Every finding on record at The Greens at Viewmont

Based on observations and staff interviews, the facility failed to remove an expired medication stored in 1 of 4 medication carts reviewed for medication storage (300 hall medication cart). The findings included:Review of the manufacturer's package insert for Latanoprost ophthalmic solution indicated that an opened bottle of Latanoprost ophthalmic solution could be stored at room temperature up to 77 Fahrenheit for up to 6 weeks (42 days).On 07/22/26 at 2:00 PM an observation was made of the 300-hall medication cart accompanied by Nurse #1. The observation yielded one open bottle of Latanoprost ophthalmic 0.005% solution with an open date of 05/29/26. The bottle of eye drops should have been discarded 07/10/26.On 07/22/2026 at 2:00 PM an interview was conducted with Nurse #1 who explained that it was the responsibility of the nurse on the medication cart to clean and remove expired medications from the cart when the medications expired. The Nurse stated she checked the medication cart earlier that morning but did not see the expired eye drops on the medication cart. An interview was conducted with the Staff Development Coordinator (SDC) on 07/22/26 at 2:30 PM. The SDC explained that she was responsible for checking the medication carts every two weeks and the last time she checked the 300-hall medication cart (she could not remember the date) the Latanoprost eye drops would not have been expired. She continued to explain that she briefly checked the 300-hall medication cart first thing that morning on 07/22/26 for expired insulins and did not pay attention to the expiration dates on the Latanoprost eye drops.An interview was conducted with the Director of Nursing (DON) on 07/23/26 at 9:30 AM. The DON explained that the nurse on the medication cart should check their medication carts every day for cleanliness and remove the expired medications and the Assistant Director of Nursing and Staff Development Coordinator was responsible for checking the carts periodically as a second check. The DON indicated the nurses should have paid closer attention to the expiration dates on the eye drops.On 07/23/2026 at 9:55 AM during an interview with the Administrator, she stated that she was informed of the expired eye drops found on the 300-hall medication cart and explained that if the nurses were checking the expiration date on the eye drops as they used them then they would not have been left on the medication cart. She indicated she could understand if the eye drops had expired by a couple of days but not 11 days expired.

Based on observations, record reviews, and staff, Resident Representative, emergency responders, Nurse Practitioner (NP), Medical Director, hospital staff, Program of All-Inclusive Care for the Elderly (PACE) staff interviews, the facility failed to supervise a moderately cognitively impaired resident (Resident #1) who obtained a cigarette lighter and ignited herself and her bedding on fire. On 4/09/26 at 4:39 PM the fire alarm at the facility sounded. Staff responded to Resident #1's room and noted smoke coming from under the closed door. When Nurse #1 opened the door, he found Resident #1 in flames on the top portion of her body. Nurse #1 and Nurse #2 grabbed bedding from the foot of the bed and began patting out the flames. Other staff responded to the room and began wetting washcloths and towels to fully extinguish the existing embers that were on Resident #1 and her bedding. Emergency Medical Services (EMS) arrived on scene and transported Resident #1 to a helicopter pad where she was flown to a trauma center. Resident #1 remained in the Burn Intensive Care Unit (ICU) at the time of the survey with second degree (damage to the top two layers of skin resulting in intense pain, swelling, blisters, and a wet, red appearance) and third degree (destroyed all skin layers, often damaging underlying fat, muscle, or bone, affected skin appears leathery, dry, and white, charred, or brown with little to no pain due to destroyed nerves) burns over 16% of her total body surface area (considered a major burn which required immediate emergency care). On 4/10/2026 Resident #1 had a nasogastric tube (NG) (flexible, temporary tube passed through the nose, esophagus and into the stomach for feeding) inserted to receive nutrition due to low intake by mouth. On 4/11/26 Resident #1 underwent excision (surgical removal of dead or dying tissue with no blood supply) of burned skin and application of allograft (transplantation of cells and tissues or organs from a donor a recipient) to abdomen and bilateral lower extremities and the hospital records indicated Resident #1 would have another surgery scheduled for skin grafting in approximately one week. The NG tube was discontinued on 4/16/25. The facility was a non-smoking facility but allowed staff members to smoke at the back of the facility. There was also a high likelihood for serious injury or harm to Resident #1's roommate, Resident #2, who was in the same room and had an oxygen concentrator that was not in use at the time. The deficient practice affected 1 of 3 residents reviewed for accidents (Resident #1). The findings included: Review of the Facility's Skilled Nursing Center Resident admission Agreement dated 11/15/2021 revealed:Section V. Rights and Responsibilities of Resident: C. 5. Tobacco-Free Environment Policy. The Center is committed to providing a healthy and safe environment for our employees, residents and all others. This facility is smoke free campus. Resident #1 was admitted to the facility on [DATE] with diagnoses that included epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain), chronic kidney disease, hemiplegia (severe or complete paralysis on one side of the body) and hemiparesis (mild or moderate weakness on one side of the body) following cerebral infarction (or a ischemic stroke- occurs when blood flow to the brain is blocked, starving brain tissue of oxygen and causing cell death) affecting left non-dominant side, major depressive disorder, anxiety disorder, and amputation of left lower extremity above the knee. Resident #1's physicians' orders revealed an order dated 2/19/2025 for PACE (PACE is a Medicare/Medicaid program that coordinates comprehensive care and services to supplement or manage a resident's care) every 2nd and 4th Tuesday of the month. A telephone interview was conducted on 4/15/2026 at 9:58 AM with the Community Support Liaison for PACE; he stated he was familiar with Resident #1. The Community Support Liaison stated Resident #1 used to come weekly on Tuesdays, but Resident #1 called out frequently. The Community Support Liaison revealed Resident #1 had refused to come to PACE twice in March when the driver arrived to pick her up. The Community Support Liaison verified the last time Resident #1 was transferred to PACE was 3/24/2026. The Community Support Liaison stated PACE was a non-smoking facility. The Community Support Liaison spoke with staff at PACE who stated they had not heard Resident #1 voice a desire to smoke or obtain smoking materials.A telephone interview was conducted on 4/15/2026 at 10:00 AM with the Social Worker for PACE; she stated she was familiar with Resident #1. The Social Worker stated she had conducted mental status exams on Resident #1 and the results ranged from mild to moderate cognitive impairment in the past year. The Social Worker stated she would agree Resident #1 had moderate cognitive impairment but did have some days when her cognition was better than others. The Social Worker stated he had worked with Resident #1 since 2018 and Resident #1 was a heavy smoker when she lived at home, prior to admission to the facility. The Social Worker stated since Resident #1 was admitted to the facility she had not heard Resident #1 voice a desire to smoke. The Social Worker stated Resident #1 and her family were aware the facility was nonsmoking when she was admitted and wanted Resident #1 to quit smoking due to her health conditions. A telephone interview was conducted on 4/15/2026 at 3:18 PM with the PACE NP who was familiar with Resident #1. The PACE NP stated she suspected Resident #1 had some underlying vascular dementia based on her cardiac history but did not know if that was an official diagnosis in her record. The PACE NP agreed Resident #1 had moderate cognitive impairment and verified that it was documented in a progress note from June 2025. The PACE NP denied Resident #1 ever voiced a desire to smoke or wanting a cigarette. Review of a PACE Nurse Practitioner (NP) progress note dated 6/10/2025 revealed Resident #1 was alert, in no acute distress, had usual mental status, with a plan for Resident #1 for cognitive impairment (moderate): no hallucinations or rapid decline in cognition, continue monitoring progression of memory loss and provide supportive care as needed. Resident #1's annual Minimum Data Set (MDS) dated [DATE] indicated Resident #1 did not use tobacco. Record review revealed a smoking safety evaluation dated 2/27/2026 that indicated Resident #1 did not smoke. Resident #1's quarterly MDS dated [DATE] revealed Resident #1 was moderately cognitively impaired and indicated Resident #1 had not experienced pain during the 7-day look back period, had impaired range of motion to upper and lower extremities on one side, used a wheelchair for ambulation, required set up assistance for eating, required substantial to maximum assistance with oral hygiene, bathing and upper body dressing, was dependent on staff for toileting hygiene, lower body dressing, putting on and taking off footwear and personal hygiene. Resident #1 required substantial to maximum assistance to roll left and right in bed and was dependent on staff for all other bed mobility. Review of the care plan dated 3/2/2026 revealed Resident #1 was care planned for Activity of Daily Living (ADL) self-care performance deficit related to limited mobility, related to left above the knee amputation, and left hemiparesis with interventions that included Resident #1 required assist by 1 to 2 staff to turn and reposition in bed as necessary, assist by 1 to 2 staff for toileting. Resident #1 was care planned for problems with short term memory loss with interventions that included ask yes/no questions in order to determine the resident's needs, use the resident's preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Provide the resident with necessary cues- stop and return if agitated. An interview was conducted on 4/14/2026 at 4:36 PM with Nursing Aide (NA) #1 who stated she was familiar with Resident #1 and had worked 7:00AM to around 4:00 PM on 4/9/2026 and was assigned to Resident #1 but was not in the facility at the time of the fire. NA #1 stated she took care of Resident #1 and provided peri care and changed her with NA #2. NA #1 stated two people provided peri care to Resident #1 and she would roll toward the staff and hold on to them while the other staff provided care. NA #1 stated she had a lighter that looked like the one found with Resident #1 and it was now missing. NA #1 stated she did not normally carry her lighter into the facility, that she went out to car to smoke and ignited her cigarette. NA #1 stated the shirt she wore on 4/9/2026 did have a hole in the pocket, and if she had accidentally taken her lighter into the facility it would have been in her pocket. NA #1 stated she had tried to push another lighter through the hole in her shirt pocket at home and it had to be forced through the hole to fit. A follow up interview was conducted on 4/15/2026 at 11:20 AM and NA #1 verified she last saw Resident #1 on 4/9/2026 around 3:30 PM when she and NA #2 provided peri care, and at that time everything appeared normal and no lighter was seen in Resident #1's possession. NA #1 denied Resident #1 ever voiced a desire to smoke or wanting a cigarette. An interview was conducted on 4/15/2026 at 11:20 AM with NA #2 who stated she was familiar with Resident #1 and worked with Resident #1 from 7:00 AM to 11:00 PM on 4/9/2026. NA #2 stated she provided peri care to Resident #1 with NA #1 on 4/9/2026 around 3:30 PM and verified Resident #1 required assistance to roll from side to side in bed for staff to provide care and at times Resident #1 would hold onto staff while care was provided. NA #2 stated she went to care for Resident #1's roommate around 4:05 PM on 4/9/2026 and on her way out of the room she straightened Residents #1's sheets, asked Resident #1 if she needed anything then exited the room and closed the door as requested by the roommate. NA #2 stated she did not see a lighter in Resident #1's possession. NA #2 went on break around 4:20 PM and was not present in the building when the fire alarm sounded. NA #2 denied Resident #1 ever voiced a desire to smoke or wanting a cigarette. Review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 was cognitively intact. An interview was conducted on 4/14/2026 at 9:36 AM with Resident #2. Resident #2 verified she was Resident #1's roommate and was in the room at the time of the fire on 4/9/2026. Resident #2 stated on 4/9/2026 the privacy curtain was pulled between her and Resident #1's bed so Resident #2 could not see Resident #1. Resident #2 stated in the afternoon she thought she heard something fall on Resident #1's side of the room. Resident #2 indicated she called out to Resident #1 and asked if she was ok and if she had fallen. Resident #1 did not respond so Resident #2 asked Resident #1 if she needed help, and there was still no response so Resident #2 thought everything must be ok. Resident #2 stated a few minutes later she smelled smoke, called out to Resident #1 and asked if she smelled smoke and was something burning. Resident #2 stated there was no response, so she pushed her call bell and started to call out for staff and about that time she heard the fire alarm, and staff came very quickly and began working with Resident #1. Resident #2 stated she never saw any smoke, she only smelled it. Resident #2 denied she had any injury or harm from the incident. Resident #2 further stated Resident #1 sometimes talked about smoking. An oxygen concentrator was observed on the right side of Resident #2's bed. The oxygen concentrator was not running, and Resident #2 was not wearing the nasal canula during the interview. Resident #2 verified she did not wear her oxygen at all times. Review of Resident #1's medical record revealed an eMAR (electronic Medication Administration) entry dated 4/9/2026 which was visible when display eMAR was selected and written by Nurse #2 that indicated: the fire alarm sounded and identified the location source of the alarm was Resident 1's room. Nurse #1 and Nurse #2 found Resident #1 with bed linens smoldering and padded them out with other bed linens. Wet washcloths were applied to torso. breasts, groin and left-hand burn injuries. Fire Department (FD) and EMS were notified, and a lighter was found on bed. When Resident #1 was asked how did you get that by other staff, Resident #1 responded I stole it. Blood Pressure 180/120 (normal range 90/60 to 140/90), heart rate 87, (normal range 60-100), oxygen saturation 95% (normal range 95%-100%), Resident #1 had active wheezing and albuterol inhaler was given per MAR orders. Nurse #2 stayed with EMS until Resident #1 was transported via stretcher out of facility. An interview was conducted on 4/14/2026 at 2:53 PM with Nurse #2 who stated she was familiar with Resident #1 and was assigned to Resident #1's hall on 4/9/2026. Nurse #2 stated she was on 400-hall for medication pass. Nurse #2 stated when the fire alarm sounded, she started closing doors on 400 hall and saw Nurse #1 coming down 400-hall talking on the phone and indicated the alarm was from Resident #1's room. Nurse #2 stated she followed Nurse #1 into Resident #1's room and saw smoke and little flames coming from Resident #1's bed linens. Nurse #2 stated they used the blanket from the foot of the bed to put out the flames, but orange embers remained on the linens so wet towels were placed on Resident #1. Nurse #2 stated Resident #1 never yelled or called out but appeared to be in shock or scared by the way Resident #1 just looked on while staff provided care. Nurse #2 assessed Resident #1 as Unit Manager #1 and Medication Aide (MA) #1 continued to apply wet towels. Nurse #2 obtained vitals on Resident #1 while Unit Manager #1 and MA #1 began to change and remove the burned linens and clothing from Resident #1's bed. Nurse #2 heard staff ask Resident #1 where did you get that lighter and saw a pinkish purple item from the corner of her eye, and Resident #1 responded she stole the lighter. Nurse #2 assessed Resident #1 and noted discoloration to the right breast, redness near her groin area and red area on left hand with black wounds. Nurse #2 stated Resident #2 started wheezing so she administered Resident #1's inhaler per orders then FD and EMS arrived and took over care for Resident #1. Nurse #2 stated she had worked with Resident #1 for about 2 years and had never heard her complain of pain. Nurse #2 stated normally Resident #1 was alert to person and place, but Nurse #2 believed Resident #1 did have some dementia. Nurse #2 denied Resident #1 ever voiced a desire to smoke or wanting a cigarette. Nurse #2 stated Resident #2 had an oxygen concentrator but did not use it all the time. Nurse #2 stated on 4/9/2026 Resident #2 was not wearing her oxygen, and the concentrator was turned off. Review of the electronic Medication Administration Record (eMAR) for April 2026 revealed Resident #1 received ProAir HFA Inhalation Aerosol Solution 108 (90 Base) mcg/Albuterol Sulfate 2 puffs on 4/9/2026 at 4:50 PM administered by Nurse #2. Resident #1's physicians' orders revealed an order dated 1/17/2025 for ProAir Inhalation Aerosol Solution /Albuterol Sulfate (an inhaled medication that relaxes the airway muscles, improving airflow in the lungs) 2 puffs inhale orally every 6 hours as needed for wheezing.An interview was conducted on 4/14/2026 at 12:48 AM with Nurse #1, he stated he was familiar with Resident #1 and was working at the facility on 4/9/2026. Nurse #1 indicated on 4/9/2026 he was in the medication room when the fire alarm sounded at 4:39 PM. Nurse #1 looked at the fire panel and saw the location of the alarm was Resident #1's room. Nurse #1 called the Maintenance Director at 4:40 PM to notify him the fire alarm had gone off, as he made his way to Resident #1's room Nurse #1 noted the call light was on and there was light colored smoke starting to come out from under the door into the hallway. Nurse #1 opened the door to Resident #1's room and saw flames and smoke on Resident #1's abdomen and upper torso area. Nurse #1 stated Nurse #2 entered Resident #1's room right after him. Nurse #1 stated Resident #1 looked at Nurse #1 with a surprised look when he entered the room and was not voicing any pain. Nurse #1 stated he grabbed the blanket at the foot of Resident #1's bed and began to pat out the flames on Resident #1. Nurse #1 stated when the fire was extinguished, he saw burns to Resident #1's breast and abdomen and instructed the other staff in the room to put cold compresses on Resident #1. Nurse #1 stated he told the Maintenance Director there was a fire in Resident #1's room then called 911 at 4:41 PM, and at the same time the alarm company called the facility due to the fire alarm notification they received. 911 and the alarm company were informed of the fire and that they needed to come to the facility right away. Nurse #1 left Nurse #2, the Unit Manager #1 and MA #1 with Resident #1 and went to prepare paperwork for Resident #1's transfer and made sure EMS had a clear path to Resident #1's room. Nurse #1 stated when Resident #1 was first admitted to the facility, she talked about smoking, but that had been a few years ago.An interview was conducted on 4/14/2026 at 12:26 PM with Unit Manager #1 and she stated she was familiar with Resident #1 and worked at the facility on 4/9/2026. Unit Manager #1 stated she was on 300-hall when she heard the fire alarm she went to grab the fire extinguisher, someone at the panel said it was in Resident #1's room, and she went to Resident #1's room and entered behind MA #1 and saw a few embers and smoke around Resident #1. Unit Manager #1 stated she and MA #1 got cool cloths and placed them on Resident #1, then changed Resident #1's brief and sheets to make sure there was no further embers or burns. Unit Manager #1 stated Resident #1 did not appear to have any difficulty breathing while the sheets were changed and answered MA #1 and stated she stole the lighter but did not say who she stole it from. Unit Manager #1 asked Resident #1 how she was doing while Nurse #2 took vitals and Resident #1 responded she did know what we were talking about. Unit Manager #1 stated Resident #1 started to wheeze after this, and Nurse #2 administered an inhaler. Unit Manager #1 stated when FD and EMS arrived and took over care, she called and notified Resident #1's family. Unit Manager #1 denied Resident #1 ever voiced a desire to smoke or wanting a cigarette. An interview was conducted on 4/14/2026 at 11:33 AM with Medication Aide (MA) #1, and MA #1 stated she was familiar with Resident #1 and was working on 4/9/2026 when the fire occurred. MA #1 stated she was about to start the medication pass on another hall when the fire alarm sounded around 4:40 PM. MA #1 stated she closed her medication cart, grabbed the fire extinguisher, looked at the fire panel which indicated Resident #1's room as the location that triggered the alarm, and she headed to Resident #1's room. MA #1 arrived at Resident #1's room and Nurse #1 and Nurse #2 were already in the room with Resident #1. MA #1 observed orange embers on Resident #1's shirt and sheets. MA #1 stated the remaining part of Resident #1's shirt was removed from Resident #1's breast, abdomen and left hand and burns were also noted on Resident #1's inner thighs. The blankets were removed from Resident #1's bed and placed on the floor. MA #1 stated Unit Manager #1 arrived and began to wet down towels and place them on Resident #1's skin from neck to mid-thigh. MA #1 stated Resident #1's skin appeared melted and appeared to be turned/rolled out to the side and the skin appeared burned and black, the other skin was very pink. MA #1 stated Resident #1 was alert, answered questions and did not appear to have difficulty breathing. MA #1 stated she and Unit Manager #1 began to clean Resident #1 in order to remove all the sheets on the bed and make sure there were no remaining embers. MA #1 stated as Resident #1 was rolled toward her, toward the right side of the bed, Resident #1 was attempting to reach for the nightstand located at the head of the bed on the right side. MA #1 looked toward the direction Resident #1 was reaching and saw the lighter on the nightstand and asked Resident #1 how she got the lighter, and Resident #1 responded she stole it. MA #1 asked Resident #1 who she stole it from, and Resident #1 stated she didn't know who she stole it from. MA #1 removed the lighter from the nightstand, and it was given to Nurse #1 for security and safety. MA #1 stated Resident #1 did not voice any pain and appeared calm. MA #1 stated emergency responders arrived very fast, within 5 minutes, and fire fighters arrived first. MA #1 stated EMS removed the wet towels from Resident #1 to get dimensions of the burns. MA #1 stated she did not know who the lighter that was found belonged to. MA #1 stated Resident #1 was not able to use the left side of her body due to the stroke, but she could feed herself with her right hand. MA #1 stated she had seen Resident #1 open a bottle of soda, and thought Resident #1 could strike a lighter. MA #1 denied Resident #1 ever voiced a desire to smoke or wanting a cigarette. A telephone interview was conducted on 4/14/2026 at 1:58 PM with NA #3 and she stated she was familiar with Resident #1 and worked 3:00 PM to 11:00 PM on 4/9/2026 on Resident #1's hall but was not assigned to Resident #1. NA #3 stated she was letting a family out of the facility when the fire alarm went off, and then saw nurses rush to Resident #1's room. NA #3 followed them to the room and heard someone say Resident #1 had caught fire. NA #3 asked what to do and helped wet towels that other staff placed on Resident #1. NA #3 did not see the burns but stated Resident #1 just looked around, she did not scream and did not appear to be in pain. NA #3 stated the lighter was removed from the nightstand. NA #3 denied Resident #1 ever voiced a desire to smoke or wanting a cigarette. Review of a Situation Background Assessment Recommendation (SBAR) communication form dated 4/9/2026 and written by Unit Manager #1 revealed Resident #1 was burned from upper chest to bilateral inner thighs red/orange embers were still on sheet, which was smoldered and removed, then cool cloths placed over upper torso to bilateral thighs. Resident #1 was alert and talking, 911 was called, Resident #1 had the following documented vital signs: a blood pressure of 180/120, pulse of 46, respirations of 22, and indicated Resident #1 did not have pain. A telephone interview was conducted on 4/14/2026 at 3:08 PM with Fire Investigator #1. Fire Investigator #1 stated he was not the lead investigator but did take pictures at the scene on 4/9/2026. Fire Investigator #1 stated when he arrived Resident #1 was already in the ambulance. Fire Investigator #1 stated he observed the melted bed controller, the melted spot on the mattress when he arrived at Resident #1's room, and staff brought the burnt linens back into the room that had been bagged up and removed and they were examined. He verified a white shirt had been seen that was burnt on the front, and pinkish purple lighter with the word playboy was provided by the facility. A telephone interview was conducted on 4/14/2026 at 3:28 PM with the Lead Investigator from the fire department. The Lead Investigator stated Resident #1 had already left the facility by ambulance when he arrived on 4/9/2026 and was enroute to the helicopter to be flown out. The Lead Investigator stated the burned bedding had been bagged by facility staff, and there was no damage to the room other than the mattress and bed controller. The Lead Investigator stated he interviewed Nurse #1 who reported there were flames on Resident #1's abdominal area and he had staff apply wet towels to help fully extinguish the fire. The Lead Investigator stated he estimated it would have taken 5 to 10 minutes for the damage he noted to the bed controller to occur, and for the smoke to set off the fire alarm, but with the room door being closed that would have helped the smoke to be detected sooner than if the door had been open. The Lead Investigator stated when the lighter was described, an unknown staff member thought it belonged to a staff member from 1st shift, and it was reported the 1st shift staff member realized there was a hole in her scrub pocket. The Lead investigator stated due to the distance between Resident #1's bed and her roommate's oxygen concentrator, it would not have been an issue related to this situation. A telephone interview was conducted on 4/15/2026 at 12:43 PM with the Engine Captain who was the first to arrive at the facility. The Engine Captain stated there was no evidence of a fire from outside and the staff outside told him they had a resident that had been burned. The Engine Captain stated when he entered the facility all the fire doors were closed and resident room doors were closed. There was light colored smoke in the hallway, and several staff were in Resident #1's room when he entered, and the staff were layering wet towels on Resident #1. The Engine Captain stated staff reported Resident #1 was a dementia patient who had got a lighter and started the fire. The Engine Captain then focused on patient care for Resident #1, stated EMS arrived shortly after and they decided Resident #1 needed to be flown out. Review of a transfer form dated 4/9/2026 revealed Resident #1 had an unplanned transfer to a hospital medical center for burns, 911 was notified and provided report to the hospital and residents representative was notified. Review of Resident #1's EMS report dated 4/9/2026 revealed when EMS arrived on scene at 4:47 PM the Fire Department was on scene, smoke was observed in the facility, EMS was directed to Resident #1's room and found Resident #1 in bed with facility staff at bedside. Facility staff reported they heard the fire alarm going off in her room, and when staff entered Resident #1's room Resident #1 was on fire. Facility staff stated Resident #1 had a lighter. EMS noted Resident #1 was naked with wet towels on the burns, and facility staff were placing wet washcloths on Resident #1's burns. Resident #1 was alert but confused and facility staff stated Resident #1 had a history of dementia and was at her normal baseline. EMS noted Resident #1 had second- and third-degree burns noted to the left hand, left phalanges (fingers), left breast left side of the abdomen, genital area and perinium and noted the burns were brown in color with charring present. EMS noted Resident #1 was breathing on her own and no soot was noted in Resident #1's nostrils or mouth. Resident #1 was able to make complete sentences between each breath. Resident #1's lung sounds were noted to be clear and equal. Resident #1 was placed on oxygen due to room air saturation of 87%. A burn sheet was placed and two large bore intravenous (IV) (used for rapid high-volume fluids to enable faster flow rates than standard lines) were established and fluids and pain medication were administered. Resident #1's vitals and lung sounds were monitored, and Resident #1 was transferred to the care of the EMS air provider. Resident #1's Shock Index (a rapid clinical tool used in emergency care to assess the severity of circulatory shock) ranged from 0.7 to 0.5 (normal range 0.5 to 0.7) while being monitored by EMS. Review of Resident #1's hospital records from 4/9/2026 to 4/17/2026 revealed Resident #1 arrived at the Emergency Department (ED) on 4/9/2026 and indicated critical care was required for condition of burn activation (indicated a medical emergency often requiring immediate specialized critical care due to the extensive destruction of all skin layers, nerves, and sometimes underlying tissue. Critical care activation is generally for burns less than 20% of the TBSA in adults), full thickness (destroy both skin layers) burns to abdomen. Intervention was immediately required due to the risk of substantial deterioration, including death and infection. ED physician note revealed Resident #1 had suffered 16% total body surface area burns throughout the abdomen, suprapubic region, inguinal region, right foot and left hand, full thickness burns throughout the abdomen, partial thickness along the right arm, and indicated Resident #1 denied pain. Resident #1's airway was intact, no soot in mouth, no singed nasal hairs seen. Initial plan to admit Resident #1 to burn unit, and Resident #1 did not require significant pain medication in the ED. Progress noted indicated Resident #1 would require significant debridement which would be completed in the burn ICU. Resident #1 was admitted to the burn ICU from the ED with the following diagnoses: 3rd degree burn of abdominal wall with loss, full thickness burn of left breast, burn of right thigh second degree, partial thickness (damage the top layer of skin and part of the second layer) burn of multiple digits of left hand including partial thickness burn of thumb, burn erythema (a persistent, net-like red or brown rash caused by chronic, low-level heat exposure) of right foot. Further review of hospital records revealed Resident #1 had low intake by mouth and had a nasogastric tube (NG) (flexible, temporary tube passed through the nose, esophagus and into the stomach for feeding) placed on 4/10/2026 to receive nutrition. Review of surgical notes from 4/11/2026 revealed Resident #1 underwent excision (surgical removal of dead or dying tissue with no blood supply) of burned skin and application of allograft (transplantation of cells and tissues or organs from a donor a recipient) to abdomen and bilateral lower extremities. Plan to return to the operating room in approximately 1 week to remove the allograft and place autograft (a surgical procedure where tissue such as skin, is transplanted from one part of a patient's body to another, using their own living cells). Review of hospital progress notes revealed the NG tube was discontinued on 4/16/2026 and Resident #1 was placed on a dysphagia diet (modified food and fluid textures to make swallowing safer and easier while ensuring adequate nutrition) and tolerated it well. Attempted to contact Resident #1 by phone on 4/14/2026 at 4:13 PM, 4/15/2026 at 9:05 AM, and 1:40 PM, and 4:28 PM in Resident #1's hospital room, but Resident #1 did not answer the phone. A telephone interview was conducted on 4/15/2026 at 10:19 AM with the Hospital Charge Nurse for the unit Resident #1 was currently assigned. Hospital Charge Nurse stated Resident #1 was currently in the burn unit ICU and was stable. The Hospital Charge Nurse reported Resident #1 had surgery on 4/11/2026 for excision of burned areas and had scattered 2nd and 3rd degree burns on 16% of her body. He stated the burns currently had a burn dressing and Resident #1 would have another surgery for definitive grafting. The Hospital Charge Nurse stated he was told Resident #1 had dementia and had been alert to self and time. The Hospital Charge Nurse indicated Resident #1 had not reported pain. A telephone interview was conducted on 4/15/2026 at 3:20 PM with the Hospital Social Worker who was familiar with Resident #1. The Hospital Social Worker stated she had spoken to Resident #1 that morning and Resident #1 was disoriented to place, had a Total Body Surface Area (TBSA) burn of 16%, 9% second degree burns and 7% third degree burns, which were on the Resident's chest, abdomen bilateral back of thighs, left radius and hand. The Hospital Social Worker stated when she asked Resident #1 what happened Resident #1 stated a staff member went to hug her and a lighter fell out of the staff's scrubs and Resident #1 grabbed it and the staff did not know. Resident #1 stated she became curious and played with the lighter then the fire started. The Hospital Social worker verified Resident #1 had surgery on 4/11/2026 for excision of burned areas and a skin substitute was applied that was temporary to try to get the skin to heal, but Resident #1 would have another surgery upcoming for more permanent grafting. A telephone interview was conducted on 4/15/2026 with Resident #1's Resident Representative (RR). The RR stated he had visited Resident #1 at the hospital on 4/14/2026 and Resident #1 stated someone dropped the lighter in her room and Resident #1 picked it up without anyone seeing it, then she

Based on observations, record review, and staff interviews, the facility failed to accurately code a Minimum Data Set assessment when they failed to include a resident's diagnosis of neurogenic bladder for 1 of 1 resident reviewed for catheters. (Resident #74) The findings included: Resident #74 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of prostate, aftercare following joint replacement surgery, and neuromuscular dysfunction of bladder. Review of Resident #74's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #74 was coded as having a catheter. Additionally, under section I, Resident #74 was not coded as having neurogenic bladder. Review of Resident #74's physician orders revealed the following order in part dated 01/07/25: Insert urethral indwelling urinary catheter due to neurogenic bladder. An interview with MDS Nurse #1 on 05/01/25 at 10:53 AM revealed information for diagnoses included in a Minimum Data Set assessment is typically retrieved from multiple sources that included nurse practitioner notes and hospital discharge summaries. She indicated she does not typically review physician orders in the system as the program should pull those diagnoses over into the Minimum Data Set assessment automatically. She reported she did not know what happened with Resident #74's quarterly Minimum Data Set assessment and reported he did have a diagnosis of neurogenic bladder and that it should have been accurately reflected in the quarterly Minimum Data Set assessment dated [DATE]. An interview with the Director of Nursing on 05/01/25 at 11:09 AM revealed she believed diagnosis information for Minimum Data Set assessments is pulled from multiple areas including diagnosis lists, physician orders, discharge summaries, and physician notes. She stated that with Resident #74's catheter order indicating that it was used for neurogenic bladder, that the diagnosis should have been recorded in Resident #74's quarterly Minimum Data Set assessment dated [DATE]. The Director of Nursing also indicated she expected Minimum Data Set assessments to be accurate and reflect the individual resident and their care needs. An interview with the Administrator on 05/01/25 at 11:18 AM revealed she expected Minimum Data Set assessments to be accurate and reflect the individual resident and their care needs.

Based on observations, record reviews and interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when the Wound Nurse performed a pressure ulcer treatment on Resident #51 and did not wash or sanitize her hands before donning new gloves. This practice occurred for 1 of 2 staff members (Wound Nurse) observed for infection control. The findings included: Review of the facility's policy entitled Handwashing/Hand Hygiene last revised in October 2015 read in part: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: m. After removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. On 04/29/25 at 10:45 AM an observation was made of the Wound Nurse performing wound care to Resident #51's stage IV sacral pressure ulcer. The Wound Nurse washed her hands and donned a gown, and gloves then set up a work surface in preparation for the wound care. The Wound Nurse removed the old dressing which had a moderate amount of drainage then removed her gloves and washed her hands before she applied new gloves. The Wound Nurse then cleansed the stage IV pressure ulcer and removed her gloves and without washing or sanitizing her hands she applied new gloves to continue the treatment by applying the medicated pad and border dressing to secure the wound. During an interview with the Wound Nurse on 04/29/25 at 10:55 AM the Wound Nurse was asked to review the steps of the wound care procedure. The Wound Nurse repeated the steps of the procedure and when she stated she removed her gloves after she cleansed the wound she stopped and stated, I did not wash my hands before I put on new gloves. The Wound Nurse added she usually did wash her hands after she removed her gloves, but she was nervous being watched. At 10:57 AM on 10/29/25 an interview was conducted with the Director of Nursing (DON). The DON explained it was the facility's policy to utilize hand washing or sanitizing when gloves were removed. She stated the Wound Nurse should have sanitized her hands before donning new gloves.

Based on observations, record reviews, manufacturer's instructions, and staff and Pharmacy Consultant interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 26 opportunities, resulting in a medication error rate of 11.54% for 1 of 4 residents observed during the medication administration (Resident #17 and Resident #46). The findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses that included renal insufficiency, dyspnea, shortness of breath and vascular dementia. Resident #17's medical record revealed orders for *fluticasone-salmeterol (a corticosteroid) 100-50 MCG/ACT (microgram per actuation) one inhalation orally twice a day for shortness of breath. Rinse mouth after use dated 12/08/23 and *artificial tears 1% instill two drops in both eyes twice a day for dry eyes dated 04/03/24. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #17 was cognitively intact. On 04/29/25 at 8:59 AM an observation of a medication pass was made of Nurse #1 who was medicating Resident #17. Nurse #1 handed the Resident the inhaler and allowed the Resident to administer one puff and inhale the medication. Resident #17 did not rinse her mouth out nor did Nurse #1 instruct Resident #17 to rinse her mouth. Nurse #1 then attempted to instill the Resident's eye drops when Resident #17 stated she could do it herself and the Nurse handed the eye drops to the Resident. Resident #17 closed her eyes then drug the tip of the eye drop bottle over her left eye lashes then over her right eye lashes and again over her left eye lashes then stated, that eye is worse. An interview was conducted with Nurse #1 at 9:16 AM on 04/29/25. The Nurse was asked what she thought about the medication pass to Resident #17 and the Nurse explained that the Resident did not instill the eye drops correctly because Resident #17 rubbed the tip of the bottle on her eye lashes and if she had an infection going on, bacteria could potentially be on the eye drop bottle now. The Nurse stated she would get a new bottle of eye drops for Resident #17. Nurse #1 stated that the Resident put more than two drops in each eye. When the Nurse was asked what she thought about the inhaler, Nurse #1 stated the Resident did not rinse her mouth out after she administered the inhaler to herself, nor did she instruct Resident #17 to rinse her mouth out. When asked why she did not instruct the Resident to rinse her mouth out the Nurse stated she was nervous. On 04/30/25 at 11:40 AM an interview was conducted with the Director of Nursing (DON). The DON explained that Resident #17 had not been assessed to be able to self-administer her medications and Nurse #1 should not have allowed the Resident to do so. The DON stated she felt Nurse #1 would have administered the medications correctly if she had done it herself. An interview was conducted with the Pharmacy Consultant on 04/30/25 at 2:10 PM who explained that the manufacturer's recommendation was for the residents to rinse their mouths after administering steroid inhalers because of the risk of thrush and some residents were at higher risk for thrush. The Pharmacy Consultant stated if the physician's order stated to rinse mouth after use, then it should be done. 2. The manufacturer's instructions for prefilled Lispro insulin pen indicated that priming the insulin pen each time was an important step to ensure there were no air bubbles in the insulin and the full dose of insulin was given. Priming the insulin pen: 1. Dial up 2 units: turn the dose selector dial to 2 units, 2. Prime the pen: Press the injection button to let out any air bubbles and ensure the insulin is flowing correctly, 3. Check for a drop of insulin: you should see a drop of insulin on the tip of the needle, 4. Repeat if necessary. Resident #46 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #46 was cognitively intact. Resident #46's medical record revealed a physician order dated 04/02/25 for Lispro insulin via pen injector, inject 8 units subcutaneously before meals on Monday, Wednesday and Friday. On 04/30/25 at 11:31 AM an observation was made of Nurse #2 preparing to administer insulin to Resident #46 via an insulin pen. The Nurse removed the Lispro insulin pen from the medication cart and set the counter to 8 units. Nurse #2 administered the 8 units of insulin without priming the insulin pen as advised by the manufacturer's instructions. An interview was conducted with Nurse #2 at 11:37 AM on 04/30/25. The Nurse was asked to explain the procedure when giving insulin using an insulin pen and Nurse #2 stated she gave the insulin by the five rights of giving any medication. When the Nurse was asked if she was aware of priming the insulin pen before giving the insulin the Nurse stated she thought that was only for when the insulin pen was used for the first time. An interview was conducted with the Director of Nursing (DON) on 04/30/25 at 11:41 AM. The DON explained that it was the facility's policy to prime insulin pens before you inject the insulin prescribed to the resident and Nurse #2 should have primmed the insulin pen. During an interview with the Pharmacy Consultant on 04/30/25 at 2:14 PM the Pharmacy Consultant explained priming the insulin pen is recommended because there could be air bubbles in the chamber of the pen but there were very small incidences of that, but it had to be recommended. She indicated to prime the insulin pen was usually recommended with new pens.

Based on observations, record reviews, staff and resident interviews, the facility failed to ensure Resident #35 swallowed medication during medication administration for 1 of 2 residents reviewed for professional standards. The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, diabetes mellitus, peripheral vascular disease and Alzheimer's disease. Resident #35's quarterly Minimum Data Set assessment dated [DATE] revealed the Resident was cognitively intact. Resident #35's medical record revealed physician orders for *clopidogrel bisulfate 75 milligrams (mg) by mouth in the morning for peripheral vascular disease dated 02/05/25, acetaminophen 325 mg 2 tablets by mouth twice a day for pain dated 02/26/25, famotidine 20 mg by mouth twice a day for reflux dated 11/13/24, gabapentin 300 mg by mouth twice a day for neuropathy dated 02/17/25 and dapagliflozin propanediol 10 mg by mouth once a day for diabetes mellitus dated 11/14/24. On 04/29/25 at 8:37 AM an observation and interview were made of Resident #35 while she was lying in her bed eating breakfast. On the Resident's over bed table was a medicine cup that contained 6 pills. Resident #35 explained that it was her morning medication that some nurses leave with her and some do not. Resident #35 stated Nurse #1 gave her the medications that morning and placed them on the table. The Resident indicated she would take the medications when she was ready. On 04/29/25 at 8:47 AM an interview was conducted with Nurse #1 who explained that Resident #35 was with it so she thought it would be okay to leave her medications with her to take. The Nurse stated 04/29/25 was the first time she left Resident #35's medications at her bedside for her to take on her own. On 04/30/25 at 11:40 AM an interview was conducted with the Director of Nursing (DON). The DON explained that Resident #35 had not been assessed to be able to self-administer her medications and Nurse #1 should not have left the medications at her bedside. The DON indicated the nurses were educated to ensure the residents swallowed their medications and not leave them at their bedside.

Based on record review and staff interviews the facility failed to implement their abuse policy by failing to separate employment of Nurse Aide (NA) #1 on 08/15/23 when the facility became aware that she had substantiated findings of misappropriation of resident property and fraud against a resident that occurred while the individual was employed in a nursing facility. NA #1 continued her employment with the facility until 12/21/23 when she was terminated following an allegation of misappropriation of resident property. This deficient practice affected 1 of 3 residents (Resident #27) reviewed for abuse, neglect, and misappropriation of resident property and had the high likelihood to affect other residents in the facility. The census at the time of the survey was 86 residents. The findings include: Review of a facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 03/28/23 read in part, Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law, had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property, or a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. Review of NA #1's employee file revealed she was hired by the facility on 03/09/23. The employee file had an Orientation Checklist that indicated a registry verification had been completed as well as her background check. The orientation checklist had been completed by the former Human Resource Director. The employee file contained no verification identification number (number you get when you verify a nurse aide registry listing). The file contained a background check that was completed on 03/10/23 and revealed no reportable court records found. Further review of NA #1's employee file revealed a North Carolina Nurse Aide I Registry verification completed on 08/15/23 with a confirmation number provided that indicated that NA #1 has 1 substantiated finding of Misappropriation of Resident Property which occurred while the individual was employed in a Nursing Facility. This information was entered on the Registry on 04/17/23. The verification further indicated that NA #1 has 1 substantiated finding of fraud against a resident which occurred while the individual was employed in a Nursing facility. This information was entered into the registry on 04/17/23. The former Human Resource Director was interviewed via phone on 03/05/24 at 4:26 PM. The former Human Resource Director stated that when she hired new Nurse Aides, she would always run their name and social security number through the Nurse Aide Registry system and then would enter their listing number and expiration date into the facility's onboarding system. She stated she did not retain the original verification, only entered the needed information into their onboarding system. She explained that she was preparing to leave the facility to pursue other opportunities and part of preparing to leave the facility included uploading all the Nurse Aide information into the facility's electronic onboarding system and during that time she re-verified that all the Nurse Aide's registry information was valid. She stated that was when she discovered that NA #1 had findings of misappropriation and fraud on her registry listing, and she had not disclosed that information upon hire. The former Human Resource director stated that she had verified her registry listing information upon hire and there was nothing there and her background check was clean as well. She stated that after she made the discovery in August 2023, she took the information to the former Administrator who was also preparing to leave, and the information was sent to the Corporate Human Resource Director and also notified the District Director of Operations. She stated that NA #1 was terminated in December 2023 after an allegation of misappropriation of resident property but could not say what the outcome of reporting to the Corporate Human Resource Director and District Director of Operations was in August 2023. An initial allegation report dated 12/14/23 read in part, Nurse Aide (NA) #1 had been accused of misappropriation of Resident #27's property. He stated that she came into his room late one evening and the next morning his wallet was missing from his locked drawer. NA #1 was suspended pending the investigation and Resident #27's belongings secured in a locked drawer and safe. Local law enforcement were notified. The report was signed by the former Administrator. The five working day report dated 12/21/23 indicated that Resident #27 identified NA #1 from the previous night as the accused individual. Local law enforcement through the magistrate office issued an arrest warrant and NA #1 was arrested for exploitation of elderly/handicap individual. NA #1 was accused of stealing $320.00 and a $30.00 wallet. The allegation was substantiated, and NA #1 was terminated on 12/21/23. The former Administrator was interviewed via phone on 03/05/24 at 2:29 PM and again on 03/05/24 at 5:01 PM, he stated that on 12/14/23 he was notified that Resident #27 wanted to speak to him. He stated he spoke to Resident #27 who reported he thought that NA #1 had stolen his wallet during the night of 12/13/23. Resident #27 explained that NA #1 asked him to borrow a dollar and he had given her the key to his drawer to unlock it and hand him his wallet so he could give her a dollar and then he asked NA #1 to lock the wallet back up in the drawer, but he did not see her put the wallet in the drawer before she locked it. At the time Resident #27 reported the incident to the former administrator he was able to describe NA #1, but she was working in the building that day and when NA #1 walked by Resident #27 he stated that is the girl that took my wallet. The Administrator stated that they immediately suspended NA #1 and began an investigation. The former Administrator stated at the end of the investigation they ended up terminating NA #1 in December 2023 based on the direct witness statement of Resident #27 and then a couple of days later the former Administrator got notified that she had been charged and arrested. The former Administrator stated that he was only notified of NA #1's registry findings during the investigation of Resident #27's missing wallet and money, he stated had he known earlier about the finding that were on NA #1's registry listing they would have immediately separated employment with NA #1 per the facility policy. He further added that he recalled that the registry listing that he was aware of was not a conviction but was listed as a pending charge or an accusation. The District Director of Operations was interviewed via phone on 03/05/24 at 4:51PM, he stated that he was aware of the situation with NA #1. He stated he could not speak to the timing of the discovery but what he recalled was that during the investigation of Resident #27's missing wallet and money they re-verified NA#1's registry listing which was part of their routine practice and discovered that after she was hired, she had something on her registry listing. When they discovered that NA #1 had something on her registry listing, he had the staff re-verify everyone to ensure that no one else had anything on their registry listing. The District Director of Operations stated that the former Human Resource director never shared with him that registry findings in August 2023 or he would have separated employment with NA #1 at that time per their facility policy. The Corporate Human Resource Director was interviewed via phone on 03/06/24 at 10:53 AM, she stated that she had not started with the company until September 2023 and was not aware of registry findings for NA #1 until December 2023 when she was terminated from the company. She confirmed that if anything came back on the NA registry the information would be shared with her and the decision would made to separate employment and if the findings had anything to do with a resident in a nursing facility it would be grounds for immediate termination per their policy. The Director of Nursing (DON) was interviewed on 03/05/24 at 5:49 PM, she stated that on 12/14/23 Resident #27 reported to the former Administrator that he believed NA #1 had stolen his wallet during the night of 12/13/23 and so an investigation was started. The DON stated that when NA #1 was hired they verified her registry listing and there was nothing on it but during the investigation of Resident #27's missing wallet and money they re-verified her registry listing and found that she had something on her registry listing. The DON stated that if that came up after we hired NA #1, she felt like she (NA #1) should have disclosed that information to us and that was why we terminated her in December 2023. The DON stated that the former Administrator handled most of the investigation, but she made sure Resident #27 was in court on both court dates. She stated that she was unaware of the registry listing that was pulled in August 2023 and that had she known she would have immediately separated employment with NA #1 per their policy. The Administrator and DON were notified of Immediate jeopardy on 03/06/24 1:08 PM. The facility provided the following corrective action plan with a completion date of 12/22/23: F607 Failure to Implement Abuse policy. CORRECTIVE ACTION THAT WILL BE ACCOMPLISHED: On 12/20/2023, The Facility Administrator was notified by The Human Resources Director of adverse action on North Carolina Nurse Aide Registry for an employee suspended on 12/14/2023. On 12/20/2023, The Facility Administrator addressed the failure to follow abuse policy by providing education to The Human Resource Director on the abuse policy and following the process for monitoring the NC Nurse Aid Registry and the NC Board of Nursing Registry to ensure no adverse action noted on staff members licenses/certifications. On 12/21/2023, the employee with adverse findings was terminated from the facility by Director of Nursing. IDENTIFICATION OF OTHER RESIDENTS: All residents have the potential to be affected. On 12/21/23, all current licensed and certified facility staff were re-verified through North Carolina Nurse Aide Registry (NCNAR) and NC Board of Nursing Registry for any adverse finding or action by the DON with no additional employees noted with adverse actions. No other negative findings noted. MEASURES FOR SYSTEMIC CHANGE: In addition to pre-hire verification, licensed and certified employees will be verified by the Human Resources director or the DON against the NCNAR and NC Board of Nursing Registry upon license or certification renewal, and in the event of an abuse allegation. Facility administrator educated human resource director to this process on 12/20/2023. Human Resource director and director of nursing receive monthly reports of upcoming license and certification renewals. Abuse allegations involving facility staff are communicated to human resources by administrator or director of nursing. On 12/20/2023 The Human Resources Manager was made aware of this monitoring process by the Facility Administrator. A new HR Manager was hired on 1/3/2024 and was educated on this process by the Corporate HR Director. On 12/21/2023, enhanced education was added by the corporate Human Resources director to new hire orientation for any new human resources employees regarding policy and notification of any adverse findings on NCNAR checks and NC Board of Nursing Registry. HOW CORRECTIVE ACTION WILL BE MONITORED: As of 12/21/2023, The Human Resource Manager or Director of Nursing will run reports from the NC Nurse Aid Registry and the NC Board of Nursing Registry for all licensed and certified staff monthly to ensure that no staff have substantiated findings on their records. On 12/20/2023 monitoring of this process was implemented following review by QA on 12/19/23. The Administrator and/or Director of Nursing will review the reports for compliance. Results of these audits will be reviewed in the monthly Quality Assurance and Performance Improvement Committee meeting with the QAPI Committee responsible for ongoing compliance. Results of these audits will be brought before the Quality Assurance and Performance Improvement Committee monthly with the QAPI Committee responsible for ongoing compliance. Date of Compliance 12/22/2023 The corrective action plan was validated on 03/08/24. The verification of all nurse aide registry listing information and Board of Nursing verification were reviewed with no other issues noted. All newly hired nurse aide and nurses since 12/22/23 have been verified through either the nurse aide registry or Board of Nursing and those verifications were reviewed with no further issues noted. The facility had no allegations of abuse, neglect, or misappropriation of resident property since 12/22/23. The facility had re-verified all nurse aide listings and nursing license for staff monthly since 12/22/23, those were reviewed with no negative findings noted. Interviews with the Human Resource director and administrative staff revealed that they were aware that all nurse aide registry and nursing license were to be verified monthly, with renewal, and with any allegation of abuse, neglect, or misappropriation of resident property that the employee was involved with. The corrective action plan was taken to the Quality Assurance meeting on 12/19/23. The facility's compliance date of 12/22/23 was validated.

Based on record review, staff, and Health Care Personnel Investigator (HCPI) interviews the facility failed to terminate and allowed Nurse Aide (NA) #1 to continue to work after becoming aware that she had substantiated findings of misappropriation of resident property which occurred while NA #1 was employed in a nursing facility and had a substantiated finding of fraud against a resident which occurred while NA #1 was employed in a nursing facility on the North Carolina Nurse Aide Registry on 08/15/23. NA #1 was terminated on 12/21/23 following an investigation of misappropriation of Resident #27's property that allegedly occurred in the facility on 12/13/23. This deficient practice of allowing NA #1 to continue to work had the high likelihood to affect other residents. The findings included: Review of NA #1's employee file revealed she was hired by the facility on 03/09/23. The employee file had an Orientation Checklist that indicated a registry verification had been completed as well as her background check. The employee file contained no verification identification number (number you get when you verify a nurse aide registry listing). The file contained a background check that was completed on 03/10/23 and revealed no reportable court records found. Further review of NA #1's employee file revealed a North Carolina Nurse Aide 1 Registry verification completed on 08/15/23 with a confirmation number provided that indicated that NA #1 has 1 substantiated finding of Misappropriation of Resident Property which occurred while the individual was employed in a Nursing Facility. This information was entered on the Registry on 04/17/23. The verification further indicated that NA #1 has 1 substantiated finding of fraud against a resident which occurred while the individual was employed in a Nursing facility. This information was entered into the registry on 04/17/23. The former Human Resource Director was interviewed via phone on 03/05/24 at 4:26 PM, she explained that she worked for the company for a year and half. The former Human Resource Director stated that when she hired new Nurse Aides, she would always run their name and social security number through the Nurse Aide Registry system and then would enter their listing number and expiration date into the facility's onboarding system. She stated she did not retain the original verification, only entered the needed information into their onboarding system. She explained she was preparing to leave the facility to pursue other opportunities and that included uploading all the Nurse Aide information into the facility's electronic onboarding system and during that time she re-verified that all the Nurse Aide's registry information was valid. She stated that was when she discovered that NA #1 had findings of misappropriation and fraud on her registry listing, and she had not disclosed that information upon hire. The former Human Resource director stated that she had verified her registry listing information upon hire and there was nothing there and her background check was clean as well. She stated that after she made the discovery in August 2023, she took the information to the former Administrator who was also preparing to leave, and we sent the information to the Corporate Human Resource Director and also notified the District Director of Operations. She stated that NA #1 was terminated in December 2023 after an allegation of misappropriation of resident property but could not say what the outcome of reporting to the Corporate Human Resource Director and District Director of Operations was in August 2023. The former Administrator was interviewed via phone on 03/05/24 at 2:29 PM and again on 03/05/24 at 5:01 PM, he stated that on 12/14/23 he was notified that Resident #27 wanted to speak to him. He stated he spoke to Resident #27 who reported he thought that NA #1 had stolen his wallet during the night of 12/13/23. Resident #27 explained that NA #1 asked him to borrow a dollar and he had given her the key to his drawer to unlock it and hand him his wallet so he could give her a dollar and then he asked NA #1 to lock the wallet back up in the drawer, but he did not see her put the wallet in the drawer before she locked it. At the time Resident #27 reported the incident to the former administrator he was able to describe NA #1, but she was working in the building that day and when NA #1 walked by Resident #27 he stated that is the girl that took my wallet. The Administrator stated that they immediately suspended NA #1 and began an investigation. The former Administrator stated at the end of the investigation they ended up terminating NA #1 in December 2023 based on the direct witness statement of Resident #27 and then a couple of days later the former Administrator got notified that she had been charged and arrested. The former Administrator stated that he was only notified of NA #1's registry findings during the investigation of Resident #27's missing wallet and money, he stated had he known earlier about the finding's that were on NA #1's registry listing they would have immediately separated employment with NA #1. He further added that he recalled that the registry listing that he was aware of was not a conviction but was listed as a pending charge or an accusation. The District Director of Operations was interviewed via phone on 03/05/24 at 4:51PM, he stated that he was aware of the situation with NA #1. He stated he could not speak to the timing of the discovery but what he recalled was that during the investigation of Resident #27's missing wallet and money they re-verified NA#1's registry listing which was part of their routine practice and discovered that after she was hired, she had something on her registry listing. When they discovered that NA #1 had something on her registry listing, he had the staff re-verify everyone to ensure that no one else had anything on their registry listing. The District Director of Operations stated that the former Human Resource director never shared with him the Nurse Aide registry findings in August 2023, or he would have separated employment with NA #1 at that time. The Corporate Human Resource Director was interviewed via phone on 03/06/24 at 10:53 AM, she stated that she had not started with the company until September 2023 and was not aware of registry findings for NA #1 until December 2023 when she was terminated from the company. She confirmed that if anything came back on the NA registry, the information would be shared with her and the decision would made to separate employment and if the findings had anything to do with a resident in a nursing facility it would be grounds for immediate termination. The Health Care Personnel Investigator (HCPI) was interviewed via phone on 03/05/24 at 4:06 PM, she stated that she was assigned the case involving NA #1 that allegedly occurred in the facility on 12/13/23. She explained that NA #1 had another case involving misappropriation of resident property and fraud against a resident that was opened on 11/15/22 and the decision to substantiate was made on 03/01/23. At the time that decision was made the North Carolina Nurse Aide Registry would have been updated to reflect those findings. She continued to say that if the facility had verified NA #1's registry listing on 03/09/23 which was her date of hire the findings of misappropriation and fraud against a resident would have been pending but would have been present on her registry verification and the facility should not have hired her. Once the appeal process was over the pending findings would have been changed to substantiated, which they did so on 04/17/23. The HCPI further explained that NA #1 had outstanding criminal charges of misdemeanor larceny and exploitation of elderly person and was scheduled to be back in the court system on 03/27/24 and once the case was through the court system her registry information would be updated accordingly depending on the outcome of the case. The Director of Nursing (DON) was interviewed on 03/05/24 at 5:49 PM, she stated that on 12/14/23 Resident #27 reported to the former Administrator that he believed NA #1 had stolen his wallet during the night of 12/13/23 and so an investigation was started. The DON stated that when NA #1 was hired they verified her registry listing and there was nothing on it but during the investigation of Resident #27's missing wallet and money they re-verified her registry listing and found that she had something on her registry listing. The DON stated that if that came up after we hired NA #1, she felt like she (NA #1) should have disclosed that information to us and that was why we terminated her in December 2023. The DON stated that the former Administrator handled most of the investigation, but she made sure Resident #27 was in court on both court dates. She stated that she was unaware of the registry listing that was pulled in August 2023 and that had she known she would have immediately separated employment with NA #1. The Administrator and DON were notified of immediate jeopardy on 03/06/24. The facility provided the following corrective action plan with a completion date of 12/22/23: All licensed staff and certified staff were re-verified through NC Nurse Aid Registry and NC Board of Nursing Registry for any substantiated findings for any abuse/misappropriation, by the Director of Nursing. Completed on 12/21/23 Identification of other Residents: No other staff were identified with negative findings on the re-verification (re-verification was completed by the Director of Nursing running the licensure/certification off the nurse aid registry and the Board of Nursing registry) Measures for Systemic Change: All new hires will be verified to ensure no substantiated findings on their license/ certification for abuse/misappropriation, by the Human Resource (HR) Director or Director of Nursing prior to employment, upon renewal of licensure/certification and prn with allegations, any negative findings will be brought to the Administrator and Director of Nursing to review. HR Director receives a report monthly with upcoming license and certification renewals. If any substantiated findings are noted the HR Director will notify Administrator and Corporate HR for direction related to the employee's employment. HR Director was informed of this requirement and process by the Administrator on 12/20/23. How Corrective Action will be Monitored: On 12/20/23 monitoring of this process was implemented following review by QA on 12/19/23. HR Director or Director of Nursing will run reports from NC Nurse Aid registry and NC Board of Nursing Registry for all licensed and certified staff monthly X 6 months, and randomly thereafter to ensure that no staff have substantiated findings on their records. All new hires will be verified by HR Director or Director of Nursing prior to employment, upon renewal and prn with any allegations. The Administrator and/or Director of Nursing will review the reports for compliance. Results of these audits will be reviewed in the monthly Quality Assurance and Performance Improvement Committee meeting with the QAPI Committee responsible for ongoing compliance. Date of compliance: 12/22/23 The corrective action plan was validated on 03/08/24. The verification of all Nurse Aide registry listing information and Board of Nursing verification were reviewed with no other issues noted. All newly hired nurse aide and nurses since 12/22/23 have been verified through either the Nurse Aide registry or Board of Nursing and those verifications were reviewed with no further issues noted. The facility had no allegations of abuse, neglect, or misappropriation of resident property since 12/22/23. The facility has re-verified all nurse aide listings and nursing license for staff monthly since 12/22/23, those were reviewed with no negative findings noted. Interviews with the Human Resource director and administrative staff revealed that they were aware that all nurse aide registry and nursing license were to be verified monthly, with renewal, and with any allegation of abuse, neglect, or misappropriation of resident property that the employee was involved with. The corrective action plan was taken to the Quality Assurance meeting on 12/19/23. The facility's compliance date of 12/22/23 was validated.

Based on observations, record review, and resident, staff, Police Officer, and Health Care Personnel Investigator interviews the facility failed to protect the resident's right to be free from misappropriation of resident property when Nurse Aide (NA) #1 allegedly stole a wallet and $320.00 from Resident #27. Resident #27 stated he felt like he was taken advantage of, and it really bothered him that she (NA #1) would do something like that. Resident #27 become tearful as he stated that he did not want this to happen to anyone else. This deficient practice affected 1 of 3 residents reviewed abuse, neglect, and misappropriation of resident property. The findings included: Resident #27 was readmitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #27 was cognitively intact, had no signs of delirium and no behaviors. An initial allegation report dated 12/14/23 read in part, Nurse Aide (NA) #1 had been accused of misappropriation of Resident #27's property. He stated that she came into his room late one evening and the next morning his wallet was missing from his locked drawer. NA #1 was suspended pending the investigation and Resident #27's belongings secured in a locked drawer and safe. Local law enforcement were notified. The report was signed by the former Administrator. The five working day report dated 12/21/23 indicated that Resident #27 identified NA #1 from the previous night as the accused individual. Local law enforcement through the magistrate office issued an arrest warrant and NA #1 was arrested for exploitation of elderly/handicap individual. NA #1 was accused of stealing $320.00 and a $30.00 wallet. The allegation was substantiated, and NA #1 was terminated on 12/21/23. An observation and interview were conducted with Resident #27 on 03/04/24 at 11:02 AM. Resident #27 was sitting up in his wheelchair and was noted to have a purple lanyard around his neck that had two keys on it. Resident #27 stated that he kept the key to the top nightstand drawer along with the key to his safe that sat on top of his nightstand on the lanyard around his neck. Resident #27 explained that on 12/13/23 NA #1 was in his room assisting his roommate and when she was done, she came to Resident #27's bedside and asked to borrow a dollar so she could get a snack. Resident #27 stated he told NA #1 he had snacks in his drawer, and she was welcome to them, but NA #1 was insistent that she wanted to borrow a dollar to get a snack out of the vending machine. Resident #27 stated that he handed NA #1 the key to the top drawer of his nightstand so that she could hand him his wallet and she did. Resident #27 explained that he kept both of his wallets in a black zipper pouch and in one wallet he kept dollar bills in and the other one he kept larger bills. After he had gotten the dollar bill out of his wallet, he put the wallet back in the black zipper pouch and handed it to NA #1 and asked her to please lock it back up in the top drawer of his nightstand. He added that NA #1 simulated putting the zipper pouch in the drawer and then emphasized to Resident #27 that she had locked the drawer and pulled on it to show that it was locked. Resident #27 stated that he never saw NA #1 put the zipper pouch/wallet in the drawer and the following morning when he got up, he went straight to the drawer and the zipper pouch/wallet was gone. Resident #27 explained that he was certain that it was NA #1 that took his wallet because that night he never went back to sleep and no one else came in his room that night. He added that another staff member had found the zipper pouch/wallet in another resident's room a week ago but the #320.00 cash was gone, his bank card and social security card were still in the wallet, but his cash was gone. Resident #27 explained that NA #1 had not been back into his room since this event and the only time he had seen her since 12/14/23 was when he went to court on two separate occasions for her hearing which was continued. He added he would be going back to court for a third time on 03/27/24. Resident #27 stated the on 12/14/23 he reported the incident to the former Administrator and since then he purchased a small safe to keep on top of his nightstand to keep his personal affects in. A follow up interview was conducted with Resident #27 on 03/06/24 at 9:38 AM. Resident #27 stated that having his money and wallet stolen made me feel like she took advantage of me. For a while I was very bothered by it because I thought she was an all-right girl. Resident #27 stated that the wallet was in a black zipper pouch and all the cash was gone except there was a secret compartment that NA #1 did not know about and there was 14.00 in there that she did not take but the other cash she took. He added that eventually the facility replaced his cash and now he kept his wallet in the safe that was purchased after the event. Resident #27 stated I have been to court 2 times, and I would rather be doing something else besides sitting in the court room. I have to go back to court again on 03/27/24. I feel like my things are safe here as long as they are locked up in my safe. Resident #27 became tearful and stated, thank you for looking into this I don't want this to happen to anyone else. An attempt to speak to NA #1 was made on 03/05/24 at 2:04 PM and was unsuccessful. The former Administrator was interviewed via phone on 03/05/24 at 2:29 PM and again on 03/05/24 at 5:01 PM, he stated that on 12/14/23 he was notified that Resident #27 wanted to speak to him. He stated he spoke to Resident #27 who reported he thought that NA #1 had stolen his wallet during the night of 12/13/23. Resident #27 explained that NA #1 asked him to borrow a dollar and he had given her the key to his drawer to unlock it and hand him his wallet so he could give her a dollar and then he asked NA #1 to lock the wallet back up in the drawer, but he did not see her put the wallet in the drawer before she locked it. At the time he reported the incident to the former Administrator Resident #27 was able to describe NA #1, but she was working in the building that day and when NA #1 walked by Resident #27 he stated that is the girl that took my wallet. The Administrator stated that they immediately suspended NA #1 and began an investigation. The former Administrator stated at the end of the investigation they ended up terminating NA #1 in December 2023 based on the direct witness statement of Resident #27 and then a couple of days later we got notified that she (NA #1) had been arrested and charged. The Health Care Personnel Investigator (HCPI) was interviewed via phone on 03/05/24 at 4:06 PM, she stated that she was assigned the case involving NA #1 that allegedly occurred in the facility on 12/13/23. The Investigator further explained that NA #1 had outstanding criminal charges of misdemeanor larceny and exploitation of elderly person and was scheduled to be back in the court system on 03/27/24 and once the case was through the court system her registry information would be updated accordingly depending on the outcome of the case. She added that she had spoken to NA #1 via phone, and she denied the allegations and stated she had absolutely no reason why she was arrested and charged. The HCPI stated that the Director of Nursing (DON) had notified her that on 02/22/24 Resident #27's wallet had been found in another resident's room who spent all of her time in bed and was blind. She added that NA #1's case was still under investigation, and she was still attempting to speak to the Policer Officer that responded to the call on 12/14/23. NA #3 was interviewed on 03/06/24 at 9:58 AM, explained that on 02/22/24 she was working on Resident #27's unit and was making an incontinent round as usual. She stated she went into a female resident room to provide care to her, and her hearing device was squealing. The female resident's roommate stated that if the hearing device was squealing that meant the batteries were dead and her family had kept extra batteries in her nightstand. NA #3 stated she went ahead and provided care and got the resident situated and then opened her second drawer of her nightstand and there was a black zipper pouch. She stated she assumed that was where the extra batteries were kept and so she opened the black zipper pouch and when she opened it there was 2 wallets, one was green and black, and the other one was all black and when she opened the green and black one it had Resident #27's driver's license in it. NA #3 stated that she closed the wallet and put it back inside the zipper pouch and took it to the DON. The Police Officer that responded to the facility on [DATE] was interviewed via phone on 03/08/24 at 5:39 PM. He stated that he responded to a call from the facility on 12/14/23 and when he arrived, he met with the former Administrator and then spoke to Resident #27. He stated that Resident #27 told him that NA #1 had asked him to borrow a dollar and he had given her the key to unlock his nightstand drawer and hand him his wallet and when he asked her to lock it back up, she had locked the drawer but he had not seen her put the wallet in the drawer before locking it and he was certain no one else had been in his room that night and the key remained on a lanyard around his neck. The Policer Officer stated that after he spoke to Resident #27, he had gone to the magistrate on Resident #27's behalf and had a probable cause hearing and warrant to continue investigating the case. He stated that a few days later NA #1 was arrested and charged with larceny and exploitation of an elderly person. The Police Officer stated that on 03/04/24 he had spoken at the grand jury hearing about NA #1 and the case was continued and she was due in court again on 03/27/24. He added that NA #1 still had 3 pending felony charges and 3 pending misdemeanor charges that she was being tried for. The DON was interviewed on 03/05/24 at 5:49 PM, she stated that on 12/14/23 Resident #27 reported to the former Administrator that he believed NA #1 had stolen his wallet during the night of 12/13/23 and so an investigation was started. The DON stated that the former Administrator handled most of the investigation, but she made sure Resident #27 was in court on both court dates. The DON explained that NA #1 was terminated in December 2023 because when they re-verified her nurse aide registry listing it came back with substantiated findings that occurred after she was hired, and she had not disclosed that to us. The DON also stated that on 02/22/24 NA #3 found Resident #27's zipper pouch/wallet in another resident room but his cash was gone. After the event on 12/13/23, the facility had interviewed the alert and oriented residents about exploitation and all staff were educated on the abuse, neglect, and misappropriation policy. In addition, the facility initiated a valuable sheet that was required to be filled out with 2 staff signatures and resident signature anytime a resident asked the staff to purchase something with their money. The plan was introduced into the quality assurance meeting on 12/19/23. Ongoing audits of the valuable sheets were done two times monthly until directed by the QA team. The facility provided the following corrective action plan with a completion date of 12/18/23. All items on this self-imposed plan have been implemented on 12/14/23 and completed on 12/18/23 with ongoing monitoring to ensure compliance. This concludes the action plan and any potential citation associated with this plan should be considered past noncompliance as of 12/18/23. Corrective action that will be accomplished: On 12/14/23 Administrator provided affected resident with a safe for valuable items. On 12/14/23 Administrator educated this resident (BIMS 14) on how to secure valuables/money in the lockable drawers in the nightstand in his room, in the Business office, and in the new safe. Identification of other residents: All residents who keep valuables/money are at risk of the same deficient practice. Starting on 12/14/23, an audit was conducted by Administrator/designee where all residents with BIMS of 10 or greater were interviewed and questioned regarding exploitation and any concerns related to exploitation. Any concerns were addressed. Measures for system change: On or before 12/18/23, all staff were educated by the Administrator/all on abuse, neglect, and exploitation with an emphasis on exploitation and correct measures for interaction with residents related to money and valuables. On or before 12/18/23, all staff will be educated by the Administrator/designee on the new process that any staff member asked to assist any resident with money or valuable will be required to have a witness and complete an Audit sheet to any actions taken when it relates to resident's valuables/money. On or before 12/18/23, all residents with BIMS of 10 or greater were educated on how to secure valuables/money in the lockable drawer in the nightstand in their room or in the business office. How corrective action will be monitored: All activity with staff involvement related to valuables/money will be documented with signatures required by the resident, a staff member, a witness, and a Nurse Manager/Admin staff and returned to the Administrator or DON for record keeping purpose. This audit tool will be reviewed monthly x 2 months as part of QAPI process. The QAPI team will consider any changes to the process at that time. The corrective action plan was validated on 03/08/24. Resident #27 was verbally able to describe how and where he locked up his personal affects. Interviews with other alert and oriented residents also revealed that they were aware of how and where to lock up with personal affects. Staff interviews across all departments revealed that all staff were aware of the newly implemented process for handing resident money, and the requirement of having witness signatures and resident signatures and the need to turn them into the Administrator or DON. Initial audit of residents with BIMS of 10 or higher was reviewed and observations of resident's nightstand drawer with the lockable device were reviewed with no issues noted. The resident council was also educated on how and where to lock up their belongings and were educated on abuse, neglect, and exploitation. The plan went to the QA meeting on 12/19/23 and the ongoing audits of the valuable sheets were reviewed with no issues noted. The compliance date of 12/18/23 was validated.

Based on observations and staff interviews, the facility failed to safeguard protected health information (PHI) for 8 of 8 residents (Residents #7, #10, #11, #55, #72, #77, #85 and #91) observed for privacy and confidentiality, by leaving confidential PHI exposed on an unattended medication cart in an area accessible to the public. The finding included: During a continuous observation made on 03/06/24 at 9:06 AM through 9:08 AM Nurse #1 walked away from the 100 hall medication cart and left a report sheet uncovered which exposed the PHI of residents names and room numbers of Resident #7, #10, #11, #55, #77, #85 and #91. The PHI included information of code status, vital signs, medications, diets, diagnoses, continent status and safety precautions. During the observation three staff members and one visitor passed by the medication cart. An interview was conducted with Nurse #1 on 03/06/24 at 9:08 AM. The Nurse acknowledged she left the report sheet exposed and explained that she normally laid a sheet of paper over the report sheet before she left the medication cart but forgot to do it that morning. On 03/07/24 at 12:57 PM during an interview with the Director of Nursing (DON) she explained that the facility had laminated covers that were supposed to be used to cover the report sheets. The DON stated it looked like she needed to come up with something different to ensure the staff protected the PHI of the residents.

Based on observations, record review, and staff interviews, the facility failed to keep a dependent resident's fingernails clean and trimmed for 1 of 2 residents reviewed for activities of daily living (Resident #51). The findings included: Resident #51 was admitted to the facility on [DATE] with diagnoses that included seizures, major depressive disorder, and adjustment disorder. Review of Resident #51's annual Minimum Data Set assessment dated [DATE] revealed Resident #51 was independent with eating and required extensive assistance with 2 or more persons, physical assistance with personal hygiene. Review of Resident #51's quarterly Minimum Data Set assessment dated [DATE] revealed resident had moderately impaired cognition with no delirium, no behaviors, or rejection of care. Review of Resident #51's care plan, last updated on 02/20/24 revealed a care plan for [Resident #51 has an ADL (activities of daily living) self-care performance deficit related to impaired balance, incontinence, refusal of care (showers, nail care, and incontinent care), and generalized weakness. Interventions included to encourage active participation in tasks. An observation of Resident #51 on 03/04/24 at 11:21 AM revealed his fingernails to extend 1/4 inch past the tip of his finger. The nails on Resident #51's right hand was observed to have an orange and black substance underneath them from the tip of his finger to the edge of the nail. An interview with Resident #51 on 03/04/24 at 11:24 AM revealed he did not trim his own nails and relied on facility staff to clean and trim them. Another observation of Resident #51 was completed on 03/04/24 at 1:45 PM. He was still in his room and had finished his lunch meal tray. Resident #51's nails were observed to be in the same condition as they were earlier in the day with the same orange and black substance underneath them. An observation of Resident #51 was completed on 03/05/24 at 8:23 AM. Resident was in his room eating his breakfast tray. Resident #51 was using his fingers on his right hand at times to feed himself. His nails remained in the same condition as the prior day with an orange and black substance underneath the nails on his right hand. Another observation of Resident #51 was completed on 03/06/24 at 8:28 AM. Resident #51 was in his bed asleep with his breakfast tray in front of him with his right hand resting on his plate. Resident #51's nails were observed to be clean and neatly trimmed. Review of the facility's shower schedules revealed Resident #51 was scheduled for a shower on Wednesdays and Saturdays on 2nd shift. There was also a label on Sunday for nail care day. Review of facility working schedules revealed Nurse Aide #3 and Nurse Aide #4 (NA #3 and NA #4) worked with Resident #51 on his previous 2 shower days. On 03/08/24 at 12:45 an interview with NA #3 who worked with Resident #51 on Wednesday, 2/28/24 was attempted by telephone. There was no answer, and a message was unable to be left. An interview with NA #4 on 03/07/24 at 4:11 PM revealed she had worked with Resident #51 on Saturday, March 1st and had offered him a shower but he requested a bed bath instead. NA #4 reported she provided the bed bath and stated she cleaned his fingernails. NA #4 stated she remembered Resident #51's nails being very dirty with food caked underneath them. She reported his nails were not trimmed. She did not believe them to be long. NA #4 stated she cleaned Resident #51's nails but did not trim them. NA #4 also reported that Resident #51 occasionally ate his meals with provided utensils but that he mainly used his fingers to eat. An interview with NA #5 on 03/08/24 at 1:12 PM, she verified she worked with Resident #51 on 03/05/24 and she was the staff member who cleaned and trimmed Resident #51's nails on 03/05/24. She reported she was scheduled to do nail care that day and she went to Resident #51's room sometime after breakfast. She reported when she observed his nails, she noticed they were long and very dirty underneath. She reported she was able to clean and trim Resident #51's nails without any issues. During an interview with the Director of Nursing on 03/08/24 at 12:21 PM she reported she could see that the observed orange and black substance under Resident #51's nails as being food. She also reported that resident fingernails should be addressed on their shower days, every Sunday, and as needed. She reported she was unsure about the process for gathering resident preferences on the length of nails they wished to have, but that there should never be substance left under the nails.

Based on observations, record reviews and staff interviews, the facility failed to implement a care plan intervention for a non slip mat on a resident's wheelchair used to prevent the resident from sliding for 1 of 3 residents (Resident #23) reviewed for accidents. The finding included: Resident #23 was admitted to the facility on [DATE] with diagnoses that included Parkinson disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact and the behavior of rejection of care was not exhibited. The MDS indicated that the Resident had functional limitations of range of motion of upper and lower extremities on both sides and the mode of mobility was a wheelchair. She was incontinent and required set up assistance for transfers. Resident #23 had one fall since the previous assessment on 09/04/23. A review of an Incident Report dated 01/24/24 revealed Resident #23 had an unwitnessed fall and was found lying on her back on the floor and stated she was trying to get to the bathroom. Resident #23's care plan revised on 01/25/24 indicated she was at high risk for falls extensive assistance with activities of daily living, weakness and poor decision making. The goal that her risk and potential for injury will be minimized through utilization of interventions such as keeping the call light in reach and encouraging her to use it, conducting frequent rounds of toileting assistance, wearing gripper socks, keeping personal items near the Resident, applying anti roll back brakes and utilizing a non slip mat in her wheelchair. A review of an Incident Report dated 03/01/24 revealed Resident #23 had an unwitnessed fall while attempting to transfer to her wheelchair from her bed. The report indicated the Resident most likely hit her head as evidence of swelling to the right side of her head. Neuro checks were initiated and were within normal limits. An observation and interview conducted with Resident #23 on 03/04/24 at 12:36 PM revealed the Resident was sitting in her wheelchair beside her bed. The Resident was asked if she had a non slip mat in her wheelchair and the Resident replied no while lifting her buttocks up to show there was not a non slip mat in her wheelchair. During an observation and interview with Resident #23 on 03/05/24 at 12:20 PM, the Resident was observed rolling herself in her wheelchair out of the bathroom and parked beside her bed. The Resident was asked if there was a non slip mat in her wheelchair to help prevent her from sliding out of the wheelchair and the Resident appeared to not understand what she was being asked. Upon inspection, there was no non slip mat in her wheelchair. An observation was made on 03/05/24 at 3:04 PM of Resident #23 sleeping in her bed with her wheelchair parked beside her bed. There was not a non slip mat in her wheelchair. Interviews were conducted with Nurse Aide (NA) #1 and Medication Aide (MA) #1 simultaneously on 03/05/24 at 3:05 PM. The NA confirmed she cared for Resident #23 on 03/04/24 and 03/05/24 and explained she was not aware of the Resident's recent fall on 03/01/24 and did not know the interventions put in place to prevent further falls. The NA stated the non slip mat would probably be on her Kardex (care plan for the nurse aides), but she did not know because although she was assigned to care for Resident #23 that day, she did not work with Resident #23 often. The NA explained that fall interventions would be on the Resident's Kardex, but she had not reviewed the Resident's Kardex. MA #1 confirmed she worked with Resident #23 on 03/05/24 and explained that she was not aware that a non slip mat should be in the Resident's wheelchair and stated the Resident would probably not leave the mat in her wheelchair. NA #1 and MA #1 were accompanied to the Resident's Kardex and the non slip mat was listed on the Kardex as an intervention to her falls. During an interview with the Minimum Data Set Nurse #1 on 03/05/24 at 3:31 PM the Nurse explained that the Incident Reports were reviewed the in the morning during the clinical meeting and the interventions were determined and added to the updated care plan which will roll over onto the Kardex. She indicated it was the nurse aides' responsibility to review the Kardex for the added interventions. On 03/06/24 at 4:51 PM during an interview with Unit Manager (UM) #2 the UM confirmed Resident #23 had a history of falls and explained the Resident continued to transfer herself even with frequent reminders not to get up by herself. UM #2 explained the ability for the Resident to safely transfer herself varied from day to day because of her diagnosis. The UM continued to explain that several interventions had been put in place to prevent the Resident from falling and the last one was a non slip mat in her wheelchair. She stated the staff should ensure there was a non slip mat in the Resident's wheelchair every day and indicated if the Resident did not leave the non sliding mat in her wheelchair, then it should be reported so another intervention could be determined. An interview was conducted with the Director of Nursing (DON) on 03/08/24 at 10:08 AM. The DON explained that Resident #23 would often remove the non sliding mat from her wheelchair and stated it looked like they needed to add if resident allowed to the non slip mat intervention on her care plan.

Based on record reviews and staff interviews, the facility failed to ensure the code status information was accurate throughout the medical record for 3 of 19 residents (Resident #44, Resident #72 and Resident #140) reviewed for advanced directives. The findings included: a. Resident #44 was admitted to the facility on [DATE]. Review of the code status notebook that was maintained at the nursing desk revealed Resident #44 had a yellow Do Not Resuscitate (DNR) form dated [DATE] and an advanced directive for a Full Code signed on [DATE]. A review of Resident #44's electronic health record (EHR) on [DATE] at 2:16 PM revealed an order for a DNR dated [DATE]. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #44's cognition was moderately impaired. b. Resident #72 was admitted to the facility on [DATE]. Review of the code status notebook that was maintained at the nursing desk. Resident #72 had a Do Not Resuscitate order for DNR dated [DATE] in the notebook. A review of Resident #72's electronic health record (EHR) on [DATE] at 2:33 PM revealed an order for Full Code dated [DATE]. The admission Minimum Data Set assessment dated [DATE] revealed the Resident's cognition was moderately impaired. c. Resident #140 was admitted to the facility on [DATE]. A review of the Nursing Admission assessment dated [DATE] revealed Resident #140 was alert and oriented to person, place, time and situation. Review of the code status notebook maintained at the nursing desk. Resident #140 had a Resuscitation order for Cardiopulmonary (CPR) signed by the Resident on [DATE]. Also, in the code status notebook was a pink Medical Order for Scope of Treatment (MOST) dated [DATE] signed by Resident #140. A review of Resident #140's electronic health record (EHR) on [DATE] at 2:07 PM revealed an order for a Full Code dated [DATE]. An interview was conducted with the Social Worker (SW) on [DATE] at 1:24 PM. The SW explained that she had been employed by the facility for 3 years and had a very limited role in the advanced directive process. She explained that when the resident was admitted to the facility, she checked the face sheet and whatever the advanced directive was determined which care plan she developed for the resident. The SW continued to explain that when a resident's advanced directive changed the nursing department informed her and she made the adjustment to the care plan. An interview was conducted with Unit Manager (UM) #1 on [DATE] at 1:34 PM. The UM explained that the two Unit Managers were responsible for admissions and double checked each other for orders that included the advanced directives. She continued to explain that after the resident was admitted they addressed the advanced directive with the resident or their representative and completed the facility's paperwork according to their desire. The UM stated after the completion of the paperwork they gave it to the Medical Records Director who placed it in the code status notebook at the nursing desk. The UM also indicated Medical Records was responsible for auditing the two records to ensure that they matched. On [DATE] at 2:13 PM during an interview with the Medical Records Director she explained that the Admissions Director of the Unit Managers were responsible for completing the advanced directive paperwork and then it was given to her to scan into the residents' medical records, and she would place it in the code status notebook at the nursing desk. She stated she audited the code status notebook every week, but she did not realize how often the code status changed and did not know that she was supposed to ensure the code status in the notebook matched the code status in the residents' medical record. During an interview with the Director of Nursing (DON) on [DATE] at 9:23 AM the DON explained that the unit managers were responsible for obtaining the advanced directives from the residents or their representatives after the residents were admitted and the Admissions Director was responsible for completing the paperwork. The DON indicated the Medical Records Director should be auditing the code status notebook but sometimes a nurse would be assigned to do it because of the frequent transfers to the hospital.

Based on observations, record review, staff, consultant pharmacist, and Medical Director interviews the facility failed to maintain a medication error rate of less than 5% by having 2 errors out of 28 opportunities which resulted in a 7.14% medication error rate. This affected 2 of 6 residents observed on medication pass (Resident #39 and Resident #93). The findings included: 1. Resident #39 was readmitted to the facility on [DATE] with diagnoses that included end stage renal disease. A physician order dated 08/22/23 read Lanthanum Carbonate (used to keep phosphorus levels down in dialysis residents) 1000 milligrams (mg) by mouth with meals for end stage renal disease. A quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #39 was cognitively intact and received dialysis during the assessment reference period. An observation of Medication Aide (MA) #2 preparing Resident #39's medication was made on 03/06/24 at 4:04 PM. The medications that were prepared included Lanthanum Carbonate 1000 mg 1 tablet. After MA #2 had prepared Resident #39's medications she proceeded to his room and handed him the cup that contained the Lanthanum Carbonate tablet. Resident #39 was observed to sit up in bed and take the cup and put the Lanthanum Carbonate tablet in his mouth and chew it up. There was no meal on the unit or in Resident #39's room. MA #2 did not offer a snack or meal to Resident #39 before she exited the room. MA #2 was interviewed on 03/07/24 at 10:18 AM, she stated that Resident #39's lanthanum carbonate was scheduled on the Medication Administration Record (MAR) before the mealtime. She explained that the medication was scheduled to be given at 4:00 PM but the meal on that unit was not supposed to be delivered until 6:15 PM. MA #2 stated she was aware that she had an hour before and an hour after the scheduled medication time to administer the medication and she had done that. The Consultant Pharmacist was interviewed via phone on 03/07/24 at 12:19 PM, she stated that taking Lanthanum Carbonate on an empty stomach did not affect absorption, but it should be given with food to avoid gastrointestinal (GI) adverse effects. She explained that during the limited study done on the medication it was given with food to increase compliance and decrease the discontinued rate of the medication. And for that reason, it was best to give with food to avoid the GI effects and increase compliance of the medication. The Medical Director was interviewed on 03/07/24 at 11:31 AM who stated that taking the Lanthanum Carbonate without food would probably not sit well for his GI tract or stomach but that would probably be the extend of the effects of taking the medication on an empty stomach. The Director of Nursing (DON) was interviewed on 03/07/24 at 12:46 PM, she stated that she believed that the staff were nervous during the medication pass observation but stated that they should be following the physician orders. 2. Resident #93 was admitted to the facility on [DATE] with diagnosis that vitamin D deficiency. A physician order dated 02/23/24 read Cholecalciferol (Vitamin D) oral tablet 25 mcg (1000 units) by mouth in the morning for vitamin D deficiency. An admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #93 was moderately cognitively impaired. An observation of Nurse #1 preparing Resident #93's medication was made on 03/07/24 at 9:10 AM. The medications included Vitamin D3 125 micrograms (mcg) 5000 units one tablet. After Nurse #1 had prepared all of Resident #93's medication she proceed to his room to administer the cup of medications and then exited the room and returned to her medication cart. Nurse #1 was interviewed on 03/07/24 at 9:57 AM, she stated that she was aware that the physician order indicated 1000 units but instead of not giving anything I gave the 5000 units. Nurse #1 explained that the bottle of 5000 units was all that she had available on her cart, and in the past when she has contacted the pharmacy about medications, they instruct her to purchase the medication over the counter. Nurse #1 stated she believed it was cheaper to get it over the counter then have the pharmacy dispense it. The Medical Director (MD) was interviewed on 03/07/24 at 11:31 AM, he stated I do not feel good about her logic referring to Nurse #1. He explained that getting 5000 units one time would have no immediate effects, but long term could result in Vitamin D toxicity. The MD stated that there was no signs or symptoms to look for in Vitamin D toxicity and would be detected on a blood test. The Consultant Pharmacist was interviewed via phone on 03/07/24 at 11:47 AM, she stated that getting 5000 units of Vitamin D instead of 1000 units would have no adverse effects unless the resident was receiving 50,000 units weekly and then was given additional high doses throughout the week. The Consultant Pharmacist stated that she had no issues with the resident being given 5000 units instead of 1000 units because the residents are so vitamin deficient from being inside constantly, they have so much room to have additional vitamin D. She further explained that Resident #93 had no major kidney issues, and the Vitamin D was good for him, and she would argue that he may need an increased dose of Vitamin D but we would need to check his level just to be on the safe side. The Director of Nursing (DON) was interviewed on 03/07/24 at 12:46 PM, she stated that she believed that the staff were nervous during the medication pass observation but stated that they should be following the physician orders.

Based on record review, staff and Hospice Nurse interviews the facility failed to obtain a physician order for hospice services for 1 of 1 resident (Resident #44) reviewed for hospice. The finding included: Resident #44 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular disease. During an interview with the Hospice Nurse on 03/05/24 at 10:43 AM the Nurse indicated Resident #44 began hospice services on 07/07/23 for cerebral vascular disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44's cognition was moderately impaired and was coded as having a condition or chronic disease that may result in a lift expectancy of less than 6 months. The Resident was also coded as receiving hospice services. A review of Resident #44's physician order revealed no active order for hospice services. A review of Resident #44's care plan revised on 01/04/24 for a terminal prognosis related to cerebral vascular disease. The goal for his dignity and autonomy to remain at the highest level would be attained by adjusting the provisions of his activities of daily living to compensate for his changing abilities and having hospice services. An interview was conducted with the Assistant Director of Nursing (ADON) on 03/07/24 at 11:55 AM. The ADON explained that Resident #44 had been on and off hospice and in and out of the hospital several times and it was possible that a new order was not obtained when he returned from the hospital. The ADON stated it should be everyone's responsibility to audit the hospice orders.

Based on observations, record reviews, resident, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 03/25/21 and 11/17/22 and for the complaint investigation conducted on 11/09/21. This failure was for eight deficiencies that were originally cited in the areas of Resident Rights (F578) and (F583), Freedom from Abuse, Neglect, and Exploitation (F607), Quality of Care (F695), Quality of Life (F677), Resident Assessment (F641), and Comprehensive Resident Centered Care plan (F656), and Infection Control (F880) that were subsequently recited on the current recertification and complaint investigation survey of 03/08/24. The repeat deficiencies during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F578: Based on record reviews and staff interviews, the facility failed to ensure the code status information was accurate throughout the medical record for 3 of 19 residents (Resident #44, Resident #72 and Resident #140) reviewed for advanced directives. During the recertification and complaint survey of 03/25/21 the facility failed to maintain accurate advance directives throughout the medical records for 2 of 18 residents reviewed for advance directives. F583: Based on observations and staff interviews, the facility failed to safeguard protected health information (PHI) for 8 of 8 residents (Residents #7, #10, #11, #55, #72, #77, #85 and #91) observed for privacy and confidentiality, by leaving confidential PHI exposed on an unattended medication cart in an area accessible to the public. During the recertification and complaint survey of 03/25/21 the facility failed to provide privacy while providing incontinence care for 1 of 1 resident reviewed for privacy. F607: Based on record review and staff interviews the facility failed to implement their abuse policy by failing to separate employment of Nurse Aide (NA) #1 on 08/15/23 when the facility became aware that she had substantiated findings of misappropriation of resident property and fraud against a resident that occurred while the individual was employed in a nursing facility. NA #1 continued her employment with the facility until 12/21/23 when she was terminated following an allegation of misappropriation of resident property. This deficient practice affected 1 of 3 residents (Resident #27) reviewed for abuse, neglect, and misappropriation of resident property and had the high likelihood to affect other residents in the facility. The census at the time of the survey was 86 residents. During the complaint investigation on 11/09/21 the facility failed to implement their abuse and neglect policy in the area of reporting injuries of unknown origin when a Resident was observed with bruising to her neck for 1 of 3 residents reviewed for supervision to prevent accidents. F641- Based on observations, record review and staff interviews, the facility failed to accurately code the Minimum Data Set assessments in the areas of discharge and lower extremity impairment for 1 of 2 discharged residents and 1 of 1 resident reviewed for choices. (Resident #89 and Resident #1). During the recertification and complaint survey of 03/25/21 the facility failed to accurately code the Minimum Data Set Assessment for the presence of a pressure ulcer and a significant weight loss (for 2 of 2 residents reviewed for falls. F656: Based on observations, record reviews and staff interviews, the facility failed to implement a care plan intervention for a non-slip mat on a resident's wheelchair used to prevent the resident from sliding for 1 of 3 residents (Resident #23) reviewed for accidents. During the recertification and complaint survey of 03/25/21 the facility failed to develop a care plan for an indwelling urinary catheter and failed to implement the care plans for catheter stabilizing devices for 2 of 3 residents reviewed for indwelling urinary catheters. F677: Based on observations, record review, and staff interviews, the facility failed to keep a dependent resident's fingernails clean and trimmed for 1 of 2 residents reviewed for activities of daily living. (Resident #51). During the recertification and complaint survey of 03/25/21 the facility failed to provide routine incontinence care to a resident with a Stage IV pressure ulcers to the sacrum and to provide nail care to a dependent resident who was observed to have long, sharp, and jagged fingernails with dark color debris underneath the nails for 1 of 5 resident reviewed for activities of daily living (ADL). F695: Based on observations, record reviews and interviews the facility failed to post cautionary and safety signs that indicated the use of oxygen for 2 of 3 residents (Resident #6 and Resident #58) reviewed for respiratory care. During the recertification and complaint survey of 11/17/22 the facility failed to administer the prescribed rate of oxygen for 2 of 5 residents sampled for respiratory services. F880: Based on observations, record review and staff interviews, the facility failed to implement their infection control policy when Nurse Aide #3 did not handle soiled linen in a sanitary manner and did not perform hand hygiene after completing incontinence care for 1 of 2 observations of infection control. During the recertification and complaint of 03/25/21 the facility failed to follow the Enhanced Droplet Isolation sign posted on the door of 2 of 14 residents that were on Enhanced droplet isolation by not donning a gown before entering the resident rooms on the quarantine unit. Additionally, a staff member failed to remove her gloves and perform hand hygiene when exiting 1 of 14 residents that were on Enhanced Droplet Precautions. These failures occurred during a global pandemic. The Administrator was interviewed on 03/08/24 at 11:08 AM, she stated that she had only been at the facility for 3 weeks and had the opportunity to have one QA meeting. She explained normally she would direct the QA meeting but since this was her first meeting the Director of Nursing had assisted in coordinating the meeting. The Administrator stated that all department heads in the facility attended the monthly meeting along with the Medical Director and consultant pharmacist either by phone or in person. She explained that during the QA meeting they discussed on-going performance improvement plans to see if they can be resolved or need to be amended or changed. We also discuss ongoing education and educational needs of the facility staff, we discuss grievances, work orders, weight loss, wounds, falls, infection control, maintenance logs, pharmacy reviews, and other topics that the team brings up. The Administrator stated she had done interim work for a lot of different companies and this one was ran like a well-oiled machine due to the tenure of the staff in the building. She added that a good thing that she brought to the table was she had lots of experience in different setting and situation and sometimes those things were successful in other building and if needed she could try them in this one. The Administrator stated she had good audit and tracking tools and a stable DON and that alone was helpful in correcting and maintaining long-term compliance.

Based on observations, record review and staff interviews, the facility failed to implement their infection control policy when Nurse Aide #3 did not handle soiled linen in a sanitary manner and did not perform hand hygiene after completing incontinence care for 1 of 2 observations of infection control. The finding included: The facility's policy Handwashing/Hand Hygiene dated 08/2015 indicated the following: This facility considers hand hygiene the primary means to prevent the spread of infection. The policy read, Hand hygiene must be performed after touching bodily fluids and contaminated items. Expectations were to perform hand hygiene when indicated to avoid transfer of microorganisms to other residents, personnel, equipment and the environment. The following list are of some situations listed in the facility policy that require hand washing or hand sanitization: e. before and after handling an invasive device such as urinary catheter, i. after contact with resident skin, and j. after contact with blood or bodily fluids. A continuous observation was made on 03/05/24 starting at 11:24 AM of incontinence care being provided to Resident #57 by Nurse Aides (NA) #3 and NA #4. Resident #57 rang his call light at 11:24 AM which was answered by NA #4 and requested to be changed. NA #4 sanitized her hands and donned gloves then began to provide incontinence care to the Resident who was incontinent of feces. The NA turned the Resident to his right side and cleansed the feces. The NA had to leave the room to retrieve a turn sheet from the linen cart and removed her gloves and sanitized her hands before she left the Resident's room. When NA #4 returned to Resident #57's room, NA #3 followed behind her to assist NA #4 in completing the task. NA #3 donned gloves and assisted with turning Resident #57. When the Resident was turned onto his back NA #3 retrieved a premoisten wipe from NA #4 and proceeded to wipe feces from the Resident's thigh then dropped the used wipe on the floor. NA #3 retrieved another wipe and cleansed Resident #57's indwelling urinary catheter near the meatus (a passage or opening leading to the interior of the body) then dropped the used wipe on the floor. The two NAs turned the Resident and positioned him on his back then NA #3 removed the dirty bed linens and dropped it directly onto the floor next to the used wipes. When the incontinent care was completed NA #4 removed her gloves and performed hand hygiene. NA #3, who was still wearing her gloves, picked up the wipes off the floor and put them in the trash can and removed the bag from the trash can then picked the dirty linen off the floor and put it in a separate plastic bag. Without removing her gloves NA #3 opened the door with her gloved hand and proceeded to carry the two bags into the hall. NA #3 while still wearing the same gloves which she had used to provide incontinent care lifted the lids to the soiled linen and trash cart and placed the bags into the linen and trash compartment of the cart. NA #3 proceeded to walk to the shower room where a resident was sitting in the hall, the resident was observed speaking to NA #3 and the NA opened the shower room door and retrieved a cell phone and handed it to him. The resident was observed speaking again to NA #3 and the NA replied, My hands are dirty and I can't get to my phone, and while still wearing the same gloves she wore while providing incontinent care, the NA pushed the linen/trash cart up the hall, opened the door to the soiled utility room, by touching the door handle while still wearing the gloves she wore while providing incontinent care where she put the dirty linen bag into the soiled linen bin. Without removing the gloves NA #3 had used when providing incontinent care, she opened the door by touching the door handle, pushed the trash cart down the service hall, opened the back door by touching the door handle, she then proceeded to push the trash cart to the dumpster and threw the trash bag into the dumpster then removed her gloves and threw them into the dumpster. Without being observed washing her hands the NA returned to the hall where she raised the fabric covering to the clean linen cart and removed two plastic bags and put them in the trash and linen cart. NA #3 then opened the shower room door and used hand sanitizer on her hands. The observation concluded at 12:00 PM on 03/05/24 when the NA was observed to have put hand sanitizer on her hands. An interview conducted with Nurse Aide #3 on 03/05/24 at 12:00 PM. The NA explained that the facility held inservices on infection control and handwashing all the time. The NA stated the Assistant Director of Nursing (ADON) was forever telling her not to wear her gloves in the hall. The NA explained when she was providing care for Resident #57, she had put dirty wipes and linen on the floor instead of bags as she was taught because she was in a hurry, needed to get the task done, and continue her other duties on the hall. The NA stated she should have removed her gloves after performing the incontinence care and she remarked before she left the Resident's room, she should have removed the gloves and washed her hands. NA #3 realized she had not removed her gloves and washed/sanitized her hands since she left Resident #57's room and again, the NA stated she was in a hurry and needed to get the job done. On 03/07/24 at 11:02 AM an interview was conducted with the Infection Preventionist (IP). The IP explained that she held a Skills Checklist once a year where they review the nurse aide's performance on several different care tasks which included hand hygiene. The IP continued to explain that NA #3 should have removed her glove over the hand she held the bags in when she left Resident #57's room and put the bags in the appropriate bin then washed her hands before she contaminated every surface she touched while wearing her gloves in the hall. The IP stated NA #3 was frequently counseled on wearing her gloves in the hall and her last handwashing review was on 01/06/24 and it looked like she needed more training. During an interview with the Director of Nursing (DON) on 03/08/24 at 9:07 AM the DON explained that she was already aware of the infection control issue with Nurse Aide #3 and stated the NA had handwashing reviews all the time. She stated NA #3 needed one on one education in handwashing.

Based on observations, record reviews and interviews the facility failed to post cautionary and safety signs that indicated the use of oxygen for 2 of 3 residents (Resident #6 and Resident #58) reviewed for respiratory care. The findings included: a. Resident #6 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] revealed Resident #6's cognition was severely impaired. Review of Resident #6's physician orders revealed an order dated 02/28/28 for continuous oxygen at 2 liters per minute via nasal cannula. A review of Resident #6's 02/2024 and 03/2024 Medication Administration Records (MAR) revealed the Resident received continuous oxygen at 2 liters per minute via nasal cannula since 02/28/24. On 03/04/24 at 11:50 AM an observation was made of Resident #6 lying in bed sleeping. The Resident was wearing an oxygen cannula with oxygen delivered at 2 liters per minute. There was no oxygen cautionary signage posted to indicate oxygen was in use. Subsequent observations made on 03/05/24 at 12:16 PM and 03/06/24 at 9:03 AM revealed Resident #6's oxygen infusing via at nasal cannula. There was no cautionary oxygen signage posted to indicate oxygen was in use. An interview was conducted with Medication Aide (MA) #1 on 03/06/24 at 9:07 AM. The MA explained that neither the medication aides nor the nurse aides had any responsibility pertaining to the residents' oxygen and stated the only task they could do regarding the oxygen was to replace the cannula or masks. The MA indicated there should be a cautionary oxygen in use sign posted on the resident's doorframe but did not know who was responsible for posting the sign. During an interview with Unit Manager (UM) #2 on 03/06/24 at 9:17 AM the UM explained that whoever the nurse was that initiated the oxygen should post the cautionary oxygen signage on the residents' doorframe and the nurse responsible for the hall should monitor for the signs. An interview was conducted with the Assistant Director of Nursing (ADON) on 03/07/24 at 11:57 AM. The ADON explained that the unit managers and the nurses should be monitoring for the oxygen signs to be posted when they work with the residents. She continued to explain that they had several residents that removed the signs and that was all the more reason for the staff to be vigilant for the signs to be posted on the doorframes. On 03/08/24 at 9:34 AM during an interview with the Director of Nursing, she explained the receptionist was responsible for hanging the cautionary oxygen signs on the residents' doorframes when they were admitted . She indicated the nurse managers should be monitoring the oxygen signs when they make rounds on the halls. b. Resident #58 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD). A review of Resident #58's physician orders dated 12/02/23 revealed continuous oxygen at 3 liters per minute via nasal cannula. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #58's cognition was moderately impaired, and she received supplemental oxygen. A review of Resident #58's Medication Administration Record (MAR) dated 03/2024 indicated the Resident received continuous oxygen at 3 liters per minute via nasal cannula. An observation was made of Resident #58 on 03/04/24 at 1:15 PM. The Resident was lying in bed sleeping with supplemental oxygen being delivered via nasal cannula at 3 liters per minute. There was no oxygen cautionary signage posted to indicate oxygen was in use in the Resident's room. Subsequent observations made on 03/05/24 at 12:10 PM and 03/06/24 at 9:00 AM revealed Resident #58 received supplemental oxygen via nasal cannula at 3 liters per minute. There was no oxygen cautionary sign posted near the Resident's room to indicate that oxygen was in use. An interview was conducted on 03/06/24 at 9:06 AM with Nurse #1. The Nurse acknowledged there was no oxygen sign posted on Resident #58's doorframe and explained the receptionist was responsible for posting the oxygen signs outside the residents' door when they were admitted on oxygen. During an interview with Unit Manager (UM) #2 on 03/06/24 at 9:17 AM the UM explained that whoever the nurse was that initiated the oxygen should post the cautionary oxygen signage on the residents' doorframe and the nurse responsible for the hall should monitor for the signs. An interview was conducted with the Assistant Director of Nursing (ADON) on 03/07/24 at 11:57 AM. The ADON explained that the unit managers and the nurses should be monitoring for the oxygen signs to be posted when they work with the residents. She continued to explain that they had several residents that removed the signs and that was all the more reason for the staff to be vigilant for the signs to be posted on the doorframes. On 03/08/24 at 9:34 AM during an interview with the Director of Nursing, she explained the receptionist was responsible for hanging the cautionary oxygen signs on the residents' doorframes when they were admitted . She indicated the nurse managers should be monitoring the oxygen signs when they make rounds on the halls.

Based on observations, record review and staff interviews, the facility failed to accurately code the Minimum Data Set assessments in the areas of discharge and lower extremity impairment for 1 of 2 discharged residents and 1 of 1 resident reviewed for choices (Resident #89 and Resident #1). The findings included: 1. Resident #89 was admitted to the facility on [DATE]. Review of Resident #89's discharge Minimum Data Set assessment dated [DATE] revealed he was discharged from the facility with a return anticipated. Additional review of the discharge Minimum Data Set assessment revealed Resident #89 was coded as being discharged to his home or back into the community. Review of progress notes revealed a progress note dated 02/02/24 that read, in part: Resident and wife insisted that resident discharge from facility today due to copays . Unable to convince them to stay and continue rehabilitation. Home health set up . An interview with MDS Nurse #2 on 03/08/24 at 12:03 PM revealed she had coded the discharge inaccurately. MDS Nurse #2 reported Oh my, that's wrong. and reported she would correct the discharge status of Resident #89 and resubmit the Minimum Data Set assessment. An interview with the Director of Nursing on 03/08/24 at 12:21 PM revealed she expected Minimum Data Set assessments to be completed accurately and thoroughly. She verified that Resident #89 was discharged home without an expected return and his discharge Minimum Data Set assessment should have reflected that. 2. Resident #1 was admitted to the facility on [DATE] with diagnoses that included paraplegia. Review of Resident #1's annual Minimum Data Set assessment dated [DATE] revealed Resident #1 was cognitively intact. Resident #1 was coded with no impairment to her lower extremity and required substantial or maximal assistance with lower body dressing. Resident #1 was dependent on others for putting on and taking off footwear. An observation an interview of Resident #1 on 03/08/24 at 9:07 AM revealed her to be in her wheelchair propelling herself with her arms towards the activity room. Resident #1 reported due to her medical diagnoses, she had no feeling or control of her lower body. She reported she required total assistance with bathing and dressing her lower half. Resident #1 reported the only movement she had in her legs were occasional involuntary spasms. An interview with MDS Nurse #2 on 03/08/24 at 11:46 AM, she stated she reviewed therapy notes and read diagnoses to determine limitations to an extremity. She reported she had coded the Minimum Data Set with no impairment due to a physical therapy note that reported no issues with range of motion. MDS Nurse #2 then reviewed the Resident Assessment Instrument manual for instructions on coding of impairments and reported she can't do that, it's incorrect. MDS Nurse reported she would correct the annual Minimum Data Set assessment to accurately reflect Resident #1's lower extremity limitation and resubmit it. An interview with the Director of Nursing on 03/08/24 at 12:21 PM revealed she agreed that Resident #1 had a limitation to lower extremity and reported she expected it to be accurately reflected on Resident #1's Minimum Data Set assessments.

Based on record reviews, and family, Nurse Practitioner, x-ray company representative, and staff interviews, the facility failed to provide comprehensive assessments for a resident when the Unit Manager and Nurse Practitioner were made aware the resident had complaints of lower left extremity pain on 11/22/2022 and was noted to have shortening of his left leg by therapy. An x-ray was ordered on 11/22/22 with results reported to the facility on [DATE], which noted an acute, transverse, displaced left femoral neck fracture (a transverse break is usually associated with major force, displaced fracture typically required surgical intervention for repair, sub-capital meaning it occurred in the neck of the thigh bone). The x-ray results were not followed up on or acknowledged after the x-ray was completed and the resident continued to report pain during therapy. No medical evaluation or treatment were initiated until the Nurse Practitioner called the facility near midnight on 11/27/22 and reported the x-ray results to staff. Resident #1 reported left hip pain of 9 on a scale of 9 to 10 (10 being the worst pain) prior to being transferred to the hospital on 11/28/22 and the left hip fracture required surgical intervention for repair. This deficient practice occurred for 1 of 3 residents reviewed for professional standards (Resident #1). The Immediate Jeopardy (IJ) began on 11/22/22 when Resident #1 complained of significant lower extremity pain and experienced changes in his gait during therapy and assessments and interventions were not provided. The immediate jeopardy was removed on 1/1/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity D (no actual harm that is immediate jeopardy) to complete education and to ensure monitoring systems are put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] for short term rehabilitation with diagnosis that included, unsteadiness of his feet, vascular dementia, abnormal gait, and a history of falls. An admission Minimum Data Set (MDS) dated [DATE] indicted Resident #1 was cognitively intact for decision making and reflected no pain present. A physical therapy note dated 11/18/22 written by the Physical Therapist (PT) indicated Resident #1 complained of left knee pain with movement which was reduced when at rest as well as swelling of the knee was noted upon examination. The note further indicated the Therapy Program Manager notified nursing staff of the change in Resident #1's condition. A physical therapy note dated 11/22/22 written by Physical Therapy Assistant #1 (PTA) indicated Resident #1 had complained of pain in the left knee which radiated down the calf with certain movements. The note further explained PTA #1 notified both the Physical Therapist (PT) and the Therapy Program Manager of Resident #1's change of condition. The assessment by the PT was conducted which revealed Resident #1 had Trendelenburg gait with scissoring feet patterns with maximum assistance provided by staff (a stepping pattern where the feet cross when attempting to move forward and hips flex upward with each step), flexed posture, and LLE pain. The PT recommended an order for an x-ray to be obtained to the LLE and spine. The Nurse Practitioner wrote an order dated 11/22/22 requesting an x-ray for the left hip and lumbar spine to be obtained for LLE pain and leg shortening. An x-ray report dated 11/23/22 indicated Resident #1 had a radiological study of the left hip and lumbar spine on 11/22/22 which resulted with findings to include an acute, transverse, displaced sub capital fracture of the femoral neck. (a transverse break is usually associated with major force, displaced fracture typically required surgical intervention for repair, sub-capital meaning it occurred in the neck of the thigh bone). The x-ray was not signed by staff as being received. A review of the medical record of Resident #1 revealed no notification was made by facility staff to the medical provider regarding the results of Resident #1's x-ray performed on 11/22/22. A physical therapy note dated 11/23/22 written by PTA #1 revealed Resident #1 had increase confusion, continued with unsafe Trendelenburg gait with scissoring pattern, pain in the left knee which radiated into the calf. PTA #1's note indicated she notified nursing of Resident #1's condition and was told that an x-ray had been ordered the day before and the results were pending as well as she was requesting an order for a urinary analysis (UA) for increase confusion. An interview with PTA #1 on 12/30/22 at 11:00 AM revealed she was familiar with Resident #1 and had worked with him on several days while in the facility. PTA #1 explained she had provided therapy treatment to Resident #1 on 11/22/22 when he reported pain in knee down to calf with certain movements. She indicated on 11/22/22 his gait was worse than his baseline and during ambulation he was moving his feet in a scissoring motion which made his safety compromised. She stated on that date, the Physical Therapist was assisting her with Resident #1's ambulation and performed a quick exam of him and thought he should receive radiological studies. PTA #1 stated both she and the PT made the Therapy Program Manager aware of Resident #1's condition being worsened and to her knowledge an x-ray was ordered on that date. PTA #1 stated she worked with Resident #1 again on 11/23/22 when she noticed he had increased confusion, continued to complain of LLE pain and ambulate in a scissoring gait fashion. PTA #1 indicated she spoke with the nurse on the unit; however, she could not recall which nurse, and was told an x-ray had been ordered but the result was not available at the time and the nurse would request an order for a urinary analysis if the confusion continued. PTA #1 stated that was the last day she worked with Resident #1 because he was discharged from therapy services when he was sent to the hospital for a fractured hip. A telephone interview with the Physical Therapist on 12/30/22 at 1:20 PM revealed she had evaluated Resident #1 on admission and had provided therapy treatment on several days during his stay at the facility. She explained Resident #1 began having periodic vague complaints of pain beginning with his wrist about a week after admission; however, she noticed acute changes to Resident #1 on 11/18/22 and the pain to his LLE progressively got more intense over the remainder of his stay in the facility. The PT stated she had performed a couple brief tests on Resident #1 when she initially thought there was a possibility of nerve impingement or a possible blood clot due to pain in the knee with weight bearing and abnormal gait, but the test was not abnormal and therefore notified the Therapy Program Manager with recommendations of radiological studies. The PT could not recall whether Resident #1's leg lengths varied, but stated she allowed Resident #1 to continue therapy while x-rays were pending because he continued to actively participate despite some reports of pain. She indicated she had asked a hall nurse, although unable to identify which nurse, about the x-ray results but were told they remained pending. An interview with the Therapy Program Manager on 12/30/22 at 11:50 AM revealed she is the Therapy Program Manager and had not directly worked with Resident #1; however, had been made aware of his complaints of pain to his LLE and abnormal gait. She stated on 11/22/22 she had been made aware of the concerns with his change in condition and she had made the Unit Manager aware of the recommendation to obtain a radiological study to determine the changes noticed during therapy. She further stated she was later made aware an x-ray had been ordered but was not aware of the results of a hip fracture until she arrived at the facility on 11/28/22 and learned Resident #1 had been admitted to the hospital. A physical therapy note dated 11/24/22 written by PTA #2 indicated Resident #1 had reported continued pain to his LLE and nursing was made aware which informed therapy the pain was related to arthritic changes. A physical therapy note dated 11/25/22 written by PTA #2 indicated Resident #1 refused to participate in ambulation exercises in the therapy pain secondary to ongoing pain in the LLE. The hall nurse was notified of the ongoing concern at the time. A review of the November 2022 Medication Administration Record (MAR) revealed Resident #1 received no medications for pain from 11/22/22 through 11/27/22. On 11/28/22 at 12:12 AM, received a 1-time order for Norco 5/325 mg and Tylenol 1000 mg which was administered before transferring him to the emergency room (ER) for evaluation of a left hip fracture. The November MAR (Medication Administration Record) had pain documented as follows: 11/8 pain level #1, 11/12 pain level #2 on days and level #1 on 2nd. No further pain was documented until 11/22 with level #1 on both first and second shifts, 11/25 level #3 on days and level #2 on second shift. Additionally, on 11/26 Resident #1 reported pain level #1 on first and second shift and on 11/27 level #2 on first shift and level #3 on second shift. A physician's order entered by Nurse #3 on 11/28/22 at 12:07 AM indicated the following: Tylenol 500 mg (2 tablets) x 1 dose NOW and Norco 5/325 mg NOW for pain. A review of Resident #1's medical record revealed no notes reflected a comprehensive pain assessment to include LE shortening was completed besides every shift pain levels routinely listed on the MAR following the complaints made in therapy on 11/22/22. An Interact note (change of condition form) written by Nurse #1 dated 11/28/22 indicated Resident #1 was discharged to the hospital for an abnormal x-ray with a pain level #9 to the left hip. A nurses note dated 11/28/22 written by Nurse #1 indicated the hospital called to question the facility regarding the x-ray, fracture, and delayed treatment for 6 days and the nurse had no knowledge of the x-ray, or any concerns related the resident until that shift. A hospital History and Physical dated 11/28/22 indicated Resident #1 arrived in the ER via EMS on 11/28/22 after it was discovered by the facility, he had a left femoral neck fracture after the x-ray ordered on 11/22/22 had not been reviewed until then. During the ER exam, the fracture of the left femur was confirmed, and Resident #1 was admitted to the hospital with a fracture to the left hip with orthopedic and vascular surgery pending. An emergency room report dated 11/28/22 indicated the hospital had contacted the facility about the delay in treatment following the x-ray performed on 11/22/22 and was told he slipped through the cracks and therefore the results were not interpreted, nor treatment initiated for 6 days following the studies due to the provider being on vacation. The report further indicated Resident #1 had a displaced and impacted left femoral neck fracture and recommended a CT (computer tomography study- a more detailed radiological study where a computer guides the image). An interview with the Nurse Practitioner on 12/30/22 at 10:36 AM revealed she was the facility's routine NP. The NP stated she recalled Resident #1 and being informed on 11/22/22 by a staff member that requested x-rays for Resident #1 due to complaints of LLE pain and leg shortening. The NP reviewed her documentation in Resident #1's medical record and stated she had recorded a visit on 11/22/22 for a medication review; however, had not included any documentation related to the complaints of pain nor leg shortening. The NP stated if she had assessed Resident #1 after the request of the orders, an addendum would have been included in her note on 11/22/22. The NP stated she was not on duty during the period of 11/23/22 through 11/28/22 due to the holidays; however, late on the evening of 11/27/22 she was reviewing the medical record of Resident #1 and discovered the x-ray results which revealed a left hip fracture. She called the facility on 11/28/22 to see if Resident #1 had returned to the facility and nursing staff that answered the phone had no knowledge of the x-ray results. The NP stated she would expect the facility to inform a provider of all abnormal x-ray results immediately and did not feel as though the delay from 11/22/22 through 11/27/22 was an appropriate length of time for Resident #1 to go without medical intervention for a hip fracture. The NP indicated the facility had on-call services 24/7 for notification of abnormal results and orders. The NP also indicated she was not aware Resident #1 went without any pain management from 11/22/22 through 11/28/22. The NP indicated she was not an expert with orthopedics and could not specify how the injury occurred; however, stated it may have been possible the injury occurred because of an undetected hairline fracture which crumbled with increase weight bearing activities resulting in a complete break in a short period of time. The NP said because she did not assess him, she could not speak to his leg shortening or treatment plan other than she ordered the x-ray. The NP could not recall why Resident #1 was not assessed and generally stated she could have been leaving or something other patient care when staff approached her but could not specifically recall why she did not assess him before giving the orders. An interview with a dispatcher from x-ray company on 12/29/22 at 3:08 PM revealed the documentation provided in their records indicated Resident #1 had a radiological order for a left hip and lumbar spine studies which were obtained by staff on 11/22/22 at 11:55 PM and resulted in an acute, transverse, displaced, subcapital fracture of the femoral neck on 11/23/22 at 1:55 AM. The dispatcher indicated results had been faxed to the facility and a call placed to the facility; however, the notes included did not include who the dispatcher spoke with at the time of the call and no further details were included in this record for this study. An interview with Nurse #1 on 12/30/22 at 9:40 AM revealed she was the nurse who was on duty on both the evening of 11/22/22 and the evening of 11/27/22 and typically worked 7P-7A shifts. Nurse #1 indicated she was not informed during shift-to-shift report that an order was obtained on 11/22/22 for Resident #1 to have radiological studies performed, that he had complained of pain, nor whether radiological studies had been performed at the time. Nurse #1 also indicated she was on duty on the evening of 11/27/22 when she received a phone call very late in the shift from the facility's nurse practitioner (NP) questioning Resident #1's condition and if he was at the hospital. When Nurse #1 asked further questions Nurse #1 was unable to answer, Nurse #1 stated she requested assistance from another nurse on duty at the time (Nurse #2) who was able to locate the radiological studies performed on Resident #1 on 11/22/22 resulted in an acute, transverse, displaced subcapital fracture of the femoral neck. Nurse #1 stated she and Nurse #2 went to Resident #1's room during the phone call and asked him about his pain and was told he had some pain at the time. Nurse #1 did not recall if she performed any physical assessment for Resident #1 other than asked him about his pain. Nurse #1 indicated both she and Nurse #2 returned to the telephone and received orders from the NP to provide pain medications and send Resident #1 to the ER immediately for evaluation. Nurse #1 stated she collected needed paperwork while Nurse #2 called paramedics (EMS) to the facility. An interview with Nurse #2 on 12/30/22 at 9:49 AM revealed she was on duty on the evening shift (7P-7A) of 11/27/22 when Nurse #1 asked her to aid when the facility's NP called asking questions about an x-ray, she had ordered on 11/22/22. Nurse #2 stated after some difficulty, she was able to locate the results for Resident #1's studies which revealed Resident #1 had sustained an acute, transverse, displaced subcapital fracture of the femoral neck. Nurse #2 stated the NP became upset and questioned why Resident #1 was still in the facility at the time with a fractured hip. Nurse #2 stated she had not provided direct care to Resident #1 during that time frame and had no knowledge of the studies being ordered or why interventions had not been placed for the left hip fracture until that time. Nurse #2 stated she, Nurse #1, and the night shift supervisor (Nurse #3) all went to Resident #1's room that night after receiving the phone call from the NP and stated Resident #1 complained of back and hip pain at the time. Nurse #2 did not recall if she performed any physical assessment for Resident #1 other than asked him about his pain. Nurse #2 stated she completed some needed documentation and called EMS to transfer Resident #1 to the ER for evaluation immediately. An interview with Nurse #3 on 12/30/22 at 9:59 AM revealed she was the supervisor on duty on the evening of 11/27/22 when Nurse #1 and Nurse #2 gained knowledge of radiological studies for Resident #1 which included a left hip fracture. Nurse #3 indicated she had worked several days in during the time frame of 11/22/22 through 11/27/22 and had no knowledge Resident #1 had x-rays ordered, obtained, nor resulted in a hip fracture. Nurse #3 stated she did not provide direct care for Resident #1 and could not address pain management during that time; however, stated she could recall he reported pain to Nurse #1 and Nurse #2 on the evening shift of 11/27/22 to early am on 11/28/22 when he was transferred to the ER for evaluation. Nurse #3 indicated she was normally provided a generalized report on all resident conditions for the building during a brief shift to shift report which would include when radiological studies had been ordered and the results; however, she could not recall having any knowledge the studies had been ordered or she would have been on the lookout for the report to be on the fax machine. Nurse #3 stated when results are received from the x-ray company, all abnormalities are to be immediately called the provider, the copies placed in the provider's binder located at the nurses' station and the on-coming nurses to receive report of any pending x-ray results. An interview with Nurse #4 on 12/30/22 at 12:15 PM revealed she was one of the day shift supervisors/Unit Manager in the facility and was the one who obtained the orders for Resident #1 to have radiological studies of the left hip and spine on 11/22/22 and called the local x-ray company to setup the appointment to have them completed. Nurse #4 indicated when she received orders, her normal process was to inform the nurse assigned to the unit of the resident's orders or changes in condition; however, she could not recall who she informed on 11/22/22 of the orders for the radiological studies or the concerns with changes in therapy and she did not perform a physical assessment of Resident #1 at the time, but strictly requested the x-ray as a recommendation of therapy staff. Nurse #4 further stated after studies are completed, the results are faxed to the facility, and they typically receive a phone call alerting them of abnormal results; however, she could not recall why results were not available for Resident #1's studies during the typical range of 24 hours after the x-ray was obtained. She stated she had not contacted the x-ray company herself to verify the result following the order being made on 11/22/22. An interview with Nurse #5 on 12/30/22 at 12:00 PM revealed she had worked with Resident #1 during his stay; however, could not verify which dates. Nurse #5 indicated she recalled being notified by a member of therapy that he had complained of pain during his treatment and had some slight swelling in his lower extremity. Nurse #5 stated therapy had placed him back in bed and offloaded his LE's and she asked the Unit Manager about the x-ray results since she was unable to locate them in his medical record. According to Nurse #5, she was told by the Unit Manager that the results were still pending, and she thought she gave him pain medication but stated if it was not listed on the MAR she may have been waiting for an order for additional medication at the time if none was ordered. Nurse #5 explained she was unaware of any falls or injuries which would have resulted in the acute changes to Resident #1 and verified Resident #1 could not have been able to mobilize himself without staff assistance had he fallen. A telephone interview with Nurse #6 on 12/30/22 at 12:45 PM revealed she was familiar of Resident #1; however, she could not recall the x-ray being ordered stating in spite being on duty when the x-ray was obtained, she had no knowledge of what time it was obtained and at no time looked for a result or performed a physical exam of Resident #1 secondary to his pain or potential for LE shortening. Attempts to interview PTA #2 were unsuccessful. Attempts to interview Nurse #7 were unsuccessful. An interview with the Director of Nursing (DON) on 1/4/22 at 10:30 AM revealed she had become aware of Resident #1's x-ray which resulted in a left hip fracture when she arrived to the facility on [DATE] and was notified he had been admitted to the hospital. The DON stated she called the x-ray company and began formulating a plan for correcting concerns with notification of results following radiological studies. She further indicated the facility did not hold their normal meeting of the interdisciplinary team on 11/24/22 or 11/25/22 and therefore she was not made aware the results were not obtained on 11/23/22 following the x-ray being performed. The DON indicated she was unaware of any fall or injury that occurred in the facility which would have resulted in the fracture and believed it occurred prior to admission and was undetected during his previous hospital stay. The DON further explained typically all x-ray reports have been obtained within 24 hours following the x-ray being performed but could not explain why staff had not contacted the imaging company when the results continued to be pending after 24 hours nor why no formal assessment of the ongoing complaints of pain or potential LE shortening had been performed as these would be expected to be included in the medical record with any acute change in condition. The Administrator was notified of immediate jeopardy via telephone on 12/30/22 at 5:20 PM. F684 o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance *On 11/22/22 until 11/28/22 the facility failed to provide a comprehensive assessment and note a significant change in condition in resident delaying the medical intervention and treatment including pain interventions to resident #1. * On 11/22/22 resident #1 had swelling and redness of LLE. In addition, there was pain and shortening of the leg of Resident #1 noted during therapy that was reported to nursing staff and the NP that was not addressed by assessing the resident on 11/22/22 when X Ray was ordered. An X-Ray was ordered on 11/22/22 with results sent electronically on 11/23/22. X Ray provider failed to fax due to having incorrect fax number and made one attempt to call but did not get an answer at the facility and did not make any additional attempts. Facility failed to access results until 11/28/22 at which time it was discovered to be a displaced subcapital fracture neck femur and resident was sent to ED. *All other residents with X Ray services were noted at risk for this deficient practice, which was identified, and a self-imposed plan of correction related to the monitoring and completion of x-rays was initiated on 11/28/2022 and completed on 11/30/2022. The facility retains compliance as it relates to the monitoring of x-rays. *All residents were assessed for undocumented, unreported or unknown changes in condition that would result in a change in the resident plan of care including physician notification, thorough assessment and medical intervention by Unit Managers or designee on 12/30/22 - 12/31/22. No other residents were identified. o 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 On 11/28/22 an audit of all X Rays ordered in the last 14 days was completed. No concerns were found. On 11/28/22 education was provided to all Nurses on reporting of all ordered X Ray results immediately to DON or designee. On 11/28/22 DON requested a POC from the X Ray provider in relation to no verbal notification of acute X Ray findings as well as correction of fax number and creation of a pop-up screen with DON contact information when no answer at the facility to assure notification. On 11/28/22 and ongoing all X Rays will be reported to the DON or Designee when ordered and will be followed up daily until results are received. X Rays will be listed and monitored on a whiteboard each morning during morning meeting as well as the Nurse Manager office and documented on Audit form until the results are received. The DON was educated on 11/28/22 by the Regional Clinical Director. Education provided was specifically related to change of condition (specifically related to pain) and the new process of tracking pending diagnostics tracking log to ensure compliance and effectiveness. The ADON and Unit Managers were educated by the DON on 11/28/22. Education provided was specifically related to change of condition (specifically related to pain) and the new process of tracking pending diagnostics tracking log to ensure compliance and effectiveness. On 12/30/22 - 12/31/22 all direct care staff were educated to include Therapy staff by the DON, ADON, Unit Managers or designee to immediately report changes in condition (specifically related to pain, including change in appearance of the human anatomy) including a change in behavior, ADL, or participation in activities, therapy or other usual patterns to licensed nurses. This education including verbal indications as well as non-verbal indications including grimacing, withdrawing, mental status changes, etc for those residents who may not be able to verbalize a change in condition including but not limited to increased pain. NP was educated on the expectation and importance of completing assessment when notified of change in condition and/or pain. All licensed nurses working and the Nurse Practitioner were educated on thorough assessment related to change in condition and/or pain; and reporting to Physician or Physician Extender (Nurse Practitioner) immediately on 12/30/22 - 12/31/22 by DON, ADON, Unit Manager or designee. All other licensed staff members who were not present, including agency staff will receive training to include the above information prior to returning to work. The director of nursing and administrator will be responsible to ensure this occurs. Alleged IJ removal date is 1/1/23. The credible allegation was removed on 1/1/23 with a validation completed on 1/4/23 through staff interview and in-service training records. Staff were able to verbalize the process of the facility for ordering x-rays, tracking and obtaining radiological study results, and follow-up with the provider with results immediately. Staff were able to demonstrate the process established through the electronic medical record and vocalize all abnormal results were now called to the DON by the mobile x-ray company as well as fax the report and call the facility with abnormal results. Additionally, staff were able to vocalize understanding of the requirements for a physical assessment to recognize acute changes in condition of a resident as well as the urgency to obtain medical interventions for significant changes in condition.

Based on record reviews and family, nurse practitioner (NP), x-ray company representative and staff interviews, the facility neglected to provide necessary care and services after a resident complained of left lower pain during therapy on 11/22/22 and was assessed by the Physical Therapist who recommended an x-ray of Resident #1's left lower extremity and spine. The x-ray results reported on 11/23/22 noted an acute, transverse, displaced sub capital fracture of the femoral neck (a transverse break is usually associated with major force, displaced fracture typically required surgical intervention for repair, sub-capital meaning it occurred in the neck of the thigh bone). No facility staff followed up on or acknowledged the x-ray results. Resident #1 continued to report pain in his left lower extremity to therapy daily and on 11/25/22 refused therapy due to the severe pain. No medical evaluation or treatment were initiated until the Nurse Practitioner called the facility near midnight on 11/27/22 and reported the x-ray results to staff. Resident #1 reported left hip pain of 9 on a scale of 9 to 10 (10 being the worst pain) prior to being transferred to the hospital on 11/28/22 and the left hip fracture required surgical intervention for repair. This deficient practice occurred for 1 of 3 residents reviewed for professional standards (Resident #1). The Immediate Jeopardy (IJ) began on 11/22/22 when Resident #1 complained of significant lower extremity pain and no nursing or medical interventions were provided. The immediate jeopardy was removed on 1/1/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity D (no actual harm that is immediate jeopardy) to complete education and to ensure monitoring systems are put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] for short term rehabilitation with diagnoses that included, unsteady on his feet, abnormal gait, and a history of falls. An admission Minimum Data Set (MDS) dated [DATE] indicted Resident #1 was cognitively intact for decision making and reflected no pain present. A physical therapy note dated 11/22/22 written by Physical Therapy Assistant (PTA) #1 revealed, on multiple days ranging from 11/22/22 through 11/25/22, Resident #1 had complained of pain in the left knee which radiated down the calf with certain movements. The note further explained PTA #1 notified both the PT and the Therapy Program Manager of Resident #1's change of condition. Which included an assessment by the PT of Trendelenburg gait with scissoring feet patterns with maximum assistance provided by staff, flexed posture, (a stepping pattern where the feet cross when attempting to move in a forward motion as well as where hips are flexed upward with each step) and LLE pain. The PT recommended an order for an x-ray to be obtained to the LLE and spine. The Nurse Practitioner wrote an order dated 11/22/22 requesting an x-ray for the left hip and lumbar spine to be obtained for LLE pain and leg shortening. Medical record review revealed a physician's order dated 11/22/22 for an x-ray for the left hip and lumbar spine were to be obtained for LLE pain and leg shortening for Resident #1. An x-ray report dated 11/23/22 indicated Resident #1 had a radiological study of the left hip and lumbar spine on 11/22/22 which resulted with findings to include an acute, transverse, displaced sub capital fracture of the femoral neck. (a transverse break is usually associated with major force, displaced fracture typically required surgical intervention for repair, sub-capital meaning it occurred in the neck of the thigh bone). The x-ray was not signed by staff as being received. A review of the medical record of Resident #1 revealed no notification was made by facility staff to the medical provider regarding the results of Resident #1's x-ray performed on 11/22/22. A physical therapy note dated 11/23/22 written by PTA #1 revealed Resident #1 had increase confusion, continued with unsafe Trendelenburg gait with scissoring pattern, pain in the left knee which radiated into the calf. PTA #1's note indicated she notified nursing of Resident #1's condition and was told that an x-ray had been ordered the day before and the results were pending as well as she was requesting an order for a urinary analysis (UA) for increased confusion. An interview with PTA #1 on 12/30/22 at 11:00 AM revealed she was familiar with Resident #1 and had worked with him on several days while in the facility. PTA #1 explained she had provided therapy treatment to Resident #1 on 11/22/22 when he reported pain in knee down to calf with certain movements. She indicated on 11/22/22 his gait was worse than his baseline and during ambulation he was moving his feet in a scissoring motion which made his safety compromised. She stated on that date, the Physical Therapist was assisting her with Resident #1's ambulation and performed a quick exam of him and thought he should receive radiological studies. PTA #1 stated both she and the PT made the Therapy Program Manager aware of Resident #1's condition being worsened and to her knowledge an x-ray was ordered on that date. PTA #1 stated she worked with Resident #1 again on 11/23/22 when she noticed he had increased confusion, continued to complain of LLE pain and ambulate in a scissoring gait fashion. PTA #1 indicated she spoke with the nurse on the unit; however, she could not recall which nurse, and was told an x-ray had been ordered but the result was not available at the time and the nurse would request an order for a urinary analysis if the confusion continued. PTA #1 stated that was the last day she worked with Resident #1 because he was discharged from therapy services when he was sent to the hospital for a fractured hip. A telephone interview with the Physical Therapist on 12/30/22 at 1:20 PM revealed she had evaluated Resident #1 on admission and had provided therapy treatment on several days during his stay at the facility. She explained Resident #1 began having periodic vague complaints of pain beginning with his wrist about a week after admission; however, she noticed acute changes to Resident #1 on 11/18/22 and the pain to his LLE progressively got more intense over the remainder of his stay in the facility. The PT stated she had performed a couple brief tests on Resident #1 when she initially thought there was a possibility of nerve impingement or a possible blood clot due to pain in the knee with weight bearing and abnormal gait, but the test was not abnormal and therefore notified the Therapy Program Manager with recommendations of radiological studies. The PT could not recall whether Resident #1's leg lengths varied, but stated she allowed Resident #1 to continue therapy while x-rays were pending because he continued to actively participate in spite of some reports of pain. She indicated she had asked a hall nurse, although unable to identify which nurse, about the x-ray results but were told they remained pending. An interview with the Therapy Program Manager on 12/30/22 at 11:50 AM revealed she was the Therapy Program Manager and had not directly worked with Resident #1; however, had been made aware of his complaints of pain to his LLE and abnormal gait. She stated on 11/22/22 she had been made aware of the concerns with his change in condition and she had made the Unit Manager aware of the recommendation to obtain a radiological study to determine the changes noticed during therapy. She further stated she was later made aware an x-ray had been ordered but was not aware of the results of a hip fracture until she arrived at the facility on 11/28/22 and learned Resident #1 had been admitted to the hospital. An interview with Nurse #4 on 12/30/22 at 12:15 PM revealed she was one of the day shift Supervisors/Unit Manager in the facility and was the one who obtained the order the NP for Resident #1 to have radiological studies of the left hip and spine on 11/22/22 and called the local x-ray company to setup the appointment to have them completed. Nurse #4 indicated when she was notified by therapy of Resident #1's change of condition to include pain in his LLE and therefore proceeded to obtain orders. Her normal process was to inform the nurse assigned to the unit of the resident's orders or changes in condition; however, she could not recall who she informed on 11/22/22 of the orders for the radiological studies or the concerns with changes in therapy and she did not perform a physical assessment of Resident #1 at the time, but strictly requested the x-ray as a recommendation of therapy staff. Nurse #4 further stated after studies were completed, the results were faxed to the facility, and they typically receive a phone call alerting them of abnormal results; however, she could not recall why results were not available for Resident #1's studies during the typical range of 24 hours after the x-ray was obtained. She stated she had not contacted the x-ray company herself to verify the result following the order being made on 11/22/22. An interview with the Nurse Practitioner on 12/30/22 at 10:36 AM revealed she was the facility's routine NP. The NP stated she recalled Resident #1 and being informed on 11/22/22 by a staff member that requested x-rays for Resident #1 due to complaints of LLE pain and leg shortening. The NP reviewed her documentation in Resident #1's medical record and stated she had recorded a visit on 11/22/22 for a medication review; however, had not included any documentation related to the complaints of pain nor leg shortening. The NP stated if she had assessed Resident #1 after the request of the orders, an addendum would have been included in her note on 11/22/22. The NP stated she was not on duty during the period of 11/23/22 through 11/28/22 due to the holidays; however, late on the evening of 11/27/22 she was reviewing the medical record of Resident #1 and discovered the x-ray results which revealed a left hip fracture. She called the facility on 11/28/22 to see if Resident #1 had returned to the facility and nursing staff that answered the phone had no knowledge of the x-ray results. The NP stated she would expect the facility to inform a provider of all abnormal x-ray results immediately and did not feel as though the delay from 11/22/22 through 11/27/22 was an appropriate length of time for Resident #1 to go without medical intervention for a hip fracture. The NP indicated the facility had on-call services 24/7 for notification of abnormal results and orders. The NP also indicated she was not aware Resident #1 went without any pain management from 11/22/22 through 11/28/22. The NP indicated she was not an expert with orthopedics and could not specify how the injury occurred; however, stated it may have been possible the injury occurred because of an undetected hairline fracture which crumbled with increase weight bearing activities resulting in a complete break in a short period of time. The NP said because she did not assess him, she could not speak to his leg shortening or treatment plan other than she ordered the x-ray. A physical therapy note dated 11/24/22 written by the PT indicated Resident #1 had reported continued pain to his LLE and nursing was made aware and informed therapy the pain was related to arthritic changes. The PT could not verify which nurse she made aware. A physical therapy note dated 11/25/22 written by PTA #2 indicated Resident #1 refused to participate in ambulation exercises in therapy due to having pain in the LLE. The hall nurse (Nurse #7) was notified of the ongoing concern at the time. Attempts to interview PTA #2 were unsuccessful. Attempts to interview Nurse #7 were unsuccessful. A review of Resident #1's medical record revealed no notes reflected a comprehensive pain assessment was completed besides what is listed on the MAR following the complaints made in therapy. A review of the November 2022 Medication Administration Record (MAR) revealed Resident #1 received scheduled Tylenol 1000 mg (milligrams) every 8 hours from 11/15/22 through 11/22/22 for joint pain. Resident #1 did not receive any additional pain medication for reported pain in therapy and mild complaints of pain to nursing staff from the evening of 11/22/22 through the morning of 11/28/22 at 12:12 AM when he received a time order for Norco 5/325 mg and Tylenol 1000 mg to be administered before transferring him to the emergency room (ER) for evaluation of a left hip fracture. The November MAR (Medication Administration Record) had pain documented as follows: 11/8 pain level #1, 11/12 pain level #2 on days and level #1 on 2nd. No further pain was documented until 11/22 with level #1 on both 1st and 2nd. 11/25 level #3 on days and level #2 on 2nd. Additionally, on 11/26 Resident #1 reported pain level #1 on 1st and 2nd and on 11/27 level #2 on 1st and level #3 on 2nd. A physician's order entered by Nurse #3 on 11/28/22 at 12:07 AM indicated the following: Tylenol 500 mg (2 tablets) x 1 dose NOW and Norco 5/325 mg NOW for pain. An Interact note (change of condition form) written by Nurse #1 dated 12/28/22 indicated Resident #1 was discharged to the hospital for an abnormal x-ray with a pain level #9 to the left hip. He was then transferred and the next of kin ([NAME]- niece) was notified of transfer. A nurses note dated 11/28/22 written by Nurse #1 indicated the hospital called to question the facility regarding the x-ray, fracture, and delayed treatment for 6 days and the nurse had no knowledge of the x-ray, or any concerns related the resident until that shift. An emergency room report dated 11/28/22 indicated the hospital had contacted the facility about the delay in treatment following the x-ray performed on 11/22/22 and was told he slipped through the cracks and therefore the results were not interpreted, nor treatment initiated for 6 days following the studies due to the provider being on vacation. The report further indicated Resident #1 had a displaced and impacted left femoral neck fracture and recommended a CT (computer tomography study- a more detailed radiological study where a computer guides the x-ray). A hospital History and Physical dated 11/28/22 indicated Resident #1 was admitted to the hospital with a fracture to the left hip with orthopedic and vascular surgery pending. A telephone interview with a Dispatcher from X-ray company on 12/29/22 at 3:08 PM revealed the documentation provided in their records indicated Resident #1 had a radiological order for a left hip and lumbar spine studies which were obtained by staff on 11/22/22 at 11:55 PM and resulted in an acute, transverse, displaced, subcapital fracture of the femoral neck on 11/23/22 at 1:55 AM. The dispatcher indicated results had been faxed to the facility and a call placed to the facility; however, the notes did not include who the Dispatcher spoke with at the time of the call and no further details were included in this record for this study. A telephone interview with Nurse #1 on 12/30/22 at 9:40 AM revealed she was the nurse who was on duty on both the evening of 11/22/22 and the evening of 11/27/22 and typically worked 7:00 PM-7:00 AM shifts. Nurse #1 indicated she was not informed during shift-to-shift report that an order was obtained on 11/22/22 for Resident #1 to have radiological studies performed, that he had complained of pain, nor whether radiological studies had been performed at the time. She did not recall him complaining of pain and she did not assess him. Nurse #1 also indicated she was on duty on the evening of 11/27/22 when she received a phone call very late in the shift from the facility's nurse practitioner (NP) questioning Resident #1's condition due to the x-ray results she reviewed in his medical record of the fracture, and to see if he was at the hospital. Nurse #1 stated she requested assistance from another nurse on duty at the time (Nurse #2) to help locate the radiological studies performed on Resident #1 on 11/22/22 and found the report revealed an acute, transverse, displaced subcapital fracture of the femoral neck. Nurse #1 stated she and Nurse #2 went to Resident #1's room during the phone call and asked him about his pain and was told he had some pain at the time. Nurse #1 did not recall if she performed any physical assessment for Resident #1 other than asked him about his pain. Nurse #1 indicated both she and Nurse #2 returned to the telephone and received orders from the NP to provide pain medications and send Resident #1 to the ER immediately for evaluation. Nurse #1 stated she collected needed paperwork while Nurse #2 called Emergency Medical Services to the facility. A telephone interview with Nurse #2 on 12/30/22 at 9:49 AM revealed she was on duty on the evening shift (7:00 PM to 7:00 AM) on 11/27/22 and recalled Nurse #1 asked her to help her find x-ray results that were ordered by the NP on 11/22/22. Nurse #2 stated after some difficulty, she was able to locate the results for Resident #1's studies which revealed Resident #1 had sustained an acute, transverse, displaced subcapital fracture of the femoral neck. Nurse #2 stated the NP became upset and questioned why Resident #1 was still in the facility at the time with a fractured hip. Nurse #2 stated she had not provided direct care to Resident #1 during that timeframe and had no knowledge of the studies being ordered or why interventions had not been placed for the left hip fracture until that time. Nurse #2 stated she, Nurse #1, and the night shift supervisor (Nurse #3) all went to Resident #1's room that night after receiving the phone call from the NP and stated Resident #1 complained of back and hip pain at the time. Nurse #2 did not recall if she performed any physical assessment for Resident #1 other than asked him about his pain. Nurse #2 stated she called EMS to transfer Resident #1 to the emergency room for evaluation immediately. A telephone interview with Nurse #3 on 12/30/22 at 9:59 AM revealed she was the supervisor on duty on the evening of 11/27/22 when Nurse #1 and Nurse #2 gained knowledge of radiological studies for Resident #1 which included a left hip fracture. Nurse #3 indicated she had worked several days during the timeframe of 11/22/22 through 11/27/22 and had no knowledge Resident #1 had x-rays ordered and resulted in a hip fracture. Nurse #3 stated she did not provide direct care for Resident #1 and could not address pain management during that time. Nurse #3 stated when results were received from the x-ray company, all abnormalities were to be immediately called to the provider, the copies placed in the provider's binder located at the nurses' station and the on-coming nurses to receive report of any pending x-ray results. An interview with Nurse #5 on 12/30/22 at 12:00 PM revealed she had worked with Resident #1 during his stay; however, could not verify which dates. Nurse #5 indicated she recalled being notified by a member of therapy that he had complained of pain during his treatment and had some slight swelling in his lower extremity. Nurse #5 stated therapy had placed him back in bed and offloaded his LLE's and she asked the Unit Manager about the x-ray results since she was unable to locate them in his medical record. According to Nurse #5, she was told by the Unit Manager that the results were still pending, and she thought she gave him pain medication but stated if it was not listed on the MAR she may have been waiting for an order for additional medication at the time if none was ordered. A telephone interview with Nurse #6 on 12/30/22 at 12:45 PM revealed she was familiar of Resident #1, however, she could not recall the x-ray being ordered even though she was on duty when the x-ray was obtained, she had no knowledge of what time it was obtained and at no time looked for a result or performed a physical exam of Resident #1 secondary to his pain or LLE shortening. Nurse #6 did not recall him being in pain. An interview with the Director of Nursing (DON) on 1/4/22 at 10:30 AM revealed she had become aware of Resident #1's x-ray which resulted in a left hip fracture when she arrived at the facility on 11/28/22 and was notified he had been admitted to the hospital. The DON further explained typically all x-ray reports are obtained within 24 hours following the x-ray being performed but could not explain why staff had not contacted the imaging company when the results continued to be pending after 24 hours nor why no formal assessment of the ongoing complaints of pain or potential LLE shortening had been performed as these would be expected to be included in the medical record with any acute change in condition. The Administrator was notified of immediate jeopardy via telephone on 12/30/22 at 5:20 PM. F600 o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance * On 11/22/22 the facility neglected to provide services in accordance with resident's physical needs upon exhibiting a significant change of condition related to pain. On 11/22/22, documentation mentioned possible shortening of the leg * On 11/22/22 resident #1 had swelling and redness of LLE. X-Ray was ordered and results identified on 11/28/22 at which time it was discovered to be a fracture. The delay in review of the X Ray was a result of lack of a process to track pending X Ray Results. During that time the patient experienced pain and confusion with no assessment or pain medication administered. *All other residents experiencing pain or other signs of significant changes without an assessment and pending x-ray results are at risk from suffering from the deficient practice. On 12/30/22 - 12/31/22, an audit of all residents was completed by the Unit Managers or designee to determine if they have experienced any pain or changes in condition without treatment and for residents with pending x-ray results. No concerns were found. o 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 On 12/30/22 education was provided to the Administrator by the Director of Operations regarding the definition of neglect. On 12/31/22 education was provided to the Human Resources Director by the Administrator regarding the definition of neglect and including education to all new hires/Agency direct care staff during orientation. The definition of neglect and the need to immediately notify the Administrator or DON of all issues related to these infractions. If Administrator or DON are not present in facility, supervisors must be notified, and they must inform the Administrator or DON immediately in person or by phone Our facility does not condone and has zero tolerance for resident neglect by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. 0n 12/30/22 - 12/31/22, education was provided by the DON, ADON, Unit Managers or designee, to all care staff to include CNA's, Nurses, Therapist, and Nurse Practitioner regarding the definition of neglect, as defined in the neglect policy and the resident's right to be free from neglect. Neglect is defined as failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. Staff, to include the Nurse Practitioner was also educated 12/30/22 - 12/31/22 to immediately address pain, complete assessments and treat pain as directed by the Physician or Physician Extender (Nurse Practitioner). DON/ADON/Unit Mangers were educated on 11/28/22 regarding the process of tracking pending diagnostic orders until results are obtained. This process includes a diagnostics log implemented by the DON utilizing the EMAR system to identify and document on the log all new orders created each day and reviewed by DON/ADON/Unit Managers daily until results are obtained to ensure compliance and effectiveness. All staff, including agency staff will receive education prior to the start of the shift to include the definition of neglect and the abuse/neglect reporting requirements including immediate intervention. The Director of nursing and administrator will be responsible to ensure this is completed for all licensed staff members On 12/30/22 - 12/31/22, after being reeducated as outlined above, education for all direct care staff to include the Nurse Practitioner was completed in person and via phone by the DON, ADON, Unit Managers or Designee. The education consisted of the following: The definition of neglect and the need to immediately notify the Administrator or DON of all issues related to these infractions. If Administrator or DON are not present in facility, supervisors must be notified, and they must inform the Administrator or DON immediately in person or by phone Signs and symptoms of neglect and mental anguish such as loss of interest, change in routine, change of condition (specifically related to pain), mood alterations, or difficulty eating. Our facility does not condone and has zero tolerance for resident neglect by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. the education focused on changes in condition, specifically related to pain and to ensure x-ray results were received and reported. This training will be provided by the Administrator or the Human Resource Director to all agency staff and new employees upon hire during orientation. All direct care staff including as-needed and agency staff, received this training on 12/30/22 - 12/31/22 and all staff will continue to receive the training yearly thereafter. The Administrator and Human Resource Director were notified by the Regional Director of Operations of the need to provide this training to new hires on 12/30/22. Alleged IJ removal date is 1/1/23. The credible allegation with an IJ removal date of 1/1/23 was validated on 1/4/23. Staff were able to verbalize the definitions of neglect and provided examples as well as vocalize they were to contact the Administrator or DON via phone or in person with any concerns of observed or reported potential of neglect. Staff report they are to provide written statements of their observations or reports made by a resident, staff member, or family member to the facility Administrator immediately. Staff vocalized and demonstrated the updated processes for obtaining and reporting results to a provider and documentation required with all acute changes to a resident.

Based on record reviews, family and staff interviews, the facility failed to protect a resident's right to be free from physical and/or emotional abuse for one of two residents sampled. The abuse occurred on [DATE] during the evening shift (,d+[DATE] PM). Nurse aide #4 (NA #4) reported she was standing in the hallway outside of a resident's room (Resident #336) when she observed NA #1 grab Resident #336's right arm while attempting to transfer her from her recliner chair to a bedside commode while Resident #336 was resistive to a bath. NA #1 did not allow Resident #336 the right to refuse care which resulted in a skin tear to Resident #336 right arm and according to interviews of a Family Member and Staff (NA #2, NA #3, and NA #4) caused Resident #336 to be fearful of NA #1 and not want her to care for her. The immediate jeopardy began on [DATE] when NA #4 witnessed NA #1 grab Resident #336's right arm to transfer her to the bedside commode which resulted in a skin tear to the right arm and Resident #336 being extremely fearful of being cared for by NA #1. The immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity D (no actual harm that is immediate jeopardy) to ensure monitoring systems that were put into place are effective. Findings included: 1. Resident #336 was readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #336 was cognitively intact and required extensive assistance for bed mobility, toileting, and transfers. It further indicated Resident #336 had exhibited no behaviors, had no mental health diagnosis, and received no [CONDITION(S)] medications. A telephone interview on [DATE] at 11:57 AM with Nurse Aide (NA) #4 was conducted. NA #4 revealed she witnessed the alleged abuse from the doorway of Resident #336 on the evening shift of [DATE]. NA #4 stated shortly after the shift began, she was standing in the hallway near Resident #336's room and overheard NA #1 and Resident #336 verbally talking. NA #4 stated Resident #336 told NA #1 she did not want a shower. NA #4 stated she immediately turned to the doorway because she was supposed to be the NA assigned to provide bathing for Resident #336 on this evening. NA #4 stated when she looked in the room, she noticed NA #1 grab Resident #336 right arm and transfer her roughly in a jerking motion from her recliner to the bedside commode. NA #4 stated she immediately entered the room and questioned NA #4 why she did grabbed Resident #336 in that way and NA #4 said to NA #1 you can't do that. NA #4 indicated NA #1 said you can't prove it; I'll say she did it herself on the bedside commode because she hurts herself often. NA #4 stated she immediately left the room and went to find a nurse. NA #4 indicated she thought the nurse was Nurse #4 but could not verify the nurses' identity for sure. NA #4 stated there were 2 to 3 nurses outside of the room when she exited, and she told an agency nurse who was outside the room at the time what she had witnessed between NA #1 and Resident #336. NA #4 stated later that night, Resident #336 expressed to her that she was fearful of NA #1 and felt like she handled her to roughly and doesn't listen when she said she did not want NA #1 to provide bathing care. NA #4 stated she also left a note under the door of the DON (Director of Nursing) later in the shift or on the following day to make her aware of what Resident #336 had reported to her because NA #1 was not removed from the care of Resident #336 following this incident and Resident #336 had told her she was afraid of NA #1 and did not want NA #1 to care for her anymore. A telephone interview on [DATE] at 11:07AM with NA #1 was conducted. NA #1 revealed she was assigned to care for Resident #336 on [DATE] during the evening shift. NA #1 indicated she had entered Resident #336's room to take her for her shower shortly after the shift began. NA #1 stated she was standing in front of Resident #336 when she dropped either her call light or recliner chair remote in the pocket of the recliner chair and reached down to obtain it and when she brought her arm up, she had a skin tear. NA #1 acknowledged she did transfer Resident #336 to the bedside commode in order to transfer her further to the wheelchair for her shower, but Resident #336 continued to refuse a shower so she left the room to make a nurse aware Resident #336 had sustained a skin tear that needed to be assessed. She indicated no one was in the room with her when the incident occurred; however, acknowledged NA #4 entered the room shortly after the incident occurred asking about what happened to Resident #336's arm. NA #1 would not elaborate on what was discussed between her and NA #4 other than NA #1 told NA #4 a skin tear had occurred. NA #1 indicated NA #4 quickly left the room and NA #1 went to tell the nurse on the cart about the skin tear. NA #1 thought the nurse she told was an agency nurse identified to be either Nurse # 4 or Nurse #5, but she could not be certain which she notified but stated there was either 2 to 3 nurses near the medication cart at the time. NA #1 vocalized sometime over the weekend she heard that Resident #336 had made accusations that staff had caused the injury which made her feel uncomfortable with caring for Resident #336 alone and NA #1 indicated she told a nurse who was on duty that day (unable to identify the nurse) and a few days after the skin tear occurred, she talked to the DON and Unit Manager about feeling it was best if Resident #336 was a 2 person gait belt transfer both for her safety and the safety of staff. NA #1 stated she continued to provide care for Resident #336 periodically until her death which was approximately 3 weeks after the incident because she felt that Resident #336 had confused her and another NA who formerly worked in the facility that fit a very similar description of physical appearance and had worked with Resident #336 shortly before the incident occurred. An offsite face to face follow-up interview on [DATE] at 11:00 AM with NA #1 was conducted at her request. NA #1 met with 2 surveyors from the team and revealed Resident #336 did not sustain the skin tear to her right arm by grabbing for a reacher (a device used assist to pick items up) nor on a bedside commode. NA #1 stated the skin tear occurred as a result of a white bedside table/cabinet which was near the residents' recliner chair before she was transferred. NA #1 acknowledged she had transferred Resident #336 for a shower but Resident #336 refused bathing assistance. NA #1 denied the interaction between her and NA #4 but acknowledged NA #4 entered the room shortly after the incident occurred asking Resident #336 what had happen and that NA #4 left the room and NA #1 was unsure where she went following being in Resident #336's room. NA #1 also stated when she came on shift, NA #4 and NA #3 had mentioned to her that she may not want to care for Resident #336 alone due to the allegation. NA #1 was uncertain if this notification happened on the start of the shift on [DATE] or over the weekend following ([DATE] through [DATE]) but was aware Resident #336 had alleged that a NA had caused the skin tear. NA #1 stated she felt as though Resident #336 had confused her identification and had her mixed up with NA #12. NA #1 stated she continued to believe it was an agency nurse she informed on [DATE]; however, NA #1 was informed during a telephone conversation between her and the facility on [DATE] that it was believed by the facility to be the ADON (Assistant Director of Nursing). NA #1 further indicated Resident #336 stated to both NA #1 and the nurse when the nurse entered the room to assess her, Look what you did to me but she thought she meant because they had to rearrange her belongings in her room and not because of the incident. An interview with the ADON on [DATE] at 5:18 PM revealed she was the nurse who was assigned to care for Resident #336 on [DATE] during the evening shift. The ADON stated she recalled being outside in the hallway when the incident occurred and went in Resident #336's room when she heard the resident holler Ow. The ADON stated she did not witness the alleged allegation; however, was able to confirm she saw NA #1 standing in front of Resident #336 when she entered the room to assess the resident. The ADON verified when she assessed Resident #336's skin on the evening of [DATE], there was an area approximately 1.5 by 1 where the skin was described as pushed backwards in a flap type fashion with minimal bleeding visible, but she could not recall seeing visible bruising at the time. The ADON said Resident #336 said she hurt her arm when she grabbed for a reacher, but the ADON could not verify exactly what Resident #336 had said. A follow-up interview with the ADON on [DATE] at 11:58 AM revealed she was unsure why she had not completed a note in Resident #336's medical record on [DATE] with details surrounding the incident that occurred that resulted in a skin tear. The ADON stated she thought the DON had come to her on [DATE] and asked her to complete a note in the record of what she could recall from the incident because an accusation had been made against a nurse aide. During the interview, she could not recall if any other nurses or NAs were near the room when she was told about the skin tear by NA #1 but did recall she saw NA #1 standing in front of Resident #336 when she entered the room. The ADON explained she did not think to ask NA #1 to write a statement of what occurred following the incident but usually would do that for all incidents that occur. A Situation Background Assessment Recommendation (SBAR) form completed by the ADON dated [DATE] indicated Resident #336 had a change in skin color or condition identified as a skin tear at approximately 4:30 PM. A progress note written by the ADON dated [DATE] at 4:03 PM read in part: Late entry for [DATE] at 3:55 PM: NA #1 brought Resident #336 out of her room to take a shower and stated Resident #336 dropped her call light and attempted to pick it up and scratched her arm on the bedside commode. Resident #336's right arm had a skin tear and she wanted to have a dressing applied. The ADON told Resident #336 to wait until after she had a bath, then the ADON would apply a dressing. The ADON went to the Wound Nurse and asked what dressing to apply to Resident #336's arm and the Wound Nurse told her to use [MEDICATION(S)] and a dry dressing to the right arm. The ADON informed NA #1 that Resident #336's bedside commode needed to be set away from the resident's side so if she dropped any object then her arm would not hit her arm on the side of the chair. A telephone interview on [DATE] at 2:56 PM with Nurse #4 revealed she could not recall Resident #336 or the skin tear. Attempts were made to contact Nurse #5 without success. A telephone interview on [DATE] at 11:47 AM with NA #3 was conducted. NA #3 revealed she learned of an incident with Resident #336 when she worked on the evening shift of [DATE]. NA #3 stated she went in to see Resident #336 and noticed the bandage on her arm and bruising directly below the bandage and asked if she had to go to the hospital or if she had hurt herself. NA #3 stated Resident # 336 reported to her she had been grabbed by the arm by NA #1 on the day before which resulted in a skin tear and a dark bruise to the right arm. NA #3 stated following the report by Resident #336, she went to a nurse who was working the medication cart (unable to recall the nurses' name) and told her what Resident #336 had said. NA #3 stated that the nurse told her she was aware of the report and the DON had been made aware and seemed to think Resident #336 had hurt her arm on the bedside commode. NA #3 stated since she made the nurse aware she thought she would handle it further. A telephone interview on [DATE] at 9:40 AM with NA #2 was conducted. Nurse Aide #2 revealed she learned of an incident with Resident #336 when she worked evening shift on [DATE]. NA #2 stated Resident #336 reported to her she had been yanked up by the arm by NA #1 on the day before which caused some skin tears and bruises to the right arm. NA #2 stated following the report by Resident #336 along with the bandage on her arm and bruising directly below the bandage, she told her nurse on the unit (unable to recall nurses name) and was told they thought the injury had occurred on the bedside commode on [DATE]. NA #2 stated she also notified the DON at the time. NA #2 said she stated to the DON, I'd rather do extra work and know the residents were taken care of than to have them mistreated by another staff member. A telephone interview on [DATE] at 4:32 PM with Family Member was conducted. The family member stated several months ago while she was out of town on a Friday night ([DATE]), she received a phone call from the facility alerting her that Resident #336 had sustained a skin tear to the right upper extremity from her bedside commode. The family member stated initially she was not concerned with the incident because she was aware Resident #336 head sustained skin tears in the past. The family member explained she did not become concerned until she spoke to Resident #336 via phone over the weekend. The family member stated during a telephone conversation with the resident, Resident #336 notified her NA #1 had caused the skin tear during a transfer after Resident #336 had told NA #1 she did not want a shower and that NA #1 had told her that it would be her word against Resident #336's word and staff would believe NA #1 over the resident. The family member stated she arrived back in town late on Monday evening (,d+[DATE]) and on Tuesday (,d+[DATE]), while she was working, the family member received a phone call from Resident #336 stating Resident #336 needed the family member to come to the facility immediately because she was extremely fearful and upset. The family member recalled she was told NA #1 had returned to Resident #336's room to provide bathing assistance again on that day (,d+[DATE]) and Resident #336 had told her she did not want her to give her a bath, but NA #1 told her, I did not ask if you wanted a bath, I am giving you one. The family member indicated she rushed to the facility and requested staff to alert the DON that she wished to speak to her urgently. The family member stated a few minutes after the request, she received a telephone call from the DON. During the phone call, the family member said she told the DON she was in the facility and to come to Resident #336's room, which she did. The family member reported when the DON arrived at Resident #336's room on [DATE], she questioned the DON about the skin tear Resident #336 had sustained and how it occurred and was told by the DON that Resident #336 had sustained it on the bedside commode on [DATE]. Resident #336 stated in the presence of the family member and the DON that NA #1 had hurt her and caused the skin tear. NA #1 had arrived in the room again to make additional attempts to provide bathing and the family member explained Resident #336 pointed to NA #1 and stated she is the one that caused the skin tear and NA #1 left the room immediately. The family member stated the DON insinuated during this conversation Resident #336 was lying when she talked over her allegation and said no, that is not what happened, remember, you got that on the bedside commode and quickly changed the subject to start discussing how to transfer Resident #336 instead. The family member vocalized Resident #336 remained fearful of NA #1 for the remainder of her life (approximately 3 weeks) and begged the family member not to leave town again. The family member stated no one should not have been subject to that type of treatment and live in fear in the last days of their life. An interview with the Wound Nurse on [DATE] at 9:30 AM revealed she learned of the skin tear to Resident #336's arm when she was asked by the ADON on [DATE] to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Nurse stated Resident #336 had sustained skin tears in the past and therefore at the time of the interview could not recall exactly what the skin tear to Resident #336's right arm looked like when she saw it on [DATE], but verified she obtained and wrote the order for treatment in Resident #336's medical record on that date. An interview with the DON and Administrator on [DATE] at 10:57 AM was conducted. They both indicated they had no knowledge of the allegation of abuse. The DON recalled she had previously spoke to Resident #336's family when the skin tear occurred; however, did not recall any conversation surrounding the allegation against NA #1. A follow-up interview with the DON on [DATE] at 5:03 PM revealed she was very familiar with Resident #336 and indicated Resident #336 always sat in a recliner and refused to lay in a bed. She also indicated Resident #336 had previously been able to transfer herself independently from the recliner to the bedside commode with the use of her walker; however, after her most recent admission, she required additional assistance from staff. The DON explained Resident #336 was alert and oriented and able to make her needs known to staff. The DON stated the family member came in the facility to visit her mom regularly and was in the facility within a day or two after the incident (skin tear) occurred and Resident #336 had told her that she had not been the one to cause the skin tear but did not name anyone that caused it, but she reminded Resident #336 that the incident occurred from her bedside commode as a result of the need for safer transfer techniques and continued discussing interventions to protect Resident #336's skin and safe transfer techniques. The DON verified no incident report was completed and no witness statements were obtained at the time of the incident because the facility felt this incident to be an ordinary skin tear that didn't look suspicious. The DON stated she was not present and verified she did not witness the alleged abuse. An additional follow-up interview with the DON on [DATE] at 12:25 PM stated she had no knowledge of the allegation until the survey team entered the facility on [DATE]. The DON indicated she had been educated, with all incidents, the interdisciplinary team should review them on the next day during clinical meeting to ensure a root cause had been identified, a nurses note, a SBAR and incident report completed, and orders obtained and entered the EMR. The Administrator, Director of Nursing, and a corporate consultant were notified of immediate jeopardy on [DATE] at 5:30 PM. The facility provided the following credible allegation for IJ removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance * On [DATE] the facility failed to protect a resident's right to be free from physical abuse. * On [DATE] resident #336 sustained a skin tear and mental anguish as a result of physical abuse. *All other residents are at risk from suffering from the deficient practice and resident who are resistive to care were identified as more at risk for abuse. On [DATE], an audit of all residents with a Brief Interview of Mental Status (BIMS) of 10 or above, was completed by the DON, ADON, and Unit Managers or designee to determine if they have experienced any type of resident abuse. No concerns were found. On [DATE], an audit consisting of thorough skin assessment of all residents with a BIMS of 9 or less was completed by licensed nurses to determine if there is evidence of abuse. No concerns were found. o 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 0n [DATE], education was provided to the Administrator, DON, and the Staff Development RN by the Corporate Consultant, Regional Director of Operations, regarding the definition of abuse as defined in the abuse policy and the resident's right to be free from abuse. On [DATE] - [DATE], after being reeducated as outlined above, education for all staff was completed in person and via phone by the Staff Development RN. The education consisted of the following: The definition of abuse, neglect and misappropriation of property and the need to immediately notify the Administrator or DON of all issues related to these infractions. If Administrator or DON are not present in facility, supervisors must be notified, and they must inform the Administrator or DON immediately in person or by phone Signs and symptoms of abuse and mental anguish such as loss of interest, change in routine, mood alterations, or difficulty eating Our facility does not condone and has zero tolerance for resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. the education focused on tactics to deal with difficult residents such as walking away to allow for de-escalation, providing time/place orientation, using a soothing tone of voice, providing gentle tactile cueing, use of gestures, offering distractions such activities, music, or person-centered strategies (pictures, personal memorabilia) This training will be provided by the Administrator or the Human Resource Director to all agency staff and new employees upon hire during orientation. All facility staff in all departments, including as-needed and agency staff, received this training on [DATE]-[DATE] and all staff will continue to receive the training yearly thereafter. The Administrator and Human Resource Director were notified by the Regional Director of Operations of the need to provide this training to new hires on [DATE]. Alleged IJ removal date is [DATE]. On [DATE] the credible allegation of IJ removal with a completion date of [DATE] was validated through staff interview and review of in-service training records. Staff were able to verbalize examples of abuse to include physical, mental, emotional, financial and sexual. Each were able to verbalize they were to report all susupected or allegations of abuse regardless of source to the Administrator and the Director of Nursing to include after hours and weekends.

Based on record reviews family and staff interviews, the facility failed to protect all residents in the facility when Nurse Aide #1 (NA #1) was allowed to continue to care for residents after an allegation of abuse was made against her and according to interviews of a Family Member and Staff (NA #2, NA #3, and NA #4) caused Resident #336 to be fearful of NA #1 and not want her to care for her. The facility also failed to investigate an allegation of abuse made by a cognitively intact resident and failed to report the allegation to the State Agency (SA), Adult Protective Services (APS) and local law enforcement for 1 of 2 residents reviewed for abuse (Resident #336). The immediate jeopardy began on [DATE] when NA #1 was allowed to continue to provide care to residents in the facility after an allegation of abuse was made against NA #1 which resulted in a skin tear and bruising to Resident #336's right arm and according to staff and family interviews left Resident #336 fearful of NA #1. The immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity D (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. Findings included: 1. Resident #336 was readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #336 was cognitively intact and required extensive assistance for bed mobility, toileting, and transfers. It further indicated Resident #336 had exhibited no behaviors. A telephone interview on [DATE] at 11:57 AM with Nurse Aide (NA) #4 was conducted. NA #4 revealed she witnessed the allegation of abuse from the doorway of Resident #336 on the evening shift of [DATE]. NA #4 stated shortly after the shift began, she was standing in the hallway near Resident #336's room and heard NA #1 and Resident #336 verbally talking in an undignified manner. NA #4 stated Resident #336 was resistive to allowing NA #1 to provide bathing assistance and told her she did not want a shower. NA #4 stated she immediately turned to the doorway because she was supposed to be the NA assigned to provide bathing for Resident #336 on this evening. NA #4 stated when she looked in the room, she noticed NA #1 grab Resident #336 by the right arm and transfer her roughly almost jerking motion from her recliner to the bedside commode. NA #4 stated she immediately entered the room and questioned NA #4 why she did that and NA #4 said to NA #1 you can't do that. NA #4 indicated NA #1 said you can't prove it; I'll say she did it herself on the bedside commode because she hurts herself often. NA #4 stated she immediately left the room and went to find a nurse. NA #4 indicated she thought the nurse was Nurse #4 but could not verify the nurses ' identity for sure. NA #4 stated there were 2 to 3 nurses outside the room when she exited, and she told an agency nurse who was outside the room at the time. NA #4 stated she also left a note under the door of the DON later in the shift or on the following day because NA #1 was not removed from the care of Resident #336 following this incident and Resident #336 had told her she was afraid of NA #1 and did not want NA #1 to care for her anymore. A telephone interview on [DATE] at 11:07AM with NA #1 was conducted. She indicated no one was in the room with her when the incident occurred; however, acknowledged NA #4 entered the room shortly after it occurred asking about what happened to Resident #336's arm. NA #1 indicated NA #4 quickly left the room and NA #1 went to tell the nurse on the cart whom she thought was an agency nurse identified to be either Nurse # 4 or Nurse #5 she could not be certain which she notified but stated there was either 2 to 3 nurses near the medication cart at the time. NA #1 vocalized sometime over the weekend she heard that Resident #336 was making accusations that staff had caused the injury which made her feel uncomfortable with caring for Resident #336 alone and NA #1 indicated she told a nurse who was on duty that day. A few days after the initial incident, she talked to the DON and Unit Manager about feeling it was best if Resident #336 was a 2-person gait belt transfer both for her safety and the safety of staff. NA #1 stated she continued to provide care for Resident #336 periodically until her death which was approximately 3 weeks after the incident because she felt that Resident #336 had confused her and another NA who formerly worked in the facility that fit a very similar description of physical appearance and had worked with Resident #336. NA #1 stated she felt as though Resident #336 was confused in her identification and had her confused with NA #12. NA #1 stated she continued to believe it was an agency nurse she informed on [DATE]; however, NA #1 was informed during a telephone conversation between her and the facility on [DATE] that it was believed to be the ADON. NA #1 further indicated Resident #336 stated to both NA #1 and the nurse when the nurse came to the room to assess her, Look what you did to me but she thought she meant because they had to rearrange her belongings in her room and not as a result of the incident. A follow-up interview with NA #1 on [DATE] at 11:00 AM revealed the skin tear did not occur as a result of a bedside commode but according to NA #1 it was from a white bedside table or cabinet which was near Resident #336's recliner chair. NA #1 also explained at the time of the incident, Resident #336 stated to both NA #1 and the nurse when the nurse came to the room to assess her, Look what you did to me but she thought she meant because they had to rearrange her belongings in her room and not as a result of the incident. A verification of employment for NA #12 determined her employment was terminated prior to the incident involving Resident #336 on [DATE]. An interview with the ADON on [DATE] at 5:18 PM revealed she was the nurse who was assigned to care for Resident #336 on [DATE] during the evening shift. The ADON stated she recalled being outside in the hallway when the incident occurred and went in Resident #336 ' s room when she heard the resident holler Ow. The ADON stated she did not witness the alleged allegation; however, was able to confirm she saw NA #1 standing in front of Resident #336 when she entered the room to assess the resident. The ADON verified when she assessed Resident #336's skin on the evening of [DATE], there was an area approximately 1.5 by 1 where the skin was described as pushed backwards in a flap type fashion with minimal bleeding visible, but she could not recall seeing visible bruising at the time. The ADON said Resident #336 said she hurt her arm when she grabbed for a reacher (a device used to aide a person to pick up items), but the ADON could not verify exactly what Resident #336 had said. A follow-up interview with the ADON on [DATE] at 11:58 AM revealed she was unsure why she did not complete a note in Resident #336's medical record on [DATE] with details surrounding the incident that occurred that resulted in a skin tear. The ADON stated she thought the DON had come to her on [DATE] and asked her to complete a note in the record of what she could recall from the incident because an accusation had been made against a nurse aide. The ADON stated she went to the Wound Nurse who provided her an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON explained she did not think about asking NA #1 to write a statement of what occurred following the incident but usually would do that for all incidents that occur. When asked if she assists with any investigations of incidents in the facility, she indicated all investigations are conducted by the DON. A Situation Background Assessment Recommendation (SBAR) form completed by the Assistant Director of Nursing (ADON) dated [DATE] indicated Resident #336 had a change in skin color or condition identified as a skin tear at approximately 4:30 PM but included no other details surrounding the incident. There was not a nurses note in the medical record dated [DATE] which would include additional details regarding the skin tear to Resident #336's right arm or the bruising. A progress note written by the ADON dated [DATE] at 4:03 PM read in part: Late entry for [DATE] at 3:55 PM: NA #1 brought Resident #336 out of her room to take a shower and stated Resident #336 dropped her call light and attempted to pick it up and scratched her arm on the bedside commode. Resident #336's right arm had a skin tear and she wanted to have a dressing applied. The ADON told Resident #336 to wait until after she had a bath, then the ADON would apply addressing. The ADON went to the Wound Nurse and asked what dressing to apply to Resident #336's arm and the Wound Nurse told her to use [MEDICATION(S)] and a dry dressing to the right arm. The ADON informed NA #1 that Resident #336's bedside commode needed to be set away from the resident's side so if she dropped any object then her arm would not hit her arm on the side of the chair. A telephone interview on [DATE] at 2:56 PM with Nurse #4 revealed she was unable to recall Resident #336 or the skin tear. Attempts were made to contact Nurse #5 without success. A telephone interview on [DATE] at 11:47 AM with NA #3 was conducted. NA #3 revealed she learned of an incident with Resident #336 when she worked on the evening shift of [DATE]. NA #3 stated she went in to see Resident #336 and noticed the bandage on her arm and asked if she had to go to the hospital or if she had hurt herself. NA #3 stated Resident # 336 reported to her she had been grabbed by the arm by NA #1 on the day before which resulted in a skin tear and a dark bruise to the right arm. NA #3 stated following the report by Resident #336, she went to a nurse who was working the medication cart (unable to recall the nurses' name) and told her what Resident #336 had said. NA #3 stated that nurse told her she was aware of the report and the DON had been made aware and seemed to think Resident #336 had hurt her arm on the bedside commode, so she was not sure if the DON planned to further investigate the incident reported by Resident #336. NA #3 stated since she made the nurse aware she thought she would handle it further. A telephone interview on [DATE] at 9:40 AM with NA #2 was conducted. Nurse aide #2 revealed she learned of an incident with Resident #336 when she worked evening shift on [DATE]. NA #2 stated Resident #336 reported to her she had been yanked up by the arm by NA #1 on the day before which caused some skin tears and bruises to the right arm. NA #2 stated following the report by Resident #336, she told her nurse on the unit and was told they thought the injury had occurred on the bedside commode on [DATE]. NA #2 stated she also notified the DON at the time and was told the DON was unable to terminate everyone that might be doing something incorrectly or the facility would not have anyone to take care of her residents. NA #2 said she stated to the DON, I'd rather do extra work and know the residents were taken care of than to have them mistreated. A telephone interview on [DATE] at 4:32 PM with a Family Member was conducted. The Family member stated several months ago while she was out of town on a Friday night, she received a phone call from the facility alerting her that Resident #336 had sustained a skin tear to the right upper extremity from her bedside commode. The Family Member stated initially she was not concerned with the incident because she was aware Resident #336 head sustained skin tears in the past. The family member stated she did not become concerned until she spoke to her mother via phone over the weekend. The Family Member stated during a telephone conversation, Resident #336 had notified her NA #1 had caused the skin tear during a transfer after Resident #336 had told NA #1 she did not want a shower and that NA #1 had told her that it would be her word against Resident #336's word and staff would believe staff over the resident. The Family Member stated she arrived back in town late on Monday evening from a flight and on Tuesday, while she was working, Family Member received a phone call from Resident #336 stating Resident #336 needed Family Member to come to the facility immediately. Family Member recalled she was told NA #1 had returned to Resident #336's room to provide bathing assistance again on [DATE] and Resident #336 had told her she did not want her to give her a bath, but NA #1 told her, I did not ask if you wanted a bath, I am giving you one. Family Member stated she rushed to the facility and requested staff to alert the DON that Family Member wished to speak to her urgently. Family Member stated a few minutes after the request, she received a telephone call from the DON. During the phone call, Family Member says she told the DON she was in the facility and to come to Resident #336's room, which she did. Family Member #1 indicated when the DON arrived at Resident #336's room on [DATE] shortly after evening shift began, she questioned the DON about the skin tear Resident #336 had sustained and how it occurred and was told by the DON that Resident #336 had sustained it on the bedside commode on [DATE]. Resident #336 stated in the presence of Family Member and the DON that NA #1 had hurt her and caused the skin tear. NA #1 had arrived in the room again to make additional attempts to provide bathing and Family Member reported Resident #336 pointed to NA #1 and stated she is the one that caused the skin tear and NA #1 left the room immediately. Family Member stated the DON insinuated Resident #336 was lying when she talked over her allegation and said no, that is not what happened remember, you got that on the bedside commode and quickly changed the subject to start discussing how to transfer Resident #336 instead. Family Member stated Resident #336 remained fearful of NA #1 for the remainder of her life (approximately 3 weeks) and begged Family Member not to leave town again. Family Member stated no one should be subjected to that type of treatment and live in fear in the last days of their life. An interview with the DON and Administrator on [DATE] at 10:57 AM was conducted. They both indicated they had no knowledge of the allegation of abuse. The DON recalled she had previously spoke to Resident #336 ' s family when the skin tear occurred; however, did not recall any conversation surrounding the allegation against NA #1. A follow-up interview with the DON on [DATE] at 5:03 PM revealed the family member came in the facility to visit her mom within a day or two after the incident occurred and Resident #336 had told her that she was not the one who caused the skin tear, but she reminded Resident #336 that the incident occurred from her bedside commode as a result of the need for safer transfer techniques and continued discussing interventions to protect Resident #336's skin and safe transfer techniques. The DON verified no incident report was completed and no witness statements were obtained because the facility felt this incident to be an ordinary skin tear that 't look suspicious. The DON stated she was not present and verified she did not witness the alleged abuse. The DON stated she was aware Resident #336 had been resistive to staff providing bathing assistance due to hospice staff providing bathing on a rotating schedule where hospice staff and facility staff each provided one bath each per week. An additional follow-up interview with the DON on [DATE] at 12:25 PM stated she had no knowledge of the allegation until the survey team entered the facility on [DATE]. The DON indicated she had been educated, with all incidents, the interdisciplinary team should review them on the next day during clinical meeting to ensure a root cause had been identified, a nurses note, a SBAR and incident report completed, and orders obtained and entered the medical record. The DON did not recall a conversation between herself, Family Member, and Resident #336 on [DATE] where the skin tear was discussed or that Family Member indicated she did not want NA #1 caring for her family member, but strictly discussed the skin tear and reviewed transfer status and provided Resident #336 with a gait belt to remind her to call for assistance and left the room and thought both Family Member #1 and Resident #336 to be satisfied with the resolution. A review of nursing staff scheduling sheets provided by the facility dated [DATE] through [DATE] indicated the following: On [DATE], the schedule indicated Nurse #1, NA #1 and NA #4 were assigned to Resident #336 hall on evening shift. The documents further indicated NA #3 was also assigned to work on the evening shift; however, NA #3 was assigned to work an adjacent hall. It further detailed NA #4 was assigned to work the night shift (11PM- 7 AM) on [DATE]. On [DATE], the schedule indicated Nurse #2 was assigned to Resident #336 from 7AM-7PM and Nurse #3 was scheduled from 7PM-7AM. The schedule further indicated NA #1 and NA #3 were scheduled to provide care to Resident #336 on the evening shift; however, NA #2 was scheduled but assigned to work on an adjacent hall. On [DATE], the schedule indicated Nurse #1 was assigned to Resident #336 from 7AM-11PM and NA #1 was assigned to Resident #336 ' s care from 4 PM-11 PM. The schedule further indicated NA #2 was assigned to work, however on an adjacent hall. On [DATE], the schedule indicated Nurse #4 was assigned to Resident #336 from 7 AM to 3 PM and NA #3 was assigned to the resident from 5:30 PM to 11 PM and NA #4 was assigned to the resident from 11 PM to 7 AM. On [DATE], NA #1 and NA #2 were assigned to the care of Resident #336 from 3 PM to 11 PM. Nurse #1 was assigned to Resident #336 ' s care from 7 AM- 11 PM. According to the Nurse Aide Documentation Report dated [DATE] and comparison staff initial report for verification of documented initials provided by the facility, NA #1 also provided care for Resident #336 on ,d+[DATE] and ,d+[DATE] on the evening shift. A review of facility reported incidents (FRIs) for [DATE] through [DATE] revealed no reports of an allegation of abuse involving NA #1 and Resident #336 filed to the State Agency (SA), Adult Protective Services (APS), or local law enforcement. The Administrator, Director of Nursing, and a corporate consultant were notified of immediate jeopardy on [DATE] at 5:30 PM. The facility provided the following credible allegation of IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance *On [DATE], the facility failed to identify, protect, assess other residents, and thoroughly investigate an allegation of abuse. The facility failed to notify law enforcement and APS when NA #4 witnessed NA #1 abuse resident #336 and the facility administration was aware that the resident was fearful of the aide. The perpetrator continued to be assigned to provide care for this resident until the resident's death. *All residents are at risk from suffering from the deficient practice and residents who are resistive to care are the ones more at risk for abuse. On [DATE], a 24-hour report was made to DHSR. Law enforcement and Adult Protective Services were notified. An investigation around this incident is underway. This investigation is being conducted by the Administrator. On [DATE], an audit was completed by interviewing all residents with a Brief Interview of Mental Status (BIMS) of 10 or above by Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers or designee to determine who could alert staff to instances of abuse. These residents were interviewed for unreported abuse occurrences. No other residents were identified as being abused and not reported. On [DATE], an audit consisting of thorough skin assessment of all residents with a BIMS of 9 or less was completed by licensed nurses to determine if there is evidence that these residents have experienced any type of abuse. No other residents were identified as being abused and not reported. On [DATE] -[DATE], all staff in all departments were interviewed by members of the interdisciplinary team (IDT) that consists of Administrator, DON, ADON, and Unit Managers to determine if any other resident may have been affected and if they had observed and not reported any abuse. No concerns 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 On [DATE], the ADON was reeducated on how to respond to situations where potential abuse may have occurred to include assessing the situation, removing a potential perpetrator from the resident, and reporting to the DON and/or Administrator On [DATE], the Administrator, DON, and Staff Development RN were also reeducated on all components of the facility's abuse policy and how to identify abuse by the Regional Director of Operations. Education included the definition of abuse, reporting requirements, the need to conduct a thorough investigation, and monitoring for psychosocial changes by qualified individuals, as well as immediately separating the victim from the alleged perpetrator. On [DATE], after being reeducated as outlined above education for all staff was completed by the Staff Development RN. The education consisted of the following: The definition of abuse and the need to immediately notify the Administrator or DON of all issues related to these infractions. If Administrator or DON are not present in facility, supervisors must be notified, and they must inform the Administrator or DON immediately in person or by phone Staff members who observe situations of abuse should immediately intervene to prevent continued potential abuse to residents. The perpetrator should be removed from the situation and placed under 1:1 supervision by the immediate supervisor or designee until they can be removed from premises or restricting visitation for accused individuals not employed by the facility Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing. The following information should be reported: The name(s) of the resident(s) to which the abuse or suspected abuse occurred The date and time that the incident occurred Where the incident took place The name(s) of the person(s) allegedly committing the incident, if known The name(s) of any witnesses to the incident The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.) Any other information that may be requested by management. The individual conducting the investigation will, as a minimum: Review the completed documentation forms Review the resident's medical record to determine events leading up to the incident Interview the person(s) reporting the incident Interview any witness to the incident Interview the resident (as medically appropriate) Interview the residents attending physician as needed to determine the resident ' s current level of functioning and cognitive condition Interview staff members on all shifts who have had contact with the resident during the period of the alleged incident Interview the resident's roommate, family members, and visitors Interview other residents to whom the accused employee provides care of services; and Review all events leading up to the alleged incident Preserve all audio and video recordings of the incident (if applicable) In effort to protect residents from abuse, education included identification strategies for signs and symptoms of abuse such as physical abnormality, withdrawal, loss of appetite, and general changes in patterns and psychosocial well-being Also, in effort to provide protection from abuse, keeping residents engaged in their community, supporting primary caregivers by identifying caregivers who appear stressed or need a break from working with difficult residents. (This situation should also be brought to the immediate attention of the supervisor.) The fact that our facility does not condone and has zero tolerance for resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. This training will be provided by the Administrator or the Human Resource Director to all agency staff and new employees upon hire during orientation. All facility staff in all departments, including as-needed and agency staff, received this training on [DATE]-[DATE] and all staff will continue to receive the training yearly thereafter. The Administrator and Human Resource Director were notified by the Regional Director of Operations of the need to provide this training to new hires on [DATE]. Alleged IJ removal date is [DATE]. On [DATE] the credible allegation of immediate jeopardy with a removal date of [DATE] was validated through staff interview and review of in-service training records. Staff were able to verbalize the definitions of abuse and provided examples as well as vocalize they were to contact the Administrator or DON via phone or in person with any concerns of observed or reported potential of abuse. Staff reported they are to provide written statements of their observations or reports made by a resident, staff member, or family member to the facility Administrator immediately. Staff expressed knowledge that abuse is not tolerated and any staff member accused of abuse must be immediately removed from the facility while further evaluation is completed. Staff knew abuse allegations must be thoroughly investigated to include collecting written witness statements from all staff associated with allegation.

Based on observations, record review, and Medical Director, facility staff, and family member interviews, the facility observed a family member forcefully feeding a Resident and failed to implement effective interventions to prevent reoccurrence and further injury for 1 of 3 residents' reviewed for supervision to prevent accidents (Resident #1) resulting in another observation of the family member force feeding Resident #1 on 10/16/21 with bruising noted to Resident #1's neck and arms on 10/27/21. Immediate jeopardy began on 10/14/21 when a Resident's family member was observed force feeding the Resident and the facility failed to implement effective supervision to prevent repeated incidents and injury. The immediate jeopardy was removed on 10/30/21 when the facility provided and implemented an acceptable credible allegation. The facility remains out of compliance at a lower scope and severity of a D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The Findings Included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], unspecified severe protein calorie malnutrition, dysphagia, abnormal posture, and stroke. A review of Resident #1's admission Minimum Data Set assessment dated [DATE] revealed her to be severely impaired for daily decision making. Resident #1 was coded as having nutritional issues including complaints of difficulty or pain when swallowing, holding food in her mouth or having residual food in her mouth after meals, and loss of liquids and/or solids from her mouth while eating and/or drinking. Resident #1 was coded as not receiving Hospice Care either prior to admission or while a resident in the facility. A review of Resident #1's care plan dated 09/21/21 revealed [Resident #1} had a nutritional problem or potential nutritional problem as related to disease process [CONDITION(S)], inadequate meal intake, mechanically altered diet, impaired skin integrity, low body weight, low body mass index, malnutrition, and other comorbidities. Interventions included meal assistance as needed, and to observe, document, and reported as needed any signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in her mouth, several attempts at swallowing, refusing to eat, or appearing concerned during meals. Review of Resident #1's physician orders revealed an order for Aspirin 81 milligrams (mg) take one tablet daily in the morning and an order for [MEDICATION(S)] 10mg take 1 tablet by mouth in the morning. Taking these medications can cause a person to bruise easily. Review of a nursing progress note dated 10/14/21 read, in part: Staff called to room shortly after by Certified Nursing Assistant (NA #1), [family member] holding resident's face and rubbing neck trying to get resident to eat. Neck bright red from rubbing neck trying to get resident to eat. Staff stated [family member] became angry when asked to stop forcing resident to eat. Neck bright red from rubbing. Resident requesting [family member] to stop, daughter sitting in chair watching situation and saying nothing. [family member] and daughter left shortly afterwards. - written by the Director of Nursing During an interview with NA #1 on 10/27/21 at 3:54 PM, he reported he was familiar with Resident #1 and her family member. NA #1 stated Resident #1's family member visited daily and attempted to try and feed resident at least her lunch and sometimes her dinner meal. NA #1 verified he was working on the 300 hall on 10/14/21. He reported he saw Resident #1's family member attempt to force feed her and went and told Nurse #1, who came in and told the family member he needed to stop. NA #1 stated he observed the family member trying to push food into Resident #1's mouth while she was trying to push his hand away and telling him no. NA #1 stated he has started trying to feed Resident #1 when her tray arrives if her family member is not there due to his worry that he may try to force feed her again. During an interview with Nurse #1 on 10/28/21 at 12:29PM, she reported she was working on the 300 hall on 10/14/21. She stated she was familiar with Resident #1 and reported her family member visited daily and typically attempted to feed Resident #1 her lunch and dinner meal. She stated on 10/14/21 she was alerted by NA #1 that Resident #1's family member was in the room attempting to force feed resident. She reported she went to the room and noted Resident #1's family member trying to push a spoonful of food into resident's mouth. She stated Resident #1 had her mouth clinched and was attempting to push his hand away. Nurse #1 stated she told Resident #1's family member to stop and that he could not force her to eat. She reported Resident #1's family member became angry stating that he was not force feeding Resident #1 and that they needed to do more to get Resident #1 to eat. She stated she left the room and got Nurse #2 for assistance. She stated Nurse #2 entered the room and told Resident #1's family member he could not force feed Resident #1 and that he needed to stop. She reported Resident #1's family member began to yell at Nurse #2 who in turn left the room. She reported Resident #1's family member eventually stopped trying to force feed resident and calmed down. Nurse #1 reported prior to 10/14/21 she had discussed concerns she had with Resident #1's family member demanding the facility staff force Resident #1 to eat and drink more with the Administrator and DON who reported they would speak with him. She reported he would sit in the room for hours, trying to get her eat and pushing her to eat and drink, and yelling at the staff stating they were letting her die and they needed to force feed her. She reported the evening of 10/14/21 was the first and only time she has seen Resident #1's family member physically try to push a spoon into her mouth. During an interview with Nurse #2 on 10/27/21 at 5:32 PM, he stated he was familiar with Resident #1 and her family member. Nurse #2 reported Resident #1's family member visited the facility daily and typically fed Resident #1 at least one meal. He verified he was working on 10/14/21 and stated he was informed by Nurse #1 that she had observed Resident #1's family member attempting to force feed her. He stated when he entered the room, Resident #1 had red marks on her throat from, what he was told by Nurse #1, Resident #1's family member rubbing her throat to get her to swallow food. He reported he immediately told Resident #1's family member to stop and that he could not force her to eat. He stated Resident #1's family member became irate and confronted him and Nurse #2 left the room. He reported he went and immediately notified the Director of Nursing of the incident but was unsure what had happened to prevent it from happening again. During an interview with the Director of Nursing (DON) on 10/28/21 at 10:08 AM she reported she did receive a phone call on 10/14/21 about Resident #1's family member attempting to force feed her. The DON reported once she received the phone call, she discussed the incident with the Administrator. She reported the administrative team discussed Resident #1's right to refuse to eat with her family member and continually try to educate him on what he can and cannot do while assisting her with eating. She reported she had not seen Resident #1's family member attempt to force feed her but has received concerns from her staff regarding him insisting the facility staff force Resident #1 to eat more, to which he is educated on Resident #1's right to refuse. She reported since the incident on 10/14/21, the nurses have been keeping a closer eye on Resident #1 when her family member is visiting, and he had been educated on keeping the door open. She also reported that the Assistant Director of Nursing's office is directly across the hall from Resident #1's room and she has kept a close eye on the room when he is visiting as well. During an interview with Speech Therapist (ST) on 10/28/21 at 10:53 AM, she stated Resident #1 received speech therapy from 09/22/21 through 10/01/21. She reported while she worked with Resident #1, swallowing and chewing were not really an issue, but rather her becoming easily fatigued while eating. She stated Resident #1's intake was always poor with most meal intakes being 25% and few at 50%. ST had recommended that resident be on a mechanical soft diet and be assisted with eating. She stated she has worked with families in the past but had not been asked to speak with Resident #1's family member and provide education and instruction on the proper technique to assist her with feeding. Review of progress note dated 10/16/21 read: Today this nurse (Nurse #4) was approached by [Resident #1's family member] and asked how [she] was eating. The nurse proceeded to tell him that she was not eating well and refusing but that he would need to speak with the patient's actual Nurse to get further information. He proceeded to tell the Nurse that we should be doing more to force her to eat. The Nurse explained that we could not force feed her and that ultimately it is her right to refuse to eat as patients have rights. He proceeded to tell the Nurse that was wrong and that she was participating in killing [Resident #1] by not forcing her to eat and continued to argue. The Nurse told him that he would need to speak to management because she was not going to argue with him. He continued to yell and put down said Nurse, stating that we were killing her. The Nurse walked away, and he proceeded to go on to other nurses to communicate his concern with said Nurse. An additional progress note dated 10/16/21 and written by Nurse #4 read This writer came in at [3:00 PM] and was approached at the nurse desk by [Resident #1's family member] who began the conversation by asking who was in charge of 300 hall. This writer explained that the Nurse was on the hall and his name is [Nurse #5]. [Resident #1's family member] begin by saying he had an argument with that Nurse and pointed to the Nurse on 200 hall. Stating that Nurse said I could not force [Resident #1] to eat, and I want to say that's not true. This writer stopped [Resident #1's family member] and stated Sir, I need you to return to [Resident #1's] room or you may leave the facility but this writer is not going to argue with you about this subject again. You have been told repeatedly by nursing staff and the DON and the ADON and by every nurse who has worked the 300 hall that the state says the resident has the right to refuse. During an interview with Nurse #4 of 10/28/21 at 7:54PM, she stated she observed Resident #1's family member attempting to try and feed her with resident's mouth clinched closed on 10/16/21. She stated she immediately told him to stop which he did. She reported she reported the incident to the DON and the DON told her to write a note and put in the progress notes (refer to progress note on 10/16/21). She reported she did not feel that he was safe to feed her, and she was afraid Resident #1 may choke while he was feeding her. Nurse #4 stated she does not know of any incidents where Resident #1 has choked while being fed by her family member. Review of skin assessment dated [DATE] revealed no documented bruising to Resident #1's neck or upper body. Review of a progress note dated 10/27/21 written by the facility's Medical Director read [AGE] year-old female with a history of [CONDITION(S)], stage IV decubitus ulcer, multiple comorbidities with poor prognosis seen today with some ecchymosis. Has both on her arms and under her neck. Nursing reports [family member] tries to assist with feeding her and lifting her neck likely the cause of ecchymosis. Patient does not recall. No current signs of pain or distress. During an interview with the Medical Director on 10/28/21 at 4:20 PM, he stated he was informed by the facility staff that Resident's husband comes in daily and tries to feed her. Stated he looked at the bruising and felt that it was most likely from him trying to lift her head up to eat. He reported she is very weak and not motivated to eat. The Medical Director stated that he did not feel the bruising was malicious or suspicious and felt it was caused by Resident #1's family member trying to help without having the knowledge or training to do it appropriately. The Medical Director reported he had not spoken to Resident #1's family member since the initial observation of him force feeding her on 10/14/21. An observation of Resident #1 on 10/27/21 at 3:27 PM revealed bruising noted to her neck about the size of a dollar bill with coloring of purplish small dots. Resident also noted with a bruise right above her right wrist almost the size of a silver dollar, purple in color, and round in shape. During an interview with Speech Therapist (ST) on 10/28/21 at 10:53 AM, she stated Resident #1 received speech therapy from 09/22/21 through 10/01/21. ST reported while she worked with resident, she never had to rub Resident #1's throat to assist in swallowing and stated although she has used that technique in the past, it was not something she would teach a family or staff member as it should be used minimally by a professional and not for long periods of time. An interview with Resident #1's family member on 10/28/21 at 12:37 PM revealed he felt he had never hurt or bruised Resident #1. He stated he did not know how the bruising to her neck occurred. Resident #1's family member reported he felt the facility was not doing enough to make sure she eats enough which was the reason he feeds her. He reported he had never held her arms down when trying to feed her but had moved them at times. During an interview with the Director of Nursing on 10/28/21 at 4:37 PM, she reported since the incident on 10/14/21, they have increased rounds on Resident #1 when her family member is in the facility, they have also educated her Resident #1's family member that he must keep the door to the room open while he is in there. She reported it was her opinion that Resident #1's bruising could be from her body breaking down due to her continually declining health and diagnoses and may not be from her family member holding her head up to feed her or from rubbing her throat. The Administrator was notified of immediate jeopardy on 10/29/21 at 9:08 AM. The facility provided the following Credible Allegation of Immediate Jeopardy Removal: Hickory Viewmont Immediate Jeopardy (IJ) Abatement Plan- F 689 Free of Accident Hazards/Supervision/Devices Identify those residents who have suffered, or are likely to suffer, a serious adverse outcome as a result of noncompliance. Resident #1 is a [AGE] year-old female admitted to the center on 9-21-21 following a hospitalization . Resident #1 admission diagnosis include [CONDITION(S)] with Bone Metastasis, Severe Protein Calorie Malnutrition, Dysphagia, Abnormal Posture, Failure to Thrive and Stroke following hospitalization from [DATE] to 9-21-21. Resident #1's [family member] was offered Hospice Care during hospitalization and refused. Resident #1 received Skilled Speech Therapy from 9-22-21 to 10-1-21 for treatment of dysphagia to obtain an improved level of safety with mechanical soft diet with thin liquids. On 10-1-21, Resident #1 was safely tolerating a mechanical soft diet with thin liquids at less than mild to moderate level of dysphagia. Resident's quick fatigue and poor endurance are the main complicating factors for Resident #1. Compensatory swallowing techniques recommended by the Speech Therapist include small alternating bites/sips, slow rate of bolus presentation, and swallow of the bolus prior to the next bolus presentation. The nursing staff continued to provide care for Resident # 1 using the swallowing techniques as instructed by the Speech Therapist. In addition, the nursing staff continued the plan of care for Resident #1's dysphagia by educating [family member] during every opportunity including positioning upright, offering small alternating bites/sips, slow rate of bolus presentation, and swallow of the bite/sip before offering the next bite/sip. In an effort to accommodate Resident #1 and her [family member] of [AGE] years and his desire to assist [Resident #1] with feeding during end-of-life care, the facility staff have provided support and education regarding safe feeding techniques. Resident #1's [family member] visits almost daily at mealtimes for lunch and dinner to help with feeding for [her]. Resident #1 [family member] is also elderly & frail and is unable to reposition [her] for feeding. Resident #1's [family member] depends on the staff to reposition Resident #1 prior to feeding. The nursing staff deliver the meal tray, position resident, set up meal tray and provide drop-in supervision and on-going cueing for [family member]. Resident #1's room is across the hall from the Assistant Director of Nurses office. The ADON provides emotional support and drop in supervision for Resident #1 and [family member] for feeding on an almost daily basis during the week M-F when she is at the center. In addition, Nurse #3 and Nurse #4 who are routinely assigned to provide care for Resident #1 state that they provide emotional support for Resident #1 and [family member], education on safe feeding techniques including positioning upright, offering small alternating bites/sips, slow rate of bolus presentation, and swallow of the bolus prior to the next bolus presentation. Of note, Resident #1's [family member] was unable to visit Resident from 10-8-21 to 10-11-21 and 10-22-21 to 10-25-21. During this time frame, Resident #1 intake remained consistent at 25%. The Administrator provided updates to [family member] and daughter regarding resident's intake following each meal. On 10/4/21, the Administrator and Director of Nurses spoke with Resident #1's [family member] and daughter about concerning rapid decline, overall well-being and family consider palliative /hospice services due to un-healing wound, rapid weight loss, diagnosis of cancer and spiraling down to failure to thrive status. The Director of Nurses explained that Resident #1 is not wanting to consume meals or drink liquids like she should to maintain adequate nutrition. The Director of Nurses asked Resident #1's [family member] about placing a G-Tube and educated him on caloric intake and weight loss. The Director of Nurses educated the [family member] on safe feeding techniques including ensuring that resident is in the upright position before assisting with feeding, offering small bites, allow resident to swallow before the next bite and to remain up for 30 minutes. The Director of Nurses educated the [family member] on the risk of choking, aspiration and vomiting. In addition, on 10/5, 10/11 and 10/12 the LPN/MDS Coordinator provided support and education to Resident #1's [family member] regarding safe feeding techniques. The facility staff have repeatedly offered Hospice and/or Palliative Services for Resident #1; however, her [family member] continues to refuse. Despite exhausting all efforts at re-education, on 10/5, 10/11 and 10/12 from the LPN/MDS Coordinator, Resident #1's [family member] has been observed attempting to assist Resident #1 with feeding using techniques that resulted in redness and bruising to Resident #1's neck. Resident #1 has fragile skin and is on ASA 81 mg daily in addition to [MEDICATION(S)] 10 mg po daily which makes her at increased risk for bruising and ecchymosis. On 10-13-21, LPN Activity Director provided emotional support for Resident #1 and [family member] during 1:1 visit. LPN Activity Director educated [family member] on safe feeding including positioning in the upright position, alternating small bites/sips, allow to swallow before offering next bite/sip and remain upright for 30 minutes after feeding. On 10-17-21, Resident #1's diet was changed at [family member's] request to puree because it takes to much energy to chew the food. On 10/21/21, Resident #1 was sent to the ED at [family member's] request. During the ED Visit, there were no signs and symptoms of respiratory illness and there were no significant findings on the chest x-ray. This indicates that Resident #1 was tolerating pureed diet texture with thin liquids without signs of aspiration. On 10/27/21, the ADON met with Resident #1's [family member] and educated him regarding resident's condition, skilled coverage, therapy involvement, sacral decubitus, interventions, hospice, fragile skin and ecchymosis. Any additional residents with impaired self-feeding who are being fed by family members are at risk. On 10/28/21, The Director of Nurses, Assistant Director of Nurses and SLPN completed an audit of all current residents. There were no additional residents identified that are fed by family members. Immediate action the Facility has taken to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring. On 10-14-21, the Director of Nurses was contacted by the nursing staff that Resident #1's [family member] was holding Resident #1's face and rubbing her neck trying to get Resident #1 to eat. The nursing staff stated that Resident #1's [family member] became angry when redirected. The Director of Nurses instructed the Licensed Nurse to increase monitoring of [family member] during meal time and educate the [family member] on safe feeding techniques as directed by Speech Therapy. On 10-14-21, the Licensed Nurse immediately re-educated [family member] on safe feeding techniques including positioning in the upright position before assisting with feeding, offering small bites, allow resident to swallow before the next bite and to remain up for 30 minutes. The Licensed Nurse held a huddle with the nursing assistants providing care for Resident #1 to communicate the need for increased monitoring of [family member]. On 10-16-21, the Licensed Nurse #1 re-educated Resident #1's [family member] that we could not force feed [Resident #1] and that it is her right to refuse to eat. On 10-16-21, Resident #1's [family member] stated that the nurse told him that he could not force {Resident #1] to eat and Resident #1's [family member] denied that this was true. Licensed Nurse #2 again re-educated Resident #1's [family member] that Resident #1 has the right to refuse treatment including refusal to eat. On 10-27-21, the Director of Nurses spoke with Resident #1's Attending Physician/Medical Director regarding ecchymosis noted on Resident #1's upper extremities and neck. MD evaluated Resident #1 and planned to meet with Resident #1's [family member] on next scheduled MD visit on 11-3-21 to discuss Resident #1's current condition and the need for him to be gentle due to fragile skin. MD stated that he would rather speak with Resident #1's [family member] with a face to face conversation instead of a phone call. On 10-28-21, the Administrator contacted the Ombudsman regarding Resident #1. The Ombudsman contacted the Administrator on 10-29-21 and did not make any recommendations stating that she would follow up with the State Ombudsman's Office for further direction. On 10-29-21, the Administrator participated in an interview with Resident #1. When questioned if she had been forcibly fed by anyone, Resident #1 responded emphatically No. On 10-29-21, the LPN MDS Coordinator reported that she had spoken with Resident #1's [family member] on multiple occasions and re-educated him on proper feeding techniques and not to forcibly feed [Resident #1] to which he verbalized understanding. On 10/5/21, 10/11 and 10/12/21 the LPN MDS Coordinator educated [Resident #1's family member] to slowly feed the resident only when she agrees to eat, in an upright position and encouraged him to offer liquids between small bites. The District Director of Clinical Services educated the Administrator and Director of Nurses on the facility policy for investigation of incidents and accidents. This was completed on 10-29-21. On 10-29-21, the Administrator, Director of Nurses, and Assistant Director of Nurses worked with the District Director of Clinical Services to develop a plan of action and an education tool for training nursing staff on safe feeding techniques. On 10-29-21, the Director of Nurses, Assistant Director of Nurses and the Speech Language Pathologist audited all residents to identify all residents who are assisted with feeding by their family members. No additional residents were identified. On 10-29-21, the Speech Therapist screened Resident #1 and provided education on safe feeding techniques with Resident #1's [family member]. No additional residents were identified. On 10-29-21, the Administrator and Director of Nursing met with Resident #1's [family member] and provided re-education on safe feeding techniques and again offered Hospice and/or Palliative Care. [Resident #1's family member] continues to refuse Hospice and/or Palliative Care but agreed not to attempt to feed [Resident #1] at any time in the future. Beginning on 10-29-21, Resident #1 will have meal-time visits by family members supervised by the licensed nursing staff for proper feeding techniques and to identify any opportunities for re-education. On 10-29-21, the Director of Nurses educated the licensed nurses and certified nurse's assistants of this responsibility to supervise the family feeding this resident for all meals. The speech therapist instructed and completed a one hour education class with the [family members] and the assigned certified nursing assistants. The assigned aide will supervise the [family member]. If he is force feeding, the aide will intervene and notify the nurse assigned to that room. The nurse will then notify the Director of Nursing immediately. The facility alleges removal of immediate jeopardy on 10-30-21. The Credible Allegation with an IJ removal date of 10/30/21 was validated on 11/09/2021. Staff education was initiated on 10/29/21 regarding new facility policy on required training for resident family members that wished to assist their loved ones with meals. Education also included refreshers on proper feeding techniques and behaviors to monitor for to ensure residents are not force fed. All staff interviewed (nursing and non-nursing staff, and administrative staff) reported they were aware that family members wishing to assist their loved ones with meals were to be trained by the speech therapist and then still must be monitored to ensure proper feeding techniques were followed. If they noted any improper feeding techniques, they were to immediately stop the family members and notify the Director of Nursing. Verification of education for staff regarding the education of proper feeding techniques and the new facility policy was completed on 11/01/21.

Based on observations, record review, and Medical Director, facility staff, and family member interviews, the facility failed to provide effective administration by not responding to staff concerns about a family member force feeding a Resident causing redness to her neck and ensure interventions were implemented to protect the Resident from continued force feeding causing bruising to her neck and arms for 1 of 3 residents reviewed for supervision to prevent accidents. (Resident #1) The immediate jeopardy began on 10/14/21 when a Resident's family member was observed force feeding the Resident and causing redness to the neck and the administration failed to ensure effective interventions were implemented to protect a Resident from continued force feeding by a family member causing bruising to the Resident's neck. The immediate jeopardy was removed on 10/30/21 when the facility provided and implemented an acceptable credible allegation. The facility remains out of compliance at a lower scope and severity of a D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: Cross Refer to F689: Based on observations, record review, and medical director, facility staff, and family member interviews, the facility observed a family member forcefully feeding a Resident and failed to implement effective interventions to prevent reoccurrence and further injury for 1 of 3 Resident's reviewed for supervision to prevent accidents (Resident #1) resulting in another observation of the family member force feeding Resident #1 on 10/16/21 with bruising noted to Resident #1's neck and arms on 10/27/21. On 11/04/21 at 10:53 AM, the Administrator was informed of the Immediate Jeopardy for F835. The facility provided the following Credible Allegation of Immediate Jeopardy Removal: Hickory Viewmont Immediate Jeopardy (IJ) Abatement Plan- F 835- Administration Identify those residents who have suffered, or are likely to suffer, a serious adverse outcome as a result of noncompliance. On 10-14-21, the Director of Nurses was contacted by the nursing staff that Resident #1's spouse was holding Resident #1's face and rubbing her neck trying to get Resident #1 to eat. The nursing staff stated that Resident #1's spouse became angry when redirected. The Director of Nurses instructed the Licensed Nurse to increase monitoring of the spouse during mealtime and educate the spouse on safe feeding techniques as directed by Speech Therapy. On 10-14-21, the Licensed Nurse immediately re-educated spouse on safe feeding techniques including positioning in the upright position before assisting with feeding, offering small bites, allow resident to swallow before the next bite and to remain up for 30 minutes. The Licensed Nurse held a huddle with the nursing assistants providing care for Resident #1 to communicate the need for increased monitoring of spouse. Following a report by the Licensed Nurse on 10-14-21, the facility's Administrator did not provide supervision of resident's spouse during meals to ensure interventions were utilized to prevent unsafe feeding techniques Any additional residents with impaired self-feeding who are being fed by family members are at risk. On 10-28-21, The Director of Nurses, Assistant Director of Nurses and SLP completed an audit of all current residents. There were no additional residents identified that are fed by family members. Immediate action the Facility has taken to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring. On 10-29-21, the Administrator, Director of Nurses, and Assistant Director of Nurses worked with the District Director of Clinical Services to develop a plan of action and an education tool for training nursing staff on safe feeding techniques. On 10-29-21, the Director of Nurses, Assistant Director of Nurses and the Speech Language Pathologist audited all residents to identify all residents who are assisted with feeding by their family members. No additional residents were identified. On 10-29-21, the Speech Therapist screened Resident #1 and provided education on safe feeding techniques with Resident #1's spouse. On 10-29-21, the Administrator and Director of Nursing met with Resident #1's spouse and provided re-education on safe feeding techniques and again offered Hospice and/or Palliative Care. Spouse continues to refuse Hospice and/or Palliative Care but agreed not to attempt to feed his wife at any time in the future. Beginning on 10-29-21, Resident #1 will have meal-time visits by family members supervised by the licensed nursing staff for proper feeding techniques and to identify any opportunities for re-education. On 10-29-21, the Director of Nurses educated the licensed nurses and certified nurse's assistants of this responsibility to supervise the family feeding this Resident for all meals. The speech therapist instructed and completed a one-hour education class with the spouse, daughter and the assigned certified nursing assistants. The assigned aide will supervise the spouse. If he is force feeding, the aide will intervene and notify the nurse assigned to that room. The nurse will then notify the Director of Nursing immediately. On 10-29-21 The Director of Nursing notified the Nurse Managers of their ongoing responsibility to educate new licensed nurses and certified nurse aides regarding their responsibility to supervise families providing assistance with feeding. The District Director of Clinical Services educated the administrative team, Administrator, Director of Nurses and Assistant Director of Nurses on effective supervision interventions to protect a resident from continued force feeding from family and further injury. This was completed by re-education on the facility policy Incident/Accident Reporting for Residents on 10-29-21. The District Director of Clinical Services educated the administrative team, Administrator, Director of Nurses and Assistant Director of Nurses on an having an effective system in place for all disciplines to report concerns that put residents at risk for injury and a means for the administrative staff to promptly analyze and investigate each situation and determine effective interventions to prevent injuries to residents. This was completed by education on the company PowerPoint presentation General Investigation Guidelines on 10-29-21. All facility Department Heads including the Director of Nursing, Assistant Director of Nursing, Rehab Manager, Social Services Director, Activities Director, Business Office Manager, Housekeeping Supervisor and Maintenance Director were re-educated by the NHA by 10-30-21 regarding requirements to immediately report concerns related to resident safety to the Administrator. Facility staff were notified to report safety concerns related to families providing feeding assistance to Administration immediately. The Administrator will ensure a full investigation is completed. The outcomes of the investigation, with planned interventions, will be reviewed with the Department Heads for further recommendations as part of the QAPI process. The facility alleges removal of immediate jeopardy on 10-30-21. The Credible Allegation with an IJ removal date of 10/30/21 was validated on 11/09/2021. An education training tool and plan of action was developed by the ADON, DON and the Director of Clinical Services for the purposes of training nursing staff on safe feeding techniques. New hires will receive this training during the orientation process and will be on-going for all staff throughout the year. An audit was competed to identify all residents who may be at risk for being fed by their family members and no additional residents were identified. The Speech Therapist screened Resident #1 and provided education to the spouse on safe feeding techniques. Resident #1 was no longer in the facility at the time of this validation. The Speech Therapist completed a one-hour training with Resident #1's spouse, the daughter, and the nursing assistants assigned to Resident #1. Education was competed on 10/29/2021 for all nursing staff regarding their responsibility to supervise family feeding residents. Re-education on facility policy, Incident/Accident Reporting for Residents was provided on 10/29/2021 for the Administrator, Director of Nursing and Assistant Director of Nursing on effective supervision to protect Resident #1 from continued force feeding from family and preventing further injury. Education was provided on 10/29/2021 to the administrative team, Administrator, Director of Nurses and Assistant Director of Nursing regarding having an effective system in place for all disciplines and how to report concerns that put residents at risk for injury. All staff would report all abuse/neglect concerns to the administrative staff for prompt analyzing and investigating each situation and determine effective interventions to prevent injuries to residents. This education was completed by company PowerPoint presentation General Investigation Guidelines on 10-29-21. Staff interviews confirmed understanding of training and education. The outcomes and interventions have been reviewed by the facility QAPI team as of 10/30/2021.

Based on observations, record review, resident, staff and nurse practitioner interviews, the facility failed to assess a resident for pain, administer pain medication as ordered by the physician and as requested by the resident for pain control for 1 of 5 residents reviewed for medication administration. (Resident #141) The findings included: Resident #141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident # 141's physician orders [REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident #141 had intact cognition. The MDS also revealed that Resident #141 had no behaviors, was always continent of urine and stool and received scheduled and prn (as needed) pain medication for occasional pain at a level of 6 out of a scale of 1-10. The Care Area Assessment (CAA) dated 03/27/17 for Resident #141 did not trigger for pain at the time of the admission assessment and there was no care plan for pain. An observation of Resident #141 on 06/27/17 at 11:11 am revealed he was sitting in his wheelchair and watching TV. He was dressed neatly and rubbing his knees and complained of pain due to arthritis at a level 7 out of 10. The resident stated his pain medication was not [MEDICATION NAME] until the next dose. Resident #141 stated that he was going to tell the nurse when she brought his next dose of pain medication. An interview with Resident #141 on 06/27/17 at 11:32 am revealed he had waited last night for approximately 1 hour and 45 minutes for pain medication for pain at a level of 7. He stated he put his call light on some time around 4:30 pm to 5:00 pm (could not remember exact time) and the nurse aide (NA) came in (could not remember who came in) and he told her he needed something for pain. The resident stated the NA came back into his room and told him that she had told the medication aide. Resident #141 stated it was after 6:00 pm before Certified Medication Aide #1 (CMA) brought his pain medication to him and by that time his pain level was at a 9 out of 10. Resident #141 stated CMA #1 told him no one told her he needed something for pain. A review of the June Medication Administration Record [REDACTED]. A review of a nursing progress note dated 06/26/17 at 6:21 pm revealed Nurse #4 had assessed Resident #141 for pain at a level of 7 out of 10. A review of a nursing progress note on 06/27/17 at 6:23 pm revealed Resident #141 was given his pain medication by CMA #1 at 6:23 pm. An interview with nurse aides #11 and #12 on 06/27/17 at 6:08 pm revealed they did not remember answering his call light last evening (06/26/17 around 4:30 to 5:00 pm) when he requested pain medication. They both stated they knew he had asked for it because they saw CMA #1 bring it to him. An interview with CMA #1 on 06/27/17 at 6:20 pm revealed she had not been told by any of the NAs that Resident #141 had requested pain medication last evening. She stated she and Nurse #4 had been on another hall working with a resident and then she went to Resident #141's hall to give medications. CMA #1 stated she went into Resident #141's room and asked if he wanted something for pain with his afternoon meds and stated Resident #141 said, Did they not tell you I wanted something for pain? I asked for something an hour and a half ago. CMA #1 stated she told Resident #141 no one had told her he had requested something for pain but she would get it and give it to him. CMA #1 stated after a while Resident #141 came out of his room and apologized for being short with her about his pain medication. CMA #1 stated she understood his frustration and did not like for anyone to be in pain. An interview with the NA who was assigned to care for Resident #141 during first shift, NA #13, on 06/28/17 at 2:20 pm revealed Resident #141 had not asked her about pain medication on 06/26/17 during first shift. She stated if he had asked her for pain medication she would have told the medication aide. An interview with the Nurse Practitioner (NP) on 06/30/17 revealed the resident had refused an order for [REDACTED]. The NP stated that she was not sure if this would work but they were going to try it at least for a few days to see if Resident #141 would get better pain relief. An interview with the Director of Nursing on 06/30/17 at 2:54 pm revealed her expectation was for all residents to receive pain medication as needed and ordered to relieve their pain.

Based on observations, record review and staff interviews the facility failed to prevent 1 of 9 cognitively impaired residents, who were assessed as being at risk for elopement, from exiting the facility and leaving the facility's grounds (Resident #4). Immediate Jeopardy began on 02/16/17 when Resident #4 eloped from the facility without staff's knowledge that she was outside without supervision. Resident #4 had crossed the parking lot approximately 135 feet in a straight path from the facility front door to the postal box across the road and was brought back to the facility by a visitor that saw her cross the road. The speed limit on the road was 35 miles per hour and the temperature was in the low 50's and overcast. Resident #4 was wearing a long sleeve cotton shirt, slacks, socks and shoes and was assessed by Nurse #2 with no injuries noted. Immediate Jeopardy was removed on 03/16/17 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D to ensure monitoring of systems put in place and completion of employee training. The findings included: Review of the facility's Resident Elopement Policy and Procedure with release/revision date of June 2007 specified the following: The facility will provide a safe environment and preventive measures for elopement. Nursing personnel must report and investigate all reports of missing residents. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse and document the occurrence. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 was severely cognitively impaired. The MDS further indicated Resident #1 had wandering behavior 1 to 3 days during the assessment period. Review of the care plan with a creation date of 08/30/16 and last updated date of 02/17/17 revealed Resident #4 was an elopement/wanderer related to being disoriented to place, impaired safety awareness and elopement that occurred on 02/16/17. The goal was for her safety to be maintained through the review date. The interventions included: identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Wander alert checks daily. Review of Nurse's notes: 08/21/16 4:05 PM Resident #4 observed by this nurse attempting to go out front door of facility. Resident #1 is alert with [DIAGNOSES REDACTED]. Resident was easily redirected. Wanderguard bracelet placed on resident for elopement risk and safety. Will continue to monitor. 08/27/16 2:16 PM Resident pleasantly confused. Alert to self but disoriented to place, time and situation. Redirected from exit doors multiple times. No distress noted. 09/08/16 3:35 PM Resident placed herself on the floor in front of her wheelchair and began to cut her wanderguard off with a pair of nail clippers. She was placed back into her chair and wanderguard was replaced and nail clippers were taken from her. No injuries were noted from her cutting off the wander guard. 09/16/16 2:36 PM Resident is alert with confusion, attempts to leave the facility by shaking the front door until she gets it open. She also has started putting herself on the floor from her wheelchair. 11/17/16 7:13 PM Resident continually wandering around the facility. Resident walking around with her wanderguard in hand. Resident knows how to turn chair alarm off. Asked therapy to reassess her for independent status. 02/16/17 5:30 PM Resident, in a wheelchair, was brought into the facility building by a staff member. A visitor was following close behind and stated, She had went across the road and I had stopped my car to allow her to cross back into the parking lot. Upon resident entering into building, wanderguard sounded at the door immediately locked. The resident stated, If you wait long enough someone will open the door for you. Entered facility. Full assessment with no injury presented. Alert and verbal, disoriented to time and place. Immediate elopement protocol placed into action, monitoring resident's location every 15 minutes, to continue for 72 hours. Review of the facility Incident/Accident Report dated 02/16/17 at 5:30 PM revealed Resident #4 exited the facility, elopement - no injury. Investigation follow-up - Resident was in wheelchair and seen by mailbox, a visitor observed resident cross the street. Staff re-directed resident in the facility on entry alarm sounded wander guard functioning properly. Resident stated she was going to check mail. Asked Resident how she was able to get out of the door, she replied, You just have to wait and someone will open the door for you. Past Interventions attempted - Sign on door for visitors to see nurse for residents - do not open door for residents. Recommendations - New elopement assessment completed. Wanderguard checked for proper functioning. All doors checked by Maintenance Director. Code to wanderguard changed (front door). Resident placed on every 15 minute checks for 72 hours than 1 hour until placement can be found at a locked unit. An interview conducted on 03/15/17 at 11:38 AM with Nurse #2 revealed on 02/16/17 she was walking to the nurse's desk in the front lobby and saw a visitor pushing Resident #4 in her wheelchair in the parking lot toward the front door of the facility. She stated she immediately went outside to see why Resident #4 was outside. Nurse #2 stated the visitor told her she was coming to the facility and had to stop her car in front of the facility, on the main road to let Resident #4 come back across the road to the facility parking lot and she parked her car and brought Resident #4 back to the facility. She stated Resident #4 had gone approximately 135 feet from the facility across the street and 135 feet back to the facility. She stated the weather was gloomy and in the low 50's and Resident #4 had on a long sleeved cotton shirt, slacks and tennis shoes. Nurse #2 stated when they approached the front door it locked due to Resident #4's wander guard and staff inside had to unlock the door to let them in. Nurse #2 stated she assessed Resident #4 and found no injuries, placed her on elopement precautions protocol, informed the Administrator, who was in the building and called the Director of Nursing per Administrator's order. Nurse #2 further stated she did not hear Resident #4's wanderguard alarm go off and was not aware she was out of the building until she saw her outside and did not know how she went out without the alarm sounding. An interview was conducted on 03/15/17 at 3:15 PM with Restorative Aide (RA) #2 revealed he worked on 02/16/17 with Resident #4 on the 3:00 PM to 11:00 PM shift. He stated he saw Resident #4 eating supper in the main dining room around 5:00 PM and did not hear an alarm go off and did not know she had gone out of the building. RA #2 stated Resident #4 was her baseline during supper and wasn't anxious or in a hurry to leave the dining room. He stated Resident #4 would sit in the front lobby after supper and watch the news and she would wander throughout the building and would try to go out the front door with visitors and would tell him she wanted to go home. RA #2 stated she had gone out the front door one time before and her alarm went off and he brought her right back into the building. RA #2 further stated some of the alert and oriented residents that sat in the front lobby knew the code and would let visitors in if the door was locked. Interview conducted with the DON at 3:46 PM on 03/15/17 revealed she was not in building on 02/16/17 when Resident #4 eloped but she was called and notified by Nurse #1 and came to the facility later that evening. The DON stated she interviewed Nurse #1 and Resident #4 about the incident the following day. She stated Resident #4 told her she was going to check the mail and when she asked her how she got out the door Resident #4 told her if you watched long enough you could press those buttons and go out. The DON stated she assumed she had watched staff put in the code or heard staff telling visitors and staff the code and she knew how to go out without the alarm sounding. The DON stated she interviewed all staff and none of them heard the alarm go off when Resident #4 exited the building. She stated she called the Maintenance Director and he came in and reset the code for the front door. The DON stated there was no one at the reception desk in the evenings after supper but the nurses were in and out of the nurse's desk and were able to observe the residents that liked to sit in the front lobby in the evenings. During an interview conducted on 03/15/17 at 5:00 PM the Administrator stated she was working in the conference room on 02/16/17 around 5:30 - 6:00 PM when Nurse #2 came in and informed her Resident #4 had eloped, crossed the road and was pushed back to the facility by a visitor. The Administrator stated she informed her to call the DON and complete an incident report. The Administrator stated she was not aware Resident #4 had tried to exit the building in the past. She stated the investigation conducted revealed staff would tell other staff or visitors the code to unlock the front door and Resident #4 had to know the code to exit without the alarm from her wander guard sounding. The Administrator stated Resident #4's wanderguard was functioning properly because it the locked the door when they tried to re-enter the building and the Maintenance Director checked it that evening and the alarm sounded when the code for the door wasn't put in first. On 03/15/17 at 5:20 PM an interview with Resident #8, who was alert and oriented, was conducted. During this interview Resident #8 stated he was aware of the code to unlock the facility's front door to exit the facility. The resident stated he knew the facility's front door exit code by hearing staff yell the code out to each other. During this interview Resident #8 correctly provided the current code to unlock the facility's front door to the surveyor. Observations made on 03/15/17 at 8:35 AM, 03/15/17 at 3:30 PM and 03/16 17 at 4:30 PM revealed Resident #4 in her room talking with her roommate and watching television. Her wanderguard was observed on her left ankle each observation. The Administrator and DON were informed of Immediate Jeopardy on 03/15/17 at 6:38 PM. On 03/16/17 at 6:35 PM, the facility provided the following Credible Allegation of Compliance: 1. Resident #1 was assessed as being at risk for elopement and a Wanderguard was initiated on 08/21/16. On 2/16/17 at approximately 5:30pm Resident #1 was assisted back into the facility at the building's front door by Nurse #3. As Resident #1 re-entered the facility, in her wheel chair, the wander guard she was wearing sounded and the door immediately locked. A visitor reported to Nurse #3 that she observed Resident #1 cross the street, in her wheel chair and rolled herself back into the facility parking lot, prior to being assisted back into the facility. Nurse #3 immediately completed a Head to Toe Assessment of Resident #1 with no injuries noted. An updated Elopement Assessment was completed for Resident #1 and the care plan was reviewed and updates by the Director of Nursing on 2/16/17. The Director of Nursing validated the placement and function of the Wanderguard for Resident #1. Increased supervision was initiated for Resident #1 to include every 15 minute checks to monitor location. These checks were completed by the Nursing Assistants and documented on the flow record by the Charge Nurse for 72 hours following the incident. Nurse #3 notified Resident #1's Responsible Party and Physician regarding Resident #1 exiting the facility, physical assessment following the event and plan for increased monitoring on 2/16/17. No new physician's orders [REDACTED].#3 on 2/16/17 and an investigation was completed by the Director of Nursing on 2/16/17 who interviewed Resident #1 and determined that she exited the Facility via the front door by entering the Wanderguard code into the key pad. Since 2/16/17 the Restorative Aides have validated the placement and function of Resident #1's Wanderguard daily and documented on the Wanderguard Log. On 3/16/17 Incident and Accident reports for the last 90 days were reviewed by the Director of Nursing and Administrator and it was determined there were no other unsupervised exits reported for Resident #1. There were no other unsupervised exits reported for other residents assessed at risk for elopement during the last 90 days. To the knowledge of Facility Staff and Leadership, Resident #1 has had no other instances of exiting the facility without supervision since 2/16/17. 2. The code for the Wanderguard System was changed by the Maintenance Director on 2/16/17 and again on 3/15/17. The Maintenance Director completed a review of the Wanderguard System including validation of properly functioning Wanderguard keypads and alarms for all facility doors on 2/16/17 and again on 3/15/17. The Maintenance Director or Administrator will continue to monitor the Wanderguard System for all facility doors daily and document on the Wanderguard Log. The Director of Nursing and Nurse Managers completed an audit of all current residents with Wanderguards and validated placement and function of each device on 2/16/17 and again on 3/15/17. On 2/17/17 and 3/16/17 the Director of Nursing and Nurse Managers conducted an audit of all current residents at risk for elopement to include a review of current Elopement Assessments for accuracy, validation of Wander guard placement and operation as required, validation of physician's orders [REDACTED]. These checks for placement and function will be documented by the Charge Nurse on the Medication Administration Record. Elopement care plans were reviewed and validated on 2/17/17 by the Nurse Managers. All care plans of Residents with Wanderguard were updated on 2/17/17 and on 3/16/17 to reflect required interventions based on the review of Elopement assessments by the Nurse Managers. Beginning on 3/16/17, the Admissions Director will review referrals for potential admissions with identified exit seeking behaviors with the Director of Nursing and Administrator prior to offering placement to ensure proper placement. The Director of Nursing and Nurse Managers will continue to review new admissions and readmission daily during the Clinical Morning Meeting to validate accurate elopement assessments and care plans as required. The Director of Nursing and Nurse Managers will review current residents assessed at risk for elopement monthly to validate accurate assessments and care plans. Beginning on 3/16/17 any Resident elopement will be reported immediately to the Facility's Administrator or Director of Nursing and an Incident and Accident report will be completed. 3. On 3/16/17 The Director of Nursing and Nurse Managers re-educated all current Facility Staff regarding the facility policy for Elopement. On 3/15/17 the Director of Nursing and Nurse Managers educated all current facility staff regarding changing the code on the Wanderguard System and keeping this code discrete which includes not sharing with families, visitors, vendors or residents and to report any deviations from this process to the Administrator or the Director of Nursing. On 3/15/17 the Maintenance Director changed the code for the Wanderguard System. On 3/15/17 the Administrator and the Maintenance Director implemented a process for changing the code for the Wanderguard System monthly or as needed and included this as part of the staff education. No staff shall work after 3/15/17 before receiving this education. This education has been added to the Facility Orientation program for all new hires and agency staff to be completed prior to beginning work after 3/15/17. Immediate Jeopardy was removed on 03/16/17 at 6:35 PM when interviews with direct care staff, administrative staff and non-nursing staff confirmed they had received in-service training on the facility's Elopement Policy and not giving out the code to the front door.

Based on record reviews and staff interviews the facility's Quality Assessment and Assurance committee failed to maintain implemented procedures and monitor interventions that the committee put into place on July 8, 2016. This was for a recited deficiency originally cited in July of 2016 and subsequently recited in March of 2017 on the current complaint investigation survey. The deficiency was in the area of Accident Hazards/Supervision/Devices. The continued failure during two federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assurance Program. Immediate Jeopardy began on 02/16/17 when Resident #4 eloped from the facility without staff's knowledge that she was outside without supervision. Immediate Jeopardy was removed on 03/16/17 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D to ensure monitoring of systems put in place and completion of employee training. The findings included: This tag was cross referred to: F 323: Based on observations, record review and staff interviews the facility failed to prevent 1 of 9 cognitively impaired residents, who were assessed as being at risk for elopement, from exiting the facility and leaving the facility's grounds (Resident #4). The facility was recited for F323 for failing to prevent a resident from eloping from the facility. F323 was originally cited in July 2016 on the recertification survey for failing to provide adequate supervision to prevent a resident from falling during independent transfers from bed to wheelchair. During an interview conducted on 03/15/17 at 5:00 PM the Administrator stated she was working in the conference room on 02/16/17 around 5:30 - 6:00 PM when Nurse #2 came in and informed her Resident #4 had eloped, crossed the road and was pushed back to the facility by a visitor. The Administrator stated she informed her to call the DON and complete an incident report. The Administrator stated she was not aware Resident #4 had tried to exit the building in the past. She stated the investigation conducted revealed staff would tell other staff or visitors the code to unlock the front door and Resident #4 had to know the code to exit without the alarm from her wander guard sounding. The Administrator stated Resident #4's wander guard was functioning properly because it locked the door when they tried to re-enter the building and the Maintenance Director checked it that evening and the alarm sounded when the code for the door wasn't put in first. The Administrator further stated she started a Performance Improvement Plan (PIP) on 02/17/17 for elopement for the facility Quality Assessment and Assurance (QA) Committee to begin reviewing at the meetings. She stated they will continue to monitor and audit elopement risks and supervision to prevent accidents at morning meetings and QA meetings on an ongoing basis. The Administrator and DON were informed of Immediate Jeopardy on 03/15/17 at 6:38 PM. On 03/16/17 at 6:35 PM, the facility provided the following Credible Allegation of Compliance: 1. On 3/16/17, the Area Staff Development Coordinator conducted re-education for the Administrator on the facility's policy and procedures for assembling a QAPI committee, collecting data and analyzing trends, and development and implementation of a plan to improve with ongoing monitoring to sustain compliance. The facility utilizes the Plan, Do, Study, Act method for Quality Assurance and Performance Improvement Program including scheduling, identification of trends or patterns, submission of data, and initiation of quality improvement plans related to identified areas of opportunity. The committee has met monthly in the past to monitor ongoing compliance with F323 Supervision to prevent Accident but will begin meeting weekly on 3/16/17 to increase monitoring with F323 Supervision to prevent Accidents with a focus on the review and monitoring of audits being conducted to correct and maintain the elopement management process and to evaluate systems for effectiveness of the facility's overall compliance with F323 Supervision to prevent Accidents. 2. On 3/16/17 the Administrator, Director of Nursing and Facility Interdisciplinary Team including the Social Services Director, Admission Coordinator and Maintenance Director conducted a root because analysis regarding facility processes for elopement prevention. Based on the results of this root cause analysis a QA plan was developed to include re-education of all current facility staff regarding the Elopement policy and management of the Wander guard System. A review of elopement assessments and care plans for residents at risk for elopement were reviewed and updated by the Nurse Managers. Current Residents with Wander guards were observed for validation of placement and function of the Wander guards. A new system was implemented to change the Wander guard door code monthly and as needed. All current facility staff were re-educated regarding the requirements to complete an Incident Report for all elopements and to immediately report elopements to the Administrator and Director of Nursing. The Director of Nursing will implement increased supervision for the Resident involved immediately to establish safety and continue until the investigation has been completed and required interventions have been implemented. Incident Reports will be reviewed by the Interdisciplinary Team daily during the morning Stand Up meeting led by the Administrator. The Interdisciplinary team will determine acceptable interventions and ensure the care plan is revised. The Administrator will conduct the final review of the Incident report and sign off on completion. The District Director of Clinical Services will conduct a review of all Incident reports with the Administrator and Director of Nursing 3 times per week to validate completion of investigations and implementation of required interventions. The results of this meeting and QA Plan were shared with the Facility Medical Director on 3/16/17 and he was in agreement. 3. On 3/16/17, the Administrator and the Quality Assurance Committee were retrained on the Quality Assurance & Performance Improvement Program by the Area Staff Development Coordinator. The Quality Assurance committee consists of: Administrator Director of Nursing Dietary Manager Rehabilitation Manager Maintenance or Environmental Representative Activities Director Social Services Director Human Resource Designee Business Office Director Resident Care Management Director Medical Director Infection Preventionist 4. New Admission and readmission will be monitored by the Director of Nursing and Nurse Managers daily during the morning clinical meeting for accurate assessments and care planned interventions as required. Current Residents at risk for elopement will be monitored by the Director of Nursing and Nurse Managers weekly and as needed to review the accuracy of assessments and care plans for ongoing interventions. The Maintenance Director or Administrator will continue to monitor the Wander guard System for all facility doors daily and document on the Wander guard Log. The Administrator and the Director of Nursing will present the results of this monitoring of the Elopement Process and Wander guard System to the Quality Assurance & Performance Improvement committee weekly for 12 weeks and then monthly thereafter. The next Quality Assurance & Performance Improvement meetings will be conducted weekly for 12 weeks, then monthly with oversight by District Director of Clinical Services for three months. Immediate Jeopardy was removed on 03/16/17 at 6:35 PM when interviews with direct care staff, administrative staff and non-nursing staff confirmed they had received in-service training on the facility's Elopement Policy and not giving out the code to the front door.