9/25 at 2:18 PM revealed she remembered being in Resident #48's care plan meeting on 4/3/25, and discussing about his code status changing from full code to DNR. The Social Services Assistant stated that she had Resident #48's DNR form signed by the Medical Director, let the nurse on the hall know so she could update the order, and placed it in the advance directive book at the nurses' station. She further stated that she didn't update the care plan regarding the advance directive, and was not sure who was responsible for doing that. She also stated that she was still in training, and had not been doing the full scope of her job duties as a Social Worker. An interview with the Administrator on 4/10/25 at 5:23 PM revealed both the Social Workers and the MDS Coordinator were responsible for updating the care plans to indicate a change in the advance directives.

Based on record review and staff interviews, the facility failed to complete Care Area Assessments (CAA) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 6 sampled residents reviewed for CAA (Residents #99 and Resident #508). The findings included: a. Resident #99 was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes mellitus, and atrial fibrillation. The admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #99 with intact cognition. A review of Section V (care area assessment summary) of the admission MDS assessment dated [DATE] revealed 7 care areas were triggered for Resident #99. Other than the care area for nutritional status, the MDS Coordinator #2 did not provide any information for analysis of findings for 6 of the 7 triggered areas to describe the nature of Resident 99's problems, root causes, contributing factors, risk factors related to the care area, and reasons to proceed with care planning for the following triggered care areas: 1. Communication 2. Functional abilities (self-care and mobility) 3. Urinary incontinence and indwelling catheter 4. Falls 5. Dehydration/Fluid maintenance 6. Pressure ulcer/injury b. Resident #508 was admitted to the facility on [DATE] with diagnoses including non-Alzheimer's dementia, anxiety disorder, and depression. The admission MDS assessment dated [DATE] coded Resident #508 with severely impaired cognition. A review of Section V (care area assessment summary) of the admission MDS assessment dated [DATE] revealed 9 care areas were triggered for Resident #508. Other than the care area for nutritional status, the MDS Coordinator #2 did not provide any information for analysis of findings for 8 of the 9 triggered areas to describe the nature of Resident 508's problems, root causes, contributing factors, risk factors related to the care area, and reasons to proceed with care planning for the following triggered care areas: 1. Cognitive loss/dementia 2. Visual function 3. Functional abilities (self-care and mobility) 4. Urinary incontinence and indwelling catheter 5. Falls 6. Dehydration/fluid maintenance 7. Pressure ulcer/injury 8. Psychotropic drug use During an interview conducted on 04/09/25 at 9:22 AM, MDS Coordinator #2 confirmed 6 of the 7 triggered care areas for Resident #99's admission MDS dated [DATE] and 8 of the 9 triggered care areas for Resident #508's admission MDS dated [DATE] were submitted without providing any information for analysis of findings in Section V. She stated she was responsible for both MDS and acknowledged that it was an error to submit them without completing analysis of findings comprehensively for any of the triggered areas. She could not explain how it happened and added she would correct the errors and resubmit both MDS as soon as possible. On 04/09/25 at 10:01 AM an interview was conducted with the Director of Nursing. She stated all the CAAs must be individualized and completed comprehensively. It was her expectation for the MDS Coordinators to complete the analysis of findings for all the triggered areas in Section V comprehensively before submission. An interview was conducted with the Administrator on 04/10/25 at 5:29 PM. She expected the MDS Coordinator to follow MDS guidelines and completed all the CAAs comprehensively before submission.

Based on record review and staff interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment for respiratory care (Resident #91), antibiotic use (Resident #48), and PASRR (Resident #63) for 3 of 29 resident assessments reviewed. Findings included: 1. Resident #91 was admitted to the facility on [DATE] with a diagnosis of sleep apnea. A physician order dated [DATE] revealed Resident #91 wore a continuous positive airway pressure (CPAP). The order was for staff to apply nightly as tolerated and to remove the CPAP in the morning. Review of Resident #91's quarterly MDS assessment dated [DATE] revealed the resident was coded as having no CPAP device. Review of Resident #91's medication administration record (MAR) for February 2025 revealed an order which read, CPAP remove every A.M. when resident wakes, every day and night shift. The order was initialed as completed by nursing staff during the lookback period. On [DATE] at 11:08 AM an interview was conducted with Nurse Aide (NA) 5. During the interview she stated Resident #91 had a CPAP machine that was applied nightly. On [DATE] at 10:11 AM an interview was conducted with Nurse #3. During the interview Nurse #3 stated Resident #91 had a CPAP that was applied nightly and removed in the morning. The interview revealed the physician order was located on the MAR and nursing staff were to sign off if the CPAP was in place for Resident #91. On [DATE] at 10:27 AM an interview was conducted with MDS Nurse #1. She stated she had been responsible for MDS for over a year and a half. The interview revealed she collected her information from the MAR and Treatment Administration Record (TAR) to decide how to code residents for respiratory care. MDS Nurse #1 stated after review of Resident #91's MAR, the MDS had not been coded correctly. She stated, it was just missed. On [DATE] at 5:26 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated she would like for the MDS staff to accurately code all residents for respiratory care. On [DATE] at 5:45 PM an interview was conducted with the Administrator. She stated she would expect Resident #91's MDS to be accurately coded. 41069 2. Resident #48 was admitted to the facility on [DATE]. The modification of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was taking antibiotics with indication noted. A review of the Medication Administration Record for Resident #48 for February 2025 indicated he did not receive antibiotics from [DATE] to [DATE]. An interview with MDS Coordinator #2 on [DATE] at 3:15 PM revealed Resident #48 was on antibiotics right before he went to the hospital on [DATE], but after he came back to the facility on [DATE], he didn't receive any antibiotics. MDS Coordinator #2 stated that when she reviewed Resident #48's Medication Administration Record from the hospital, she noted that Resident #48 did not receive any antibiotics during the 7-day assessment period. MDS Coordinator #2 further stated that the MDS was marked in error. An interview with the Administrator on [DATE] at 5:23 PM revealed the MDS should be coded correctly. 49160 3. Resident #63 was admitted to the facility [DATE] with diagnoses that included schizoaffective disorder. Resident #63's Preadmission Screening and Resident Review (PASRR) level II determination letter dated [DATE] revealed nursing facility placement was appropriate for 30 days and the PASRR level II expired on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had a diagnosis of schizoaffective disorder but was not coded for a PASRR level II. An interview with MDS Nurse #2 on [DATE] at 2:27 PM revealed she was responsible for completing the PASRR level II section of the MDS. MDS Nurse #2 revealed she reviewed Resident #63's PASRR determination letter but was not familiar with a PASRR level II that expired after 30 days and thought it was a PASRR level I. MDS Nurse #2 stated the admission MDS was not coded accurately because she was unaware Resident #63 had a PASRR level II. During an interview with the Administrator on [DATE] at 5:27 PM she indicated a PASRR level II determination should be coded accurately on the resident's MDS assessment.

Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II was obtained for a resident with an expired PASRR level II. This deficient practice occurred for 1 of 4 residents reviewed for PASRR (Resident #63). The findings included: Resident #63 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder. Review of the Preadmission Screening and Resident Review (PASRR) level II dated [DATE] revealed it expired on [DATE]. Resident #63 remained in the facility after [DATE] and a level II PASRR had not been completed since admission. An interview with the Social Services Director on [DATE] at 9:58 AM revealed she was responsible for monitoring and ensuring all level II PASRRs were obtained. She stated Resident #63 was admitted to the facility with a 30-day level II PASRR that expired on [DATE]. She indicated Resident #63 remained in the facility after [DATE] and a new level II PASRR should have been requested but was overlooked. During an interview with the Administrator on [DATE] 02:27 PM she revealed the Social Services Director was responsible for monitoring and ensuring all level II PASRRs were obtained. She stated if a resident was admitted with a PASRR level II that expired after 30 days, and they remained in the facility, a new level II PASRR should be obtained.

Based on observation, record review and staff interviews, the facility failed to administer medications as ordered by the physician for 1 of 5 (Resident #2) residents reviewed for medications. Findings included: a. Resident #2 was initially admitted to the facility on [DATE] and readmitted from the hospital on 1/13/2025. Resident #2 had diagnoses including chronic diastolic congestive heart failure, Type 2 diabetes Mellitus with diabetic polyneuropathy (a condition where nerve damage occurs due to persistently high blood sugar levels), intervertebral disc degeneration lumbar region without mention of lumbar back pain or lower extremity pain. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact. Resident #2's Physician's order dated 7/24/2024 read Pregabalin Oral Capsule 200mg (narcotic controlled substance) Give one capsule by mouth two times a day for Neuropathy (weakness, numbness and pain from nerve damage) Resident #2's controlled medication declining sheets from October 2024 to April 2025 were reviewed and indicated Resident #2 had not received her scheduled doses of pregabalin 200mg on: 10/20/2025 at 4:00pm 2/27/2025 at 9:00am 3/6/2025 at 9:00am 3/18/2025 at 9:00pm 3/27/2025 at 9:00am Review of Resident #2's October 2024 Medication Administration Record (MAR) indicated: Nurse #10 documented on 10/20/2024 at 4:00pm pregabalin 200mg was administered. Review of Resident #2's February 2025 MAR indicated: Nurse #14 documented on 2/27/2025 at 9:00am pregabalin 200mg was administered. Review of Resident #2's March MAR indicated: Nurse #19 documented on 3/6/2024 at 9:00am pregabalin 200mg administered. Nurse # 1 documented on 3/18/2024 at 9:00pm pregabalin 200mg was administered. Medication Aide (MA) #2 documented on 3/27/2024 at 9:00am pregabalin 200mg was administered. During an interview on 4/10/2025 at 3:10pm MA #2 verified that she worked on 3/27/2025 and did not administer pregabalin 200mg to Resident #2 at 9:00am even though it was signed on the MAR. MA #2 stated she normally worked on second shift but came in early to help that day and must have just missed it by accident. During a telephone interview on 4/11/2025 at 10:11am Nurse #1 stated she had been at the facility as an agency nurse for a year but just signed on as a fulltime staff at the facility. Nurse #1 stated she would agree that she had not administered pregabalin if the narcotic count was correct and she had not signed it out on the narcotic declining inventory sheet. During a telephone interview on 4/11/2025 at 5:18pm Nurse #10 stated if she had signed a med was administered on the MAR, but not on the controlled medication declining count sheets, and the count was correct, then she probably did not administer the medication. Attempted to interview Nurse #19, but phone calls were not returned. During an interview on 4/10/2025 at 11:57am the Director of Nursing (DON) stated if a resident had a medication signed out on the Medication Administration record but not on the controlled medication declining sheets, and the count was correct, then the medication had probably not been administered. The Medical Director (MD) was interviewed on 4/10/2025 at 12:37pm and stated missing doses of pregabalin could cause increased pain or discomfort. The MD expected staff to document accurately and honestly on the MAR and narcotic record and for residents to receive their medications as ordered. During an interview on 4/10/2025 at 5:30pm the Administrator stated she would expect a resident to receive medication as ordered. The Administrator stated she would expect staff to document accurately and honestly on the MAR. b. Resident #2's Physician order dated 1/13/2025 read Tramadol HCL Oral tablet 50 milligram(mg) (narcotic controlled substance) Give one tablet by mouth every six hours as needed for pain. Review of Resident #2's controlled medication declining sheets for March-April 2025 revealed Resident #2 had received tramadol HCL 75mg on 3/6/2025, 3/8/2025, 3/11/2025, 3/12/2025, 3/16/2025, 3/17/2025, 3/19/2025, 4/5/2025 and 4/6/2025. During an interview on 4/10/2025 at 11:50am Unit Manager #2 verified Resident #2's controlled medication declining sheets indicated 75mg of tramadol HCL had been administered on 3/6/2025, 3/8/2025, 3/11/2025, 3/12/2025, 3/16/2025, 3/17/2025, 3/19/2025, 4/5/2025 and 4/6/2025. During an interview on 4/10/2025 at 11:21am Nurse #6 verified Resident #2 had an order for tramadol HCL 50mg by mouth every 6 hours as needed for pain, and that Nurse #6 administered tramadol HCL 75 mg to Resident #2 on 3/11/2025 and 3/19/2025. During a telephone interview on 4/10/2025 at 2:58pm Nurse #11 stated that maybe she didn ' t read the label correctly. Nurse #11 stated if she documented she gave tramadol HCL, she probably gave the 75mg in the blister pack. Nurse #11 stated she thought the correct dose of medication would be in the narcotic drawer. During a telephone interview on 4/11/2025 at 11:48am Nurse #9 stated if she had signed she had administered tramadol HCL, she probably gave 75mg. During a telephone interview on 4/11/2025 at 12:02pm Nurse #8 stated she was an agency nurse and if tramadol HCL 75mg was in the blister pack, that was what she administered. During an interview on 4/10/2025 at 11:57am the Director of Nursing (DON) verified Resident #2 had an order for tramadol HCL 50mg one tab by mouth every 6 hours as needed dated 1/13/2025, and that Resident #2's medication blister packs of tramadol HCL contained 75mg in each blister pack. The Medical Director (MD) was interviewed on 4/10/2025 at 12:37pm and stated it was not good that Resident #2 had received the wrong dose of tramadol HCL multiple times. During an interview on 4/10/2025 the Administrator stated she would expect a resident to receive medication as ordered. The Administrator stated she would expect staff to document accurately and honestly on the MAR.

Based on record review, and resident, staff, Pharmacist, and Medical Director interviews the facility failed to prevent a significant medication error when scheduled pain medications were not administered as ordered by the physician for 1 of 3 residents (Resident #112) reviewed for assuring facility was free from significant medication errors. Resident #112 was ordered to receive a scheduled pain medication three times a day and failed to receive seven dosages of his scheduled pain medication due to the medication not being available at the facility. The findings included: Resident #112 was admitted to the facility on [DATE] with a readmission on 3/03/25. Diagnosis included chronic pancreatitis, severe chronic kidney disease, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #112 was cognitively intact and was also coded for pain and receiving pain medication. Review of revised care plan dated 3/07/25 revealed goal for Resident #112 to be free of signs of pain or complaints of pain and will state relief of pain daily. Interventions included administer pain medications for pain, observe for effectiveness/side effects and reporting ineffectiveness to physician. Review of the Physician order dated 3/03/25 stated to administer Morphine Sulfate (MS) Contin Oral Tablet Extended Release (ER) 30 milligrams (MG) by mouth three times a day for pain. (narcotic analgesic that releases slowly over 12 hours) Review of the Medication Administration Record (MAR) for March 2025 revealed MS Contin Oral Tablet ER 30MG three times daily (8:00 AM, 1:00 PM, 8:00 PM) was coded as not available to be administered to Resident #112 as scheduled on 3/10/25 at 8:00 PM and 3/31/25 at 1:00 PM and 8:00 PM. Review of Nursing Note written by Nurse #18 dated 3/10/25 at 8:00 PM revealed Resident #112's MS Contin Oral Tablet ER 30 MG give 1 tablet three times a day for pain, was on order and was not available to administer. Review of nursing progress note written by Nurse #16 dated 3/31/25 at 1:00 PM revealed Resident #112's MS Contin Oral Tablet ER 30 MG give 1 tablet by mouth three times a day for pain medication was not available to administer. Resident #112 was still in pain and administered as needed pain medication. A telephone interview with Nurse #16 dated 4/10/25 at 2:15 PM revealed she recalled Resident #112's scheduled pain medication being unavailable to administer during lunchtime on 3/31/25. She stated she did not contact the physician or the pharmacy but believed she did notify the on-coming nurse and documented it in the chart. Review of nursing progress note written by Medication Aide (MA) #2 dated 3/31/25 at 8:00 PM revealed Resident #112's MS Contin Oral Tablet ER 30 MG give 1 tablet by mouth three times a day for pain was on order and was not available to administer. A telephone interview with MA #2 dated 4/10/25 at 3:13 PM revealed she recalled Resident #112's scheduled pain medication being unavailable to administer on the evening of 3/31/25. She stated that she did remember notifying the on-coming nurse of the medication not being available and believed she was able to administer him his as needed pain medication in place of the scheduled pain medication. Review of the Medication Administration Record (MAR) for April 2025 revealed MS Contin Oral Tablet ER 30MG three times daily (8:00 AM, 1:00 PM, 8:00 PM) was coded as not available to be administered to Resident #112 as scheduled on 4/01/25, 4/02/25, and 4/07/25. Review of nursing progress note written by Nurse #17 dated 4/01/25 at 8:00 AM revealed Resident #112's MS Contin Oral Tablet ER 30 MG give 1 tablet by mouth three times a day for pain was not available to be administered. Nurse Practitioner was made aware, and medication was enroute per pharmacy. No new orders received. Review of nursing progress note written by Nurse #17 dated 4/01/25 at 1:00 PM revealed Resident #112's MS Contin Oral Tablet ER 30 MG give 1 tablet by mouth three times a day for pain was not available to administer. Provider was made aware of Resident #112's missed dose, no new orders were received, and medication would resume once arrived from pharmacy. A telephone interview with Nurse #17 on 4/10/25 at 2:25 PM Nurse #17 revealed she recalled Resident #112's scheduled pain medication being unavailable to administer during the morning and at lunchtime on 4/01/25. She stated that typically when a resident's medication was unavailable, she would look to see if the pharmacy had been called and if not, she would call them for a refill. Nurse #17 revealed she did not recall if she called pharmacy about Resident #112's medication not being available or if it was already noted the medication was on order. She stated Resident #112 did have an as needed pain medication that was administered in place of his scheduled pain medication and when requested. Review of nursing progress note written by Nurse Supervisor #1 dated 4/01/25 revealed Resident #112's script for MS Contin Oral Tablet ER 30 MG give 1 tablet by mouth three times a day for pain had been sent to the pharmacy would be delivered on next pharmacy run. An interview was conducted with the Nurse Supervisor #1 on 4/10/25 at 2:58 PM revealed she believed she was notified by Nurse # of Resident #112 scheduled pain medication being unavailable to administer. She stated she contacted the pharmacy and sent them a copy of the medication script and the pharmacy notified her that Resident #112's medication would be delivered on the next pharmacy run either later that evening or the following morning. Review of nursing progress note written by Nurse #20 dated 4/01/25 at 8:00 PM revealed Resident #112's MS Contin Oral Tablet ER 30 MG give 1 tablet by mouth three times a day for pain was not available to administer. Attempted interview with Nurse #20 and was unable to contact. Review of nursing progress note written by Nurse #21 dated 4/02/25 at 8:00 AM revealed Resident #112's MS Contin Oral Tablet ER 30 MG give 1 tablet by mouth three times a day for pain was not available to be administered. Attempted interview with Nurse #21 and was unable to contact. Review of nursing progress note written by Nurse #5 dated 4/02/25 revealed Resident #112's MS Contin Oral Tablet ER 30 MG medication was delivered and available on medication cart. Resume medication as ordered. An interview was conducted with Nurse #5 on 4/10/25 at 10:20 AM. She stated she was familiar with Resident #112 and his medications. She revealed Resident #112 had missed several doses of his scheduled pain medication due to nursing staff not re-ordering the medication from the pharmacy prior to the last dose. She stated resident medications must be ordered prior to the last dosage due to the facility pharmacy being in the eastern part of the state and can take longer for the medication to be delivered. Nurse #5 revealed when a resident's medication runs out the nursing staff are supposed to call the pharmacy and see if they would require a new script or not for reorder, and if a new script was needed then nursing staff would contact the physician to receive the new medication order and send the new order to the pharmacy which can also take time. She stated to her knowledge anytime Resident #112's scheduled medications have not been available he had received his as needed pain medication in place of his scheduled pain medication. Review of nursing progress note written by Nurse #18 dated 4/07/25 at 8:00 PM revealed Resident #112's MS Contin Oral Tablet ER 30 MG give 1 tablet by mouth three times a day for pain was not available to be administered. Awaiting delivery of medication from the pharmacy. Attempted interview with Nurse #18 and was unable to contact. An interview conducted with Resident #112 on 4/07/25 at 11:25 AM revealed he had chronic pancreatitis and was ordered to receive scheduled pain medication three times a day for his chronic pain related to his pancreatitis. He stated on several occasions during March and April 2025 he had not received his scheduled pain medication due to the facility running out of the medication and waiting on the pharmacy to deliver. He revealed he did not understand why the facility was not able to keep his scheduled pain medication in stock especially since he has had that prescription for a while. He also revealed during the times he did not receive his scheduled pain medication he was administered his as needed pain medication, but that medication was short acting, and he could only receive that medication every 8 hours whereas his scheduled pain medication was long acting, and he was able to receive it three times a day. He revealed when he was able to receive his regular scheduled pain medication as ordered his pain was tolerable, and he would only have to take his as needed pain medications in between his scheduled doses when he absolutely needed to. An interview was conducted with Resident #112 on 4/09/25 at 2:40 PM revealed he missed his evening dose of his scheduled pain medication on Monday (4/07/25) due to the facility running out of it but the pharmacy was able to send more, and he received his next scheduled dose the following morning. He stated he still did not understand why the facility was not able to keep his scheduled pain medication in stock or why staff did not send in an order to pharmacy when they would see that his medication was low. He revealed he did receive a dose of his as needed pain medication on Monday evening to help with his pain until he could receive his scheduled dose the following morning. A telephone interview with Pharmacist #1 on 4/09/25 at 4:24 PM revealed she was the pharmacy consultant for the facility. She stated they received a pharmacy re-order for Resident #112's MS Contin Oral Tablet ER 30 MG give 1 tablet by mouth three times a day for pain on 4/01/25 and they delivered 15 pills to the facility during the night of 4/01/25. She also stated they received another re-order for the same medication for Resident #112 on 4/07/25 and delivered another 15 pills during the night of 4/07/25. Pharmacist #1 revealed the best practice for the facility would be for the nursing staff to reorder resident medications prior to the residents' last dose so the pharmacy would have the allotted time needed to fill and deliver the residents' medications prior to them running out. An interview with the Medical Director was conducted on 4/10/25 at 12:07 PM. He stated he was familiar with Resident #112 who suffered from chronic pancreatitis which caused chronic pain. He revealed that the facility should always have resident medications available and should not wait until the last dosage of a medication to re-order especially since they account for resident medications on every shift. The Medical Director stated he would consider Resident #112 missing his scheduled pain medication as a significant medication error due to his pain from his chronic pancreatitis. He revealed Resident #112 does have an order for as needed pain medication to be administered every 8 hours and that should be sufficient to assist with pain. An interview was conducted with the Director of Nursing (DON) on 4/10/25 at 5:45 PM. She stated she also was not aware of Resident #112 missing is scheduled pain medication due to them not being available. She revealed residents should have their medication available to be administered as ordered. The DON stated nursing staff should be re-ordering resident medications prior to the resident's last dosage to keep from running out, and if nursing staff is not aware of how-to re-order medications or does not have access for re-ordering then they should notify their nursing supervisor so the medication could be ordered in a timely manner. An interview with the Administrator was conducted on 4/10/25 at 5:30 PM. She stated she was not aware of Resident #112 missing his scheduled pain medication due to not being available. She revealed the facility should have all resident medications available to be administered as ordered, and nursing staff should be re-ordering resident medications prior to them running out.

Based on record review, staff, family, Hospice Nurse, Hospice Medical Director, and Nurse Practitioner (NP) interviews, the facility failed to manage the pain of 1 of 1 resident (Resident #1) who complained of pain and exhibited non-verbal cues of pain that included moaning, groaning, and grimacing as staff moved or touched her after returning to the facility from Emergency Department (ED) following a fall that resulted in a cervical one (C-1 - upper vertebrae in the neck) fracture in her neck and left humerus (upper arm) fracture on [DATE]. There was no pain treatment from the time Resident #1 returned from the ED until she was transferred to an inpatient hospice facility approximately 28 hours later. Immediate Jeopardy began on [DATE] when Resident #1 complained of pain and exhibited nonverbal signs of pain and no pain management was offered or administered. Immediate Jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. The findings included: Resident #1 was admitted to the facility from a hospital on [DATE] with diagnoses that included rheumatoid polyneuropathy (disease affecting multiple nerves of the body causing pain) with rheumatoid arthritis of multiple sites and chronic pain. Review of Resident #1's most current care plan dated [DATE] read, resident was at risk for uncontrolled pain because of the physical effects of aging, and history of chronic pain. Resident had diagnoses of rheumatoid arthritis, cervical spondylosis (deterioration of the spinal vertebrae), and acute pain related to fall with fracture to left lower leg. The goal read: The resident's pain would be managed to the greatest extent possible, so it did not affect day-to-day activities. Interventions included: evaluate the effectiveness of pain interventions every shift and as needed, to be gentle with care as movements could be very painful, give pain medications as needed within doctor's order guidelines, offer/provide non-medication interventions such as heat or cold, exercise, rest, guided imagery, repositioning. An additional intervention dated [DATE] was added: monitor for non-verbal expression of pain such as agitation, facial expression such as wincing, holding a body part, change in posture, refusing to eat, decreased level of activity, increased heart rate/rate of breathing, dilated pupils, sweating, anxiety, restlessness, difficulty sleeping, irritability or depression). Note vocalization such as moaning, crying, or screaming. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE] revealed Resident #1 was severely cognitively impaired, was not on a schedule pain medication regime, had not received any opioid's during the seven day look back period, and received Hospice services. Review of the physician orders revealed: [DATE] -Tylenol Tablet 325 milligram (mg) Give two 325 mg tablets by mouth every 6 hours as needed for fever/pain. [DATE] - Oxycodone HCL Tablet, give one 20 mg tablet by mouth every 6 hours as needed for pain. [DATE] - Hospice to provide care and services as appropriate. Resident #1's admission diagnosis was polyneuropathy of rheumatoid arthritis of multiple sites with a life expectancy of 6 months or less. Review of the [DATE] Medication Administration Record (MAR) from [DATE] through [DATE] revealed zero (no pain) was documented as Resident #1's pain level every shift. The MAR further revealed no pain medications were administered to Resident #1 during this time period. A nursing progress note written by Nurse #4 dated [DATE] at 1:12 PM indicated the resident was observed sitting on floor and Nurse #4 and a Nurse Aide (NA) assisted Resident #1 into the bed. Resident #1 was assessed, and vital signs were taken. The Nurse Practitioner (NP) came to observe Resident #1 and gave an order to send Resident #1 to Emergency Department (ED). Resident #1 was given her ordered PRN (as needed) pain medication and Emergency Medical Services (EMS) was called. Multiple attempts were made to contact Nurse #4 with no success. The March MAR on [DATE] indicated a score of ten (worst possible pain) on [DATE] immediately after she fell from her wheelchair and Resident #1 received a 20-milligram tablet of Oxycodone at 1:09PM which was administered by Medication Aide (MA) #2. In an interview on [DATE] at 11:41 AM with MA #2, she revealed she came into Resident #1's room on [DATE] when she heard a commotion and saw staff helping Resident #1 back to bed after she fell out of her wheelchair in her room. She stated she medicated Resident #1 with an Oxycodone 20mg tablet at 1:09 PM for pain just before Resident #1 went to the hospital. An ED physician progress note dated [DATE], revealed a computerized tomography scan (CT scan - technique used to obtain detailed internal images of the body) of the cervical spine revealed a cervical one (C-1 - upper vertebrae in the neck) fracture in her neck and an x-ray of the left shoulder/arm confirmed a left humerus (upper arm) fracture. The ED physician documented Resident #1 was medicated with 15 mg of Ketorolac Tromethamine (non-steroidal anti-inflammatory pain medication) for pain on [DATE] at 2:31PM. Additionally, he documented that Resident #1 already had pain medication ordered for her at the facility, so no additional pain medication orders were written. A nursing progress note written by Nurse #2 on [DATE] at 6:00 PM, read, resident was assisted into the bed by two EMS staff. Resident has a splint on her left arm. Elbow placed on pillow for comfort. Resident is arousable but sleepy. During an interview on [DATE] at 1:10 PM with Nurse #2, she stated she cared for Resident #1 after EMS brought her back to the facility on [DATE] from the ED. Nurse #2 stated Resident #1 was calm and sleepy and was put directly in bed upon re-admission. Nurse #2 stated Resident #1 was confused but did not require any extra care more the normal level of care that shift. Nurse #2 stated she gave Resident #1 her regular medications but did not give any pain medications because she did not feel Resident #1 was in any pain as she did not ask for pain medicine. In an interview on [DATE] at 3:24 PM with Nurse Aide (NA) #8, she stated she was not assigned to Resident #1 on [DATE] but assisted with Resident #1's transfer from the EMS stretcher back to bed when she returned from the ED on [DATE] at approximately 5:45 PM. She stated she could tell Resident #1 was in pain because she was moaning, groaning, her face was curled up, and she grimaced as they moved her. She stated she informed the nurse of Resident #1's pain but unsure if Resident #1 received any pain medication. She stated she could not recall who the nurse was to whom she reported the pain concerns. The MAR for [DATE] for the night shift revealed Nurse #3 documented a pain level of 10 and no pain medication was administered. In a phone interview with Nurse #3 on [DATE] at 10:10 AM, he stated he cared for Resident #1 on the night shift that began on [DATE] and ended on [DATE] when Resident #1 returned from the ED. He stated she was confused and not communicative or verbal, had an uneventful shift and was in bed all night. He stated she could not vocalize her needs, but he looked for non-verbal cues of pain such as clenching her teeth or grimacing and did not recall any. He stated he did not recall that he documented Resident #1 had a pain level of 10 on the [DATE] night shift pain scale. He stated her pain level might have been a ,d+[DATE], but not a 10. He stated he had never scored anyone's pain as a 10. Nurse #3 stated if Resident #1's pain had been a 10, he would have medicated her for pain and called the physician. He stated he would not let a resident be in that kind of pain. He stated he did not administer any pain medication to Resident #1. Nurse #3 indicated he was unable to recall which NA worked with him and/or cared for Resident #1. The [DATE] MAR revealed only one pain level was recorded by Nurse #6. On [DATE] during the day shift, Resident #1's pain score was recorded as zero. The MAR further revealed Resident #1 had not been administered pain medication at the facility. In an interview on [DATE] at 11:07 AM with Nurse Aide #7 he stated he cared for Resident #1 on [DATE], the day shift after her fall. He stated Resident #1 had arm pain that afternoon and she asked for pain medicine. He stated she was often confused but that day she could tell him that she was in pain. He stated Resident #1 showed signs of pain such as she grimaced when she moved and wouldn't eat since the fall. He stated he reported Resident #1's pain and request for pain medicine to the MA working the 100 hallways, but he could not recall the MA's name or if she ever medicated Resident #1. He stated she stayed in bed all day on his shift. In a phone interview [DATE] at 2:30 PM with Nurse #6, she stated she worked the day shift on [DATE] on the 100 hallway. She stated she was supposed to still be in her training period but had to work a cart until 3:00 PM because a MA did not show up for work. She stated she did not receive any report and did not know anything about Resident #1. She stated she recalled when she first saw Resident #1 on [DATE] she was covered in bruises. She stated no one could tell her what happened to Resident #1, and she did not know how to navigate the electronic medical record well enough to look at her history. She explained that she had received very little training on the electronic medical record system prior to working on the floor on [DATE]. She did not recall that Resident #1 was in any pain, so she didn't offer pain medications. She stated when she gave Resident #1 her other scheduled medications, she spit them out. She stated at 3:00 PM, a MA came to take over the cart, but she did not know the name of the MA. She stated Resident #1's Family Member #2 came to see her in the afternoon and asked her what exactly had happened, and she had to tell the family member she did not know. Nurse #6 stated the family member did not tell her Resident #1 was in pain. An interview was conducted on [DATE] at 10:10 AM with Family Member #1. The Family Member #1 stated Resident #1 fell out of her wheelchair in her room and was sent to the ED and she was diagnosed with a fractured left arm and a neck fracture. Family Member #1 stated Resident #1 was always in a lot of pain from her rheumatoid arthritis and other medical issues. Family Member #1 stated they knew the facility could only give a certain amount of pain medication, and Hospice could give more pain medication and had heard Hospice was much better at pain control, so the family placed her in Hospice care. Family Member #1 stated the day after Resident #1 fell ([DATE]), Family Member #2 was with her during the day and called him and stated Resident #1 had been sitting up all day in her wheelchair and was in excruciating pain and did not get any pain medicine all day. Family Member #1 stated after he heard from Family Member #2, he immediately called the Hospice Nurse and asked her to come relieve Resident #1's pain because he knew she could do more for her than the facility staff, and he wanted Hospice to take her out of the facility and transfer her to an inpatient hospice facility. In a phone interview on [DATE] at 1:50 PM with the Hospice Nurse who was on-call the weekend of the fall ([DATE]), she stated she received a voicemail from the facility on Friday night, [DATE], and was told that Resident #1 had fallen but they did not mention that they had sent her to the hospital. She explained that she was the on-call nurse for hospice and was not familiar with Resident #1. The Hospice Nurse stated she tried to call the facility several times on Friday night ([DATE]), but the phone was never answered. She stated she called the facility on Saturday, [DATE] around noon, and was told that Resident #1 was fine so she assumed the resident was not sent to the hospital. She stated Resident #1's Family Member #1 called her on [DATE] at 6:28 PM and told her Resident #1 had fallen the day before and was sent out to the hospital and sustained fractures in her neck and left arm. The Hospice Nurse stated Family Member #1 told her Resident #1 was in excruciating pain and had been up in a wheelchair all day. The Hospice Nurse stated Family Member #1 asked the Hospice Nurse for help with Resident #1's pain and told her the family wanted their mother transferred to an inpatient facility for Hospice services. The Hospice Nurse stated she called the Hospice Medical Director who was on-call for the weekend and received new pain medication orders for liquid morphine (pain medicine) and Ativan (anti-anxiety medication). She stated she again tried to call the facility and former Director of Nursing (DON) #1 (DON at the time of the incident on [DATE] - [DATE]) regarding the new pain medication orders without success. The Hospice Nurse arrived at the facility on [DATE] at 8:10 PM and was directed by staff to several incorrect hallways but finally located Resident #1 on the 100 hallway. She stated Resident #1 was confused and grimaced when she moved and was guarded and did not want the Hospice Nurse to touch her left arm. The Hospice Nurse stated Resident #1 was grinding her teeth while trying to breathe and her respirations were ,d+[DATE] a minute. The Hospice Nurse stated she spoke with a facility nurse whose name she could not remember and told the facility nurse she had new pain medication orders for Resident #1. The facility nurse stated she did not know if they had any liquid morphine or Ativan in the facility. The facility nurse stated former DON #2 was coming in at 11:00 PM (the nursing supervisor at the time of the incident on [DATE] - [DATE]) and she would know if they had the medications. The facility nurse stated she didn't want to call former DON #2 because she was working that night and she didn't want to wake her up. In a second phone interview with the Hospice Nurse on [DATE] at 3:46 PM, she stated when she spoke with the MA on the 100 hallway, the MA stated she did not know Resident #1 and she had not gotten to her room yet to see her. The Hospice Nurse then tried to find someone in charge to help her with getting the new pain medication orders faxed to the pharmacy. The Hospice Nurse stated she ended up on the 500 hallway and a nurse whose name she did not recall, and she was also unsure about what medications were on hand in the facility. An unknown facility nurse finally called former DON #2 who told the Hospice Nurse she would be there at 11:00 PM and she would then check on what medications they had on hand. The Hospice Nurse stated she asked the former DON #2 if they transferred out Resident #1 for immediate pain management, would Resident #1 still have a bed available when she was ready to return to the facility. The Hospice Nurse indicated former DON #2 stated she thought the bed would be held for 30 days. The Hospice Nurse stated originally they planned to move Resident #1 the next day on [DATE], but once it was clear Resident #1 would have to wait until at least 11:00 PM for pain medication, and because the level of Resident #1's pain, she called her Hospice Medical Director and the Hospice Administrator and they all felt it was unsafe to leave Resident #1 in the facility until the next day and decided to immediately transfer Resident #1 to an inpatient hospice facility for pain management. Resident #1 was transferred to an inpatient hospice facility by EMS on [DATE] at 10:15 PM. In a phone interview with MA #3 on [DATE] at 3:22 PM, he stated he worked on [DATE] the day after Resident #1 fell . He stated he took over a medication cart at 3:00 PM from Nurse #6, but soon was pulled to another hall and could not remember who took over for him or where he was pulled to work. He stated he never saw Resident #1 that shift and denied that he spoke to a Hospice Nurse regarding Resident #1. He confirmed that anyone assigned to a cart, nurse, or MA, had keys to the narcotic box and could obtain and administer narcotics. He further stated liquid morphine was kept in narcotic cart. In an interview on [DATE] at 5:19 PM with NA #9, she stated she worked the 100 hallway for the 3:00 PM-11:00 PM shift on [DATE] and stated she recalled Resident #1 and did care for her on that shift. She stated she was the only NA on the 100 hallway that shift. She stated Resident #1 was calm and hard to wake up, but she would open eyes and mumbled. She stated she informed a nurse that Resident #1 was not communicating or showed any kind of reaction to anything. NA #9 could not recall which nurse she spoke with about Resident #1. She stated later in her shift a nurse, or a doctor came to check on Resident #1 and then someone called EMS and an ambulance came and took Resident #1 away. She stated she did not know who called EMS or where Resident #1 was going. In a phone interview with former DON #2 on [DATE] at 2:20 PM, she stated that nobody ever called her about liquid morphine or Ativan or any other pain medication on [DATE], for Resident #1. She stated if they had called her, she only lived three minutes away from the facility and would have immediately gone to the facility and assisted with Resident #1's pain management issues. In a phone interview on [DATE] at 3:18 PM with Nurse #5, she stated she was not assigned to Resident #1, but did go see her sometime on [DATE] on the ,d+[DATE] PM shift because she just wanted to see her. She stated Resident #1 was able to tell her she was in pain, and she was grimacing when she tried to move and was making facial grimaces. She stated she didn't tell anyone because she knew Resident #1 was already on daily pain medication. She stated she recalled that a Hospice Nurse came and asked for help with gathering the paperwork for Resident #1's transfer to an inpatient hospice facility. Nurse #5 denied that she had any discussion with the Hospice Nurse about pain medication for Resident #1. In an interview with the Unit Manager on [DATE] at 10:26 AM, she stated the facility had a safe for narcotics for emergencies and they had liquid morphine and Ativan. She stated all the nurses and MAs had the code and access to the safe. In an interview on [DATE] at 12:00 PM with the Nurse Practitioner (NP), she stated Resident #1 was usually in a confused state. She saw the resident after the fall on [DATE] and sent her to the ED for evaluation. She stated Resident #1 had severe rheumatoid arthritis, but she hadn't heard any complaints of pain lately. She stated when she was alert and oriented, she was very vocal about getting her pain medication, but as she declined, she had stopped asking for pain medication. The NP stated she didn't see Resident #1 after she went to the hospital. A phone interview was conducted on [DATE] at 5:15 PM with the Hospice Medical Director and she stated she was contacted by the Hospice Nurse on [DATE] to discuss Resident #1's lack of pain management after a fall where she sustained serious injuries. The Hospice Medical Director stated she gave the Hospice Nurse new pain medication orders, but the Hospice Nurse ran into many barriers in the facility as she tried to get Resident #1 adequately medicated for pain. She stated the Hospice Nurse, the Hospice Administrator and herself made the decision to have Resident #1 transferred to an inpatient hospice facility that evening for pain management. She stated that Hospice inpatient called her when Resident #1 arrived and told her Resident #1 was in intense pain, yelling and moaning in pain when touched or with any gentle movement, and had bruises on her hands, face, and legs. She stated once they stabilized her neck, medicated her for pain, she was calm and comfortable. The Hospice Medical Director stated they gave her pain medications around the clock to keep her comfortable. The Hospice Medical Director stated it was never their first choice to put a resident through the pain and stress of a transfer out of their home, but in this case, Resident #1 was not receiving appropriate pain management so for her well-being an intervention was required. She stated it would have been much easier on Resident #1 if she could have stayed in the facility and had her pain managed appropriately. She stated the staff were clearly not reading or responding to Resident #1's non-verbal pain cues. The Medical Director stated Resident #1 died on [DATE]. In an interview with the Interim DON, on [DATE] at 4:30 PM, she stated Resident #1's pain should have been handled better. She stated the staff should have completed more pain assessments and looked more carefully for non-verbal pain cues such as guarding, moaning, grinding teeth, and have medicated Resident #1 and called the provider. On [DATE] at 1:52 PM, the Interim Director of Nursing and the Regional [NAME] President of Operations were notified via phone of immediate jeopardy. The facility provided the IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Based on record review and staff interviews, the facility failed to manage the pain of Resident #1. Resident #1 had complained of pain and exhibited non-verbal cues of pain which included moaning, groaning, and grimacing. Resident #1 had returned from the Emergency Department on [DATE] at 5:45 PM following a fall with serious injuries. Resident had an order for PRN (as necessary) pain medication upon readmission. Resident received routine medication of Ativan at 10:00 PM and had no documentation of pain after the 10:00 PM medication administration. Resident #1 received no PRN pain medication after her return from the Emergency Department, although medication was available if needed. Resident #1 expressed pain at the facility to a non-facility staff person (Hospice Nurse) which precipitated transfer to an inpatient hospice for pain management. Current facility residents are at risk of being affected by the alleged deficient practice of not managing pain despite non-verbal cues observed by staff. The Director of Nursing and nurse supervisors completed an audit of facility residents on [DATE] to include a pain assessment to ensure no other residents were affected by the deficient practice. There were no adverse effects or other residents identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The Director of Nursing and Nurse supervisors completed education to nurses, medication aides, and nursing assistants on [DATE], regarding non-verbal cues of pain. Nurses, medication aides and nursing assistants not working on [DATE] received education prior to starting shift, including Agency staff. New nursing staff will receive education regarding non-verbal cues of pain and medication for pain management by the Director of Nursing or nurse supervisors. The Director of Nursing or nursing supervisor will be responsible for ensuring that this education is provided prior to the start of any assignment in which they are working. On [DATE] licensed nursing staff were educated by the Director of Nursing and nurse supervisors to ensure appropriate documentation was completed on residents with pain. Nurses and medication aides not working on [DATE] received education prior to starting shift, including agency staff for substantial compliance. The facility alleges the removal of the immediate jeopardy on [DATE]. Validation of the immediate jeopardy removal plan was conducted in the facility on [DATE]. The facility's initial audit was verified and signature sheet for education reviewed with no concerns. Facility nurses were interviewed and were aware of the pain management protocol, how and when to assess pain and how to appropriately respond to a resident's request or nonverbal signs of pain. Facility Medication Aides were also aware of the pain protocol and how to observe for nonverbal signs of pain and how to respond. Facility Nurse Aides were also interviewed and were able to verbalize how to respond to resident complaint of pain and recognize nonverbal signs of pain and who to report them to. The facility's immediate jeopardy removal date of [DATE] was validated.

Based on record review and interviews with the Medical Doctor and staff the facility failed to provide care in a safe manner resulting in a resident falling from the bed to the floor and sustaining a fracture to the left ulna (forearm) for 1 of 2 residents reviewed for falls (Resident #315). The findings included: Resident #315 was readmitted to the facility on [DATE] with diagnoses including [CONDITION(S)] and bilateral below the knee amputations. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #315's cognition as intact and his functional status for activities of daily living as needing extensive 2-person assistance with bed mobility and total 2- person assistance with toilet use. One fall was coded with no injury. Review of a fall investigation dated 07/05/22 described Resident #315 fell during care and was transferred to the medical center for evaluation. New interventions recommended by the Interdisciplinary Team was to provide 2-person assistance with activities of daily living care as accepted. Review of the Nurse Practitioner (NP) progress note written on 07/05/22 revealed during personal care provided by the Nurse Aide (NA) Resident #315 rolled out of bed onto the floor. The NP instructed Resident #315 be sent to the emergency room for evaluation. Review of nurse progress note written on 07/05/22 revealed Resident #315 returned to the facility with his left arm, wrist, and hand wrapped with ace bandages and a new order for [MEDICATION(S)] (a opiate pain medication) 5 milligrams every 4 hours as needed for pain. Review of the NP progress note written on 07/06/22 revealed Resident #315 was being seen for a follow-up for a fractured arm and pain. The NP noted [MEDICATION(S)] 5 milligrams every 4 hours as needed for pain and Resident #315 was to follow-up with orthopedics on 07/08/22. During an interview on 09/29/22 at 12:37 PM the Medical Doctor (MD) revealed he spoke with Resident #315 about his fall. The MD indicated the NA was unsafe during care that resulted in Resident #315 falling from the bed onto the floor and sustained a fractured arm. An interview was conducted on 09/29/22 at 3:17 PM with NA #2, the staff member who was providing care for Resident #315 on 07/05/22 when he fell from the bed to the floor. NA #2 revealed she rolled Resident #315 away from her during incontinence care and that's when he leaned towards the edge of the bed and fell to the floor before she could grab him. NA #2 revealed she was trained to roll a resident towards her during care but was in a hurry getting him ready for an appointment and wasn't thinking. An attempt to interview the previous Staff Development Coordinator/Assistant Director of Nursing who signed the fall investigation dated 07/05/22 was unsuccessful. An interview was conducted on 10/03/22 at 8:17 AM with the Director of Nursing (DON). The DON revealed she assumed the position of the Staff Development Coordinator and provided training for NA staff. She revealed NA staff were trained to roll a resident towards them when providing care for safety and prevent them from falling off the bed.