Every finding on record at The Greens at Weaverville

Based on observations and staff interviews, the facility failed to remove food stored for use that was expired or past its use by date, clean a refrigerator circulatory fan cover, and clean a juice dispenser. This was for 1 of 3 (walk-in refrigerator) refrigerators and 1 of 1 dry storage room. This practice had the potential to affect food served to residents. Findings included: a.On 7/20/26 at 9:34 AM an observation with the District Dietary Manager in the walk-in refrigerator found a left-over storage container labeled cream soup on a food storage rack. The cream soup was dated 7/12. At 9:35 AM the District Dietary Manager stated left-over foods were kept for a maximum of 7 days, and the cream soup should have been disposed of by 7/18/26. She stated it had been overlooked by the weekend cook who checked storage dates. b.On 7/20/26 at 9:36 AM the walk-in refrigerator's circulatory fan cover was observed with a buildup of clumpy debris. The clumpy debris was observed moving as the circulatory fan was running.At 9:37 AM on 7/20/26 the District Dietary Manager stated she was unaware when the fan cover was last cleaned. It was her first day at the facility, and the fan cover would be placed on a cleaning schedule.c.On 7/20/26 at 9:40 AM an observation in the dry storage room with the District Dietary Manager found a storage container labeled cornmeal. The cornmeal was labeled with a date 4/7/25 and use- by 4/7/26 and located on a food storage shelf. Additionally, 12 unopened containers of thickened liquid were found stored for use on the shelf with an expiration date of May 2026.At 9:40 AM on 7/20/26 the District Dietary Manager said cornmeal was kept for 90 days once opened, and it should have been disposed. Furthermore, she explained the thickened liquids were not rotated, overlooked and they should have been disposed of when they expired.d.On 7/20/26 at 9:50 AM an observation of the juice dispenser machine was made in the main kitchen with the District Dietary Manager. The inside of the juice dispenser nozzle was found to contain a multi-color buildup of gunk (thick, sticky substance like dirt, sludge or grime).At 9:51 AM on 7/20/26 the District Dietary Manager said the nozzle was supposed to be cleaned daily and was not aware when it was last cleaned. On 7/23/26 at 4:04 PM the Administrator stated the expired food should have been disposed of and the kitchen needed to be cleaned as scheduled.

Based on record review, Medical Director, Nurse Practitioner and staff interviews, the facility failed to follow the physician's order and obtain a blood pressure reading prior to administering a blood pressure medication with parameters to hold for 1 of 3 residents reviewed for change of condition (Resident #136). Findings included:Resident #136 was admitted to the facility on [DATE] with diagnoses including hypertension and chronic systolic congestive heart failure.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #136's cognition was severely impaired. The MDS list of active diagnoses included hypertension.Resident #136's physician's order written on 05/08/26 for metoprolol (beta blocker) 25 milligram (mg) give half tablet (12.5 mg) one time a day for hypertension, hold if the systolic blood pressure (maximum pressure in the arteries when the heart contracts) was less than 100.Review of the June 2026 Medication Administration Record (MAR) revealed on 06/15/26 at 9:00 AM, Nurse #1 documented metoprolol 25 milligram (mg) give half tablet (12.5 mg) was administered. Resident #136's MAR included vital signs as follows: blood pressure, temperature, pulse, respiratory rate, and oxygen saturation with directions to obtain twice a day every day and evening shift from 7:00 AM through 3:00 PM and from 3:00 PM through 11:00 PM. Nurse #1 documented Resident #136's vital signs on 06/15/26 at 7:00 AM through 3:00 PM as follows: blood pressure (NA), temperature 97.4, pulse 78, respiratory rate 16, and oxygen saturation 93. There was no indication what time Nurse #1 took Resident #136's vital signs. Review of Resident #136's electronic medical records labeled vital signs revealed Nurse #1 documented a blood pressure of 90/52 on 6/15/26 at 10:47 AM. During an interview on 07/22/26 at 3:31 PM, Nurse #1 confirmed she had administered metoprolol on 06/15/26 as part of Resident #136's scheduled 9:00 AM morning medications and stated typically she checked the vital signs, including the blood pressure before giving the medications. Nurse #1 stated she could not confirm Resident #136's blood pressure was checked prior to administering the metoprolol. She revealed it was after the morning medications were administered Resident #136's blood pressure result was 90/52 and she notified the Nurse Practitioner (NP). Interviews were conducted on 07/22/26 at 11:21 AM and 07/22/26 at 2:32 PM with the NP. The NP confirmed the physician's order included a parameter to hold if Resident #136's systolic blood pressure was less than 100 and required Nurse #1 to check the blood pressure before administering the metoprolol. The NP confirmed Nurse #1 notified her on 06/15/26 when the blood pressure was 90/52 and stated Resident #136 had received metoprolol for some time and she did not consider a 12.5 mg dose was significant to cause a negative change in Resident #136's condition. During an interview on 07/23/26 at 10:22 AM, the Medical Director revealed Resident #136's blood pressure was checked twice a day, and the results were reviewed, and if consistently low the medication metoprolol would have been discontinued. The Medical Director stated based on Resident #136's blood pressure results, administering a 12.5 mg dose of metoprolol, she did not consider that caused a negative change in Resident #136's condition. During an interview on 07/23/26 at 4:13 PM, the Director of Nursing (DON) revealed the physician's order required Nurse #1 check Resident #136's blood pressure prior to administering metoprolol and if not done was an oversight.

Based on record review, observation and staff interviews, the facility failed to discard six expired vials of influenza (flu) vaccine and date an open vial of tuberculosis (TB) skin testing solution in 1 of 3 medication storage rooms (400 Hall Medication Room) reviewed for medication labeling and storage.The findings included: On 7/21/26 at 5:15 PM an observation was made in the 400 Hall medication storage room with the Director of Nursing (DON) present. While looking in the medication refrigerator it was discovered that six - 5 milliliter (ml) multi-dose vials (sterile bottles with a rubber stopper that contain more than one dose) of flu vaccine in individual boxes all had a manufacturer's expiration date of 6/30/26. The DON was interviewed on 7/21/26 at 5:17 PM during the medication refrigerator observation and confirmed the six boxes each contained a 5 ml vial of flu vaccine and had a manufacturer's expiration date of 6/30/26 printed on the boxes. She stated nurses were supposed to check the medication refrigerator routinely and remove any discontinued or expired medications but had probably missed the flu vaccines. Further observation of the 400 Hall medication refrigerator revealed an open box of a 1 ml multi-dose vial of Aplisol (a sterile solution used to perform skin tests to check for tuberculosis (a contagious respiratory disease). The box contained a multi-dose vial which did not have a cap on the rubber stopper. There was no opened-on or use-by date indicated on the box or the vial, and the fluid level of solution was 2/3 full. In a follow up interview on 7/21/26 at 5:19 PM while in the 400 Hall medication room, the DON confirmed the open vial of TB testing solution looked like it probably had a few doses taken out and did not have an opened-on or use-by date on the vial or box. She stated nurses knew the procedure was to date all multi-dose vials when opened and discard any unused solution according to manufacturer's instructions and the nurse who opened this had probably forgotten. She further explained TB solution expired and was supposed to be discarded 30 days after being opened and without an opened-on or use-by date recorded it would not be known when the vial had been opened for 30 days. The DON revealed using solution from a multi-dose vial that was out of date could cause risk of contamination and the solution not being as effective as it should be. In an interview on 7/23/26 at 4:30 PM the Administrator stated the expectation was that expired medications should be removed from medication carts and storage rooms.

Based on observations, record review, staff and resident interviews, the facility failed to provide incontinence care for 1 of 5 dependent residents (Resident #103) reviewed for activities of daily living. The findings included: Resident #103 was admitted on [DATE] with diagnoses including chronic kidney disease, mild cognitive impairment, and benign prostatic hyperplasia (enlarged prostate). Resident #103's Care Plan revised 6/11/26 had focus areas for:Activities of daily living (ADL) self-care deficit with interventions including - to encourage use of call light for assistance, provide assistance with toileting and dressing as needed.Incontinence of bladder with interventions including - uses disposable briefs, check and change on routine rounds, assist to bathroom or provide incontinence care as needed, and keep call light in easy reach. Potential impairment to skin integrity related to incontinence and effects of diagnoses with interventions including - observe skin status during routine care, keep skin clean and dry. The quarterly Minimum Data Set (MDS) dated [DATE] for Resident #103 showed him to be moderately cognitively impaired, with no impairment of upper or lower extremities, frequent incontinence of bowel and bladder, and no skin problems or moisture associated skin damage. He was also coded for renal insufficiency, without rejection of care, being dependent for toileting hygiene and bathing, and required substantial assistance with transfers and toileting transfers. On 7/20/26 at 9:50 AM during an observation of Resident #103 while in bed, a strong odor was detected in the room which smelled like urine. In an interview during the observation Resident #103 was able to answer simple questions with short answers and stated he had a problem, he was wet. He also stated he had eaten breakfast in bed but was unable to explain how long he had been wet or if he had eaten breakfast while wet. Closer observation revealed Resident #103 to be wearing sweat pants which were partially pulled down over his hips, and he was not wearing a brief or undergarment. Resident #103's blanket and top sheet were bunched up between his thighs and the blanket, top sheet, sweat pants, draw sheet (a flat sheet folded in half and placed under the resident's hips to assist in bed positioning), and bottom sheet were wet and had the odor of urine and he was pulling on the blanket. No incontinence pad or used brief were observed on the bed or anywhere in the room. A small garbage can with no liner was next to Resident #103's bed which contained 1/4 inch of yellow liquid that had the appearance of urine. He did not answer when asked if he had urinated in the trash can. When asked if he had used the call bell to let someone know he was wet, Resident #103 stated he did not know where it was. The call bell was observed to be clipped on the fitted sheet above his left shoulder, next to the pillow near the top of the mattress and was partly covered by the top sheet. Record Review of Resident #103's Urinary Report from 7/19/26 at 11:00 PM to 7/20/26 at 9:50 AM indicated a continent urination on 7/20/26 recorded at 12:54 AM by Nurse Aide (NA) #4 with no other entries observed. A phone interview was conducted with NA #4 on 7/22/26 at 4:53 PM who stated she worked 11:00 PM on 7/19/20 until 7:00 AM on 7/20/26 and was assigned to Resident #103 that shift and it had been her first time taking care of him. NA #4 explained she got shift change report from the off-going NA but didn't remember their name. She further explained she had been told in report that Resident #103 used the toilet, didn't like to use briefs, and used the urinal at times, but had episodes of confusion and would sometimes urinate in a cup and added that she hadn't been told he also urinated in the waste basket at times. NA #4 described seeing Resident #103 sitting on the side of the bed about 12:00 or 12:15 AM, asked if he needed to go the bathroom, then assisted him to the bathroom because he was a little wobbly, that he urinated in the toilet and then went back to sleep in bed. NA #4 revealed she did rounds on the hall about every 2 hours through the night and each time she looked in on Resident #103 he was sleeping and didn't check to see if he was wet because of what she had been told in report. NA #4 stated she was last in Resident #103's room and saw him sleeping about 6:00 AM and did not remember a urine odor then. NA #4 concluded the interview by stating she had access to the resident's care guides on the computer system and had logged on to see her residents' code status but didn't need to look at what care to provide because she had gotten that information in report. On 7/20/26 at 9:56 AM an interview was conducted at Resident #103's bedside with Nurse Aide (NA) #1 who was his NA. He explained he had taken care of Resident #103 several times including last evening until 11:00 PM and had put a brief on him about 10:00 PM. NA #1 further explained he had come in at 7:00 AM today and hadn't changed him yet but could see that he was wet now. NA #1 revealed he had noticed the urine smell around 7:30 to 7:45 AM when he first went into Resident #103's room but did not look to see if he was wet because there were no briefs in his room and planned to change him when he got some briefs. NA #1 stated there were no briefs on the hall storage cart or in the storage room and he had let Nurse #2 know briefs were needed for the hall cart. NA #1 further explained that supplies were stocked every morning but sometimes not until breakfast time. During a follow up interview with NA #1 at10:23 AM he stated when he smelled urine earlier he did not change Resident #103 because there were no briefs and he had not looked to know that Resident #3 wasn't wearing a brief because he usually wore one at night and added that he sometimes would take his briefs off. NA #1 added he did get briefs and then breakfast trays came and he did not like to change residents right when the food was coming, that trays had come about 8:15 AM and he had been planning to do rounds right after breakfast. An interview was conducted at Resident #103's bedside with Nurse #2 who was his nurse, on 7/20/26 at 10:11 AM. Nurse #2 confirmed that Resident #103 was wet through this sweatpants, blanket, and sheets and they smelled of urine. She stated there were times when Resident #103 would remove used briefs and put them on the floor but there were no incontinence pads or used briefs on the bed or in the room now. Nurse #2 also confirmed there was urine in the trash can beside his bed and explained he would sometimes urinate in the trash can. Nurse #2 revealed she had been in his room about 7:25 AM to see if he was awake and did not remember if she smelled urine and hadn't looked to see if he was wet, she was just doing quick checks see if residents were awake. She did not recall if she had seen his call bell and stated he sometimes used his call bell, but she hadn't seen that he had used it that morning. Nurse #2 explained the NAs got briefs from the supply room to put on the hall carts, the supply room had been stocked that morning but wasn't sure what time, and the NAs could get briefs from another hall cart if needed. An observation was made on 7/20/26 at 10:15 AM of NA #1 and Nurse #2 assisting Resident #103 to the bathroom for toileting and incontinence care. When Resident #103 stood it was observed that both mid to upper buttocks cheeks had palm-shaped, 6 to 7-inch high by 4 - 5 inches wide red marks with shallow wrinkles consistent with maceration (skin condition from exposure to moisture). On Resident #103's upper left buttock and lower back were multiple 1/2 to 1-inch reddened marks in a 4-inch area which had the appearance of scratches. During the observation Nurse #2 confirmed that Resident #103 had red marks on his buttocks and lower back that had the appearance of maceration and scratches and added that sometimes he would scratch himself. Nurse #2 was unaware of how long it had been since Resident #103 had been changed and had not known about the red marks on his buttocks. In an interview with NA #2 who was Resident #103's NA that shift on 7/22/26 at 4:19 PM, she explained he used to use the urinal during the day and a wear brief at night but would often refuse to wear a brief during the day. She further explained he would still sometimes urinate in the toilet and would try to use the urinal but had a hard time managing it. She added that he would occasionally urinate in the trash can but was mostly incontinent at this point. NA #2 stated he did sometimes still used the call bell but not a lot anymore. NA #2 revealed he was mostly using a brief during the day for about the last few weeks, and they had him on routine checks to be changed every few hours. NA #2 revealed she had seen times when she came in the morning when he was not wearing a brief but not seen him having been wet in the bed. On 7/22/26 at 4:26 PM an interview was conducted with NA #3 who had worked with Resident #103 for several years and was assisting NA #2 with his care today. She stated he would sometimes use the urinal but would pull it away before he was finished and dribble on the sheets. NA #3 explained he used to have the habit of pulling briefs off wet or dry, but recently saw he was in a brief a lot when she came on in the morning and had seen him wet a few times at shift change but not all the time. She further explained he was wearing briefs during the day more often recently and staff would put an incontinence pad as well to catch drips because he would sometimes open the brief and try to use the urinal which would usually spill, or he would sit on the bed side and urinate in the trash can. During an interview with the Director of Nursing (DON) on 07/22/26 at 5:46 PM she stated staff did rounds every few hours to check and change incontinent residents. The DON explained the expectation was when it was known a resident had an incontinent episode staff should provide care as soon as possible. She further explained the NAs have access to briefs on the carts on each hall and if they ran out on the cart they could get some from another hall cart or ask any nurse to get more from the supply room. The DON revealed that NA #1 should have provided incontinence care to Resident #103 when he first noticed the urine odor at the start of the shift and NA #4 should have gotten information in report to have known to check him. The Administrator was interviewed on 7/22/26 at 5:48 PM and explained the facility had had plenty of incontinence supplies and the supply room was stocked every day. During the interview, observation was made of the supply room which contained multiple packages of briefs in a variety of sizes. The Administrator explained that Resident #103 was sometimes continent, had been known to urinate in a cup or his trash can and when he did use the urinal he often spilled urine. She stated residents were to be changed on rounds every few hours and in between as needed and should not wait to provide incontinence care until after meals if they knew it was needed.

Based on observation, and staff interviews, and resident interview the facility failed to remove a container of 70% rubbing alcohol and a container of cleaning degreaser from a resident's room. The items were found at the resident's (Resident #64) bedside. This was for 1 of 1 residents reviewed for accident hazards (Resident #64). Findings included: Resident #64 was admitted on [DATE] with diagnoses that included type 2 diabetes and chronic kidney disease.Resident #64 annual Minimum Data Set (MDS) dated [DATE] coded him cognitively intact. He was independent with transfers and always continent of bowel and bladder. Resident #64 was care planned last revised on 7/3/26, for activities of daily living self-care performance deficit with supervision needed for bathing and using stairs. Interventions included using call bell for assistance.Resident #64's roommate, Resident #67 was cognitively intact on his annual MDS dated [DATE].On 7/20/26 at 10:06 AM an in-room observation of Resident #64's room found a container of 70% rubbing alcohol and a container of degreaser cleaner. Both containers were located beside the resident's bed behind his trash can. Resident #64 was not in his room during the observation.On 7/20/26 at 2:58 PM an in-room observation of Resident #64 found the containers unchanged, and the resident was not in his room. On 7/20/26 at 3:02 PM an in-room observation was made with Nurse #2. Nurse #2 verified the containers were rubbing alcohol and degreaser cleaner. The nurse stated the rubbing alcohol and degreaser were not provided by the facility. She added, according to the label, the degreaser was for cleaning, and she did not know why the containers were in Resident #64's room. Nurse #2 said she was not assigned to the resident and did not know how long the containers had been in the room. The nurse removed the items from the room.On 7/20/2026 at 3:20 PM Nurse #3 who was assigned to Resident #64 was interviewed. She stated she had been in Resident #64's room earlier in the day and had not seen the 2 containers. The nurse added she did not know why Resident #64 had those containers in his room and thought the resident may have brought them into the facility. Nurse #3 confirmed the resident did not have a physician's order for rubbing alcohol. On 7/20/26 at 3:25 PM Resident #64 was interviewed. The resident said he had brought the rubbing alcohol into the facility. He stated he had the rubbing alcohol to use on his skin but had not used it yet. He added he was using the degreaser on his clothing when he had a stain, and he had the degreaser in his room for several months. The resident said he had not told any staff that he had the items in his room and had kept them beside his bed.On 7/23/26 at 4:07 PM the DON stated the rubbing alcohol, and degreaser should have been locked up, and the resident was not approved to have those items in his room. She added the containers should have been removed by staff.On 7/23/26 at 4:08 PM the Administrator stated the facility did daily rounds and the items should have been reported by staff.

Based on record review and interviews with the Registered Dietitian (RD), Nurse Practitioner (NP) and staff, the facility failed to implement nutritional supplements for a resident with pressure ulcer wounds and non-pressure ulcer venous wounds as recommended by the RD for 1 of 4 residents reviewed for nutrition (Resident #136). Findings included:Resident #136 was admitted to the facility on [DATE] with diagnoses including a stage 3 sacrum pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible), a left heel deep tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue), and non-pressure chronic venous/arterial ulcers (an open lesion of the skin and subcutaneous tissue) of the right and left legs.The care plan dated 05/07/26 identified Resident #136 was at risk for malnutrition related dementia, pressure ulcer wounds, and non-pressure wounds. Interventions included continue dietary recommendations.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #136 was severely impaired cognitively, needed supervision assistance with eating, had one stage 3 pressure ulcer and one deep tissue injury that were present on admission, and 4 venous/arterial ulcers.Review of the RD's progress note dated 05/22/26 revealed Resident #136's evaluation noted she met approximately 60 to 80% of her estimated nutritional needs. The RD's note included Resident #136's stage 3 pressure ulcer, a left heel pressure ulcer, and arterial wounds and a recommendation for 120 milliliters (ml) daily nutritional drink supplement to provide an additional 240 calories and a therapeutic nutritional powder (amino acids and collagen protein) supplement twice a day to provide an additional 180 calories.Review of Resident #136's physician orders revealed no order for a 120 ml daily nutritional supplement drink or a therapeutic nutritional powder supplement twice a day. Resident #136 was discharged from the facility on 06/15/26. During an interview on 07/22/26 at 10:55 AM, the RD revealed she evaluated Resident #136's nutritional needs on 05/22/26. The RD stated she evaluated Resident #136's oral intake and estimated she was not meeting nutritional needs and recommended a daily 120 ml nutritional drink supplement and a therapeutic nutritional powder supplement twice a day to meet 100% of nutritional needs. The RD stated her recommendations were sent by email to the facility typically on the same day 05/22/26 and she included the Unit Manager, Assistant Director of Nursing (ADON), Director of Nursing (DON) on the email. The RD indicated Resident #136 was discharged from facility before the next monthly review.During an interview on 07/22/26 at 11:21 AM, the NP confirmed Resident #136's nutritional status was followed by the RD and included recommendations to improve oral intake. The NP was aware of Resident #136's stage 3 pressure ulcer, a deep tissue injury pressure ulcer, and non-pressure lower extremity vascular wounds and agreed with the RD recommendations made on 05/22/26 for Resident #136 to receive nutritional supplements and stated those should have been put in place. During an interview on 07/23/26 at 4:13 PM, the DON confirmed Resident #136 was evaluated by the RD on 05/22/26 and the recommendations were sent by email to her, the Unit Manager, and the ADON for review. The DON revealed she did not recall reviewing the recommendations made for Resident #136 on 05/22/26 to ensure those were implemented and stated it was the Unit Manager's responsibility to ensure the RD's recommendations were transcribed to Resident #136's Medication Administration Record.

Based on record review, and staff, Primary Care Physician (PCP), facility Physician, Nurse Practitioner (NP), assisted living Director of Nursing, and Consultant Pharmacist interviews, the facility failed to provide an accurate medication list on an FL-2 to an assisted living facility for a resident who was discharged home from the facility while waiting on assisted living placement. The allergies listed were also incorrect. This deficient practice occurred for 1 of 3 residents reviewed for discharge (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included an encounter for orthopedic aftercare following surgical amputation of right second toe, Alzheimer's dementia, essential hypertension, and hyperlipidemia. Resident #1's discharge instructions dated 3/18/26 revealed he was discharged home on 3/18/26 with his correct current medication summary list. This list of medications was signed by the Responsible Party (RP), dated 3/18/26 and included the following medications: Acetaminophen 325 milligrams (mg) 2 tablets by mouth three times a day for painDonepezil 10 mg 1 tablet by mouth at bedtime for dementiaEscitalopram 10 mg 1 tablet by mouth one time a day for mood symptomsFamotidine 20 mg 1 tablet by mouth one time a day for stomach acidFenofibrate 145 mg 1 tablet by mouth one time a day for cholesterolLosartan 50 mg 1 tablet by mouth in the morning for hypertensionMelatonin 3 mg 1 tablet by mouth every 24 hours as needed for insomnia for 14 daysMemantine 10 mg 1 tablet by mouth two times a day for dementiaNystatin powder apply to groin and scrotum topically every day and evening for yeast for 14 daysResident allergies were listed as hydrochlorothiazide and tricor An FL-2 (The Adult Care Home FL2 Form is a document signed by a physician or nurse practitioner which contained medical diagnoses, medications, functional limitations, and care needs required to qualify for Medicaid coverage or facility admission) with Resident #1's name and date of birth was completed by the facility Social Worker (SW), signed by the NP on 3/18/26, and emailed to the assisted living facility by the SW. The FL-2 with Resident #1's name and date of birth on 3/18/26 included the following information: Anastrozole 1 mg 1 tablet by mouth one time a day (female hormone medication used to treat/prevent breast cancer in postmenopausal women)Apixaban 5 mg 1 tablet by mouth two times a day (blood thinner)Aspirin 81 mg 1 tablet by mouth one time a day (heart attack prevention)Atorvastatin 80 mg 1 tablet by mouth at bedtime (cholesterol inhibitor)Bupropion 300 mg 1 tablet by mouth one time a day (antidepressant/mood stabilizer)Diazepam 2 mg 1 tablet by mouth two times a day (antianxiety)Furosemide 40 mg 1 tablet by mouth one time a day (diuretic)Metoprolol 50 mg 2 tablets by mouth one time a day (blood pressure)Sacubitril-Valsartan 24-26 mg 1 tablet by mouth two times a day (chronic heart failure)Tramadol 50 mg 1 tablet by mouth every 4 hours as needed (opioid pain)Acetaminophen 500 mg 1 tablet by mouth two times a day (pain)Vitamin B12 500 micrograms (mcg) by mouth one time a day (supplement)Vitamin D3 25 mcg 1 tablet by mouth one time a day (supplement)The block title additional information had handwritten hydrochlorothiazide, flagyl per medical review-attached and signed. The attached medication order summary was for Resident #2, not Resident #1. An interview with the Social Worker (SW) on 6/09/26 at 9:05AM revealed Resident #1 was on the waiting list for an assisted living facility prior to admission to the facility. He was admitted to the facility for short term rehabilitation after surgical amputation of right second toe. He was discharged home from the facility on 3/18/26 before his assisted living placement was available. During the discharge process, the RP requested the necessary paperwork for the Resident #1's assisted living admission be sent to the assisted living facility. The SW stated she prepared the FL-2 which included the resident's medications and asked the NP to sign it. She stated she had mistakenly copied the medications from Resident #2's electronic health record onto Resident #1's FL-2. The SW also stated she had emailed the completed and signed FL-2 with the incorrect medication list to the assisted living facility. The SW indicated the assisted living Sales Director, contacted SW and requested additional information which included allergies which the SW handwrote the allergies under the block additional information on the FL-2 and emailed it again to the assisted living facility. The SW stated she typically completed the resident identification information on the FL-2 and nursing completed the medication information which the physician reviewed and signed. She stated she was trying to expedite the process and help by filling out the medications on the FL-2. An interview with Nurse #1 on 6/09/26 at 10:05 AM revealed she had discharged Resident #1. She stated she reviewed his discharge information with his RP and provided a medication list utilizing the facility discharge forms. She stated she had not seen an FL-2 and had not talked to the assisted living facility. An interview with the Nurse Practitioner (NP) on 6/09/26 at 10:25 AM confirmed it was her signature on the FL-2 dated 3/18/26 for Resident #1. She stated the physician usually reviewed and signed the FL-2 and she had not reviewed or signed many FL-2s in the past. She did not specifically remember signing Resident #1's FL-2 and did not know why she had signed it but believed she did not review it as thoroughly as she should have. She stated the Anastrozole which is a breast cancer medication typically given only to females would have been a red flag during a review of the medication list. A telephone interview with Resident #1's Primary Care Physician (PCP) on 6/09/26 at 12:19 PM revealed she was familiar with Resident #1. She stated she had not seen the resident in quite a while but medication concerns were brought to her attention after someone in her office reached out to the RP to check on the resident's status. The RP reported concerns about medication changes and the resident's condition which the PCP office staff relayed to the PCP. The PCP contacted the assisted living facility Director of Nursing (DON) to discuss Resident #1 condition, and they discovered he was taking the wrong medications. Resident #1's medications were corrected on 5/15/26. The PCP stated there were 2 issues with Resident #1's medication changes. He was started on all new medications at one time. She stated the blood thinner was not indicated for any of his medical conditions and that changes in his blood pressure medications could negatively impact his cardiovascular system. She also stated that he had been very stable for quite some time on his regimen of medications which included 2 dementia medications, Donepezil and Memantine, and a mood stabilizer, Escitalopram. She believed that abruptly stopping these medications was detrimental to him and could adversely affect his dementia and depression. Some of the changes could include increased confusion, depression, and loss of appetite. She stated that any sort of medication changes tended to affect a dementia resident more than a normal person. The PCP stated she had not personally seen the resident but had been told he was not doing well. A telephone interview with the facility Physician on 6/09/26 at 1:04 PM revealed she did not remember anything about Resident #1's FL-2. She stated she could not answer about his medication consequences related to the abrupt stop of current medications and being given different medications. She stated she could only assume he was having difficulties with such a big list of wrong things but could not speak about what happened. A telephone interview with the assisted living Director of Nursing (DON) on 6/09/26 at 12:32 PM revealed Resident #1 had been admitted to the facility on [DATE]. She stated the assisted living facility had received an FL-2 from his prior nursing home and had used it for his medications. She had not reached out to the nursing home and was unaware of any medication concerns until his PCP reached out to her on 5/15/26. She stated the PCP had noted medication discrepancies and these medications were immediately stopped and he was restarted on his correct medications. She stated she believed he had received the wrong medications for about 4 weeks. She was unable to say if he had any adverse effects except, she was aware that he had been very sleepy. An interview with the Consultant Pharmacist on 6/09/26 at 2:00 PM revealed that medications were very specific to a person and people were affected differently. She stated that no one should take medications they do not need. She reviewed Resident #1's medications and Resident #2's and stated that she felt there were no 'huge' cumulative changes. She did note that Diazepam required a taper and careful monitoring during discontinuation. Anastrozole was a breast cancer medication which affects estrogen in females and would not have targeted his chemical pathways. She also noted that Apixaban had a lower bleeding risk than some blood thinners. An interview with the Consultant Pharmacist Supervisor on 6/12/26 at 1:29 PM revealed he believed the abrupt discontinuation of the dementia medications, Donepezil and Memantine, may increase Resident #1's agitation if he had any, but noted the resident did not have behaviors listed on his diagnoses list. He stated the Escitalopram and Bupropion were both antidepressants and switching would likely cause no significant adverse effects. He stated that Resident #1 did not have a medical diagnosis for Apixaban, so it might cause extra bruising. The Atorvastatin and the Fenofibrate might cause an abnormal lab value but nothing clinically significant. The addition of Furosemide had the potential to increase Resident #1's thirst or electrolyte abnormality. Resident #1 was supposed to be on Losartan for high blood pressure, and this was switched to Metoprolol and Sacubitril-Valsartan which had the potential to lower his heart rate but all were blood pressure medications. He was unable to speak about the Tramadol as this was ordered as needed and did not know if Resident #1 received this medication. Diazepam could have caused increased lethargy and confusion. Anastrozole likely did not have any significant adverse effects since Resident #1 was a male. The Consultant Pharmacist Supervisor stated that a Physician should assess Resident #1, but it would likely be very difficult to discern any adverse effects from the medication errors. An interview with the Administrator on 6/09/26 at 4:18 PM revealed she was unaware there had been an error in the FL-2 for Resident #1 until the surveyor notified them and believed this was a human error.

Based on observations and interviews with staff, the facility failed to remove expired food with signs of spoilage stored for use in 1 of 3 refrigerators (the walk-in refrigerator). This had the potential to affect food served to the residents in the facility.Findings includedOn 7/28/25 at 10:15 AM an observation with the Dietary Manager (DM) in the walk-in refrigerator found a box of yellow squash with a written date of 7/9. The box of yellow squash was located underneath an additional box of yellow squash with a written date of 7/14 stored on the second shelf. The yellow squash dated 7/9 were observed to contain dark, splotchy and sunken in areas and the squash was not firm to touch. Furthermore, 1 squash located in the bottom of the box was broken into two pieces and was mushy when touched. The DM stated during the observation the yellow squash needed to be thrown out. The DM immediately removed and threw away the yellow squash. A follow-up interview with the DM was conducted on 7/31/25 at 12:56 PM. He stated it was his responsibility to check all food storage areas in the kitchen every morning for expired or out of date food. The DM stated he had checked the walk-in refrigerator on 7/28/25 prior to the observation with the state surveyor and he had overlooked the bad squash.The Administrator was interviewed on 7/31/25 at 2:56 PM. The Administrator stated any food past expiration or produce that had gone bad should have been discarded.

Based on record review and interviews, the facility failed to care plan a resident who had a physician's order for an antipsychotic medication. This was for 1 of 5 residents reviewed for unnecessary medication (Resident #86).Findings includedResident #86 was admitted on [DATE] with diagnoses that included adjustment disorder.Resident #86's admission Minimum Data Set (MDS) assessment dated [DATE] coded her cognitively intact and indicated she had received an antipsychotic during the 7-day look back period. Resident #86 had a physician's order dated 6/23/25 for quetiapine fumarate oral tablet 50 milligram (antipsychotic). With instructions to give 1 tablet by mouth at bedtime for adjustment disorder with other symptoms. A review of Resident #86's care plan that was dated last reviewed on 6/30/25 found no care plan for antipsychotic medication use. On 7/31/25 at 10:22 AM, MDS Nurse #1 stated Resident #86's care plan had not included a care plan for an antipsychotic medication. MDS Nurse #1 added the physician's order for an antipsychotic medication was added on 6/23/25 and should have been care planned for Resident #86. All new physician's orders are reviewed each morning during the interdisciplinary team (IDT) meeting and Resident #86's antipsychotic medication order was missed.The Administrator was interviewed on 7/31/25 at 2:56 PM. She stated all residents who had received an antipsychotic medication needed to have a care plan for antipsychotic medication. The care plan needed to be added when the medication was ordered for the residents. The Administrator stated the order for the antipsychotic medication was missed when reviewed by the MDS nurses during the IDT morning meeting the morning after the order was written.

Based on observations and staff interviews the facility failed to maintain a clean and sanitary kitchen floor, date an opened nutritional supplement and food in 1 of 3 nourishment rooms (300 hall), clean and sanitize an ice scoop and holder for 1 of 3 ice chests, and date opened cheese in the walk-in refrigerator. This practice had the potential to affect food served to all residents. The findings included: a. An observation of the kitchen on [DATE] at 9:44 AM found the kitchen floor tiles to be covered with a black substance and sticky when walked on as evidenced by the sound that was made when the floor was walked on, and the surveyor's shoes stuck to the floor. The black substance and sticky floor were not contained to one area of the kitchen floor and was spread throughout the kitchen. An observation of the kitchen floor on [DATE] at 12:18 PM found the kitchen floor unchanged. The floor areas underneath and directly around 3 food prep tables were found to contain food and other debris. b. An observation of the 300-nourishment room refrigerator was conducted on [DATE] at 10:54 AM with the District Food Service Manager and a Dietary Aide. The refrigerator contained an opened nutritional supplement and an opened ready to use container of applesauce that did not contain an open date or use by date. Dietary Aide #1 stated on [DATE] at 11:01 AM she had checked all the nourishment rooms around 7:00 AM that day and did not see the open items. c. An observation of the 300-nourishment room on [DATE] at 11:14 AM with the District Food Service Manager and Dietary Aide #1 found a cart that contained an ice chest with an ice scoop and ice scoop holder attached to the cart. The ice scoop was observed to be in the ice scoop container with approximately 2 inches of water and the tip of the scoop was resting in the water. The water contained multiple black and brown specks. The District Food Service Manager stated during the observation that the kitchen was not responsible for ensuring the ice carts were taken to the kitchen for cleaning. She stated the kitchen did not provide or replace the equipment on the ice cart and that the nursing department kept up with the daily maintenance of the ice carts. Dietary Aide #1 stated on [DATE] at 11:16 AM the ice carts were brought to the kitchen by nurses or nursing aides and left at random times during the day to be washed and sanitized. Dietary Aide #1 was not sure when the cart had last been cleaned. The Director of Nursing (DON) was interviewed on [DATE] at 1:20 PM. She stated the ice carts were taken down to the kitchen each morning by the nurses or nursing aides to be cleaned and sanitized. The ice cooler, ice scoops and ice scoop holders were removed from the cart, cleaned and replaced. The DON said the ice carts were then retrieved by the nurses or nursing aides and taken back to each nursing unit. The DON stated the ice scoop holder should not have contained water and the ice scoop should not have been touching the water. d. An observation of the walk-in refrigerator on [DATE] at 11:57 AM with the DM found a bag of shredded cheese on a storage shelf that did not have an open or use by date. The DM immediately removed the shredded cheese from the walk-in refrigerator. The Dietary Manager (DM) was interviewed on [DATE] at 1:37 PM. The DM stated the opened shredded cheese found in the walk-in refrigerator should have contained an open date and use by date. He said the shredded cheese was used to make salads for the lunch meal that day and was placed back into the walk-in refrigerator without being dated. The DM stated he did checks in the morning to look for expired and non-dated food and did not find any. The DM said the items found in the 300-nourishment refrigerator should have been dated when opened before placing them into the refrigerator. He said the nourishment rooms were checked each day in the morning, and the opened items found were not in the refrigerator when checked that morning. The DM stated the kitchen floors are spot swept and moped several times each day, and that walking on the floor before it dried kept the floor from looking clean. He stated the kitchen floor was hosed two times a week on Sunday and Wednesday, and the floor was not hosed on the previous Sunday. The DM stated the cleaning list schedule was assigned to the job (Cook, dietary aide) each shift and not to an individual staff member. The cleaning list schedule was not signed or marked by the staff when a cleaning task was completed, and the DM would check to ensure the cleaning was completed. The Administrator was interviewed on [DATE] at 2:23 PM. He stated the kitchen had a performance improvement project (PIP) that began in [DATE]. The PIP included properly dating and labeling food and the dietary staff had been educated and in serviced several times. He said audits of the kitchen had been ongoing and could not provide explanation for the food items found that were not dated. The Administrator stated the kitchen needed to utilize the cleaning list schedules to ensure cleaning tasks had been assigned and completed. The Administrator stated the ice chest and ice scoops should be cleaned and sanitized when dirty and as scheduled.

Based on record review, observations, and interviews with resident, staff, Registered Dietitian and the Medical Director, the facility failed to provide a nutritional supplement and double protein as ordered by the Registered Dietitian for 1 of 4 residents (Resident #90) reviewed for nutrition. The findings included: Resident #90 was admitted to the facility on [DATE] with the diagnoses of diabetes and a pressure ulcer on left buttocks. On 2/1/24 Resident #90 was weighed using a sit-down scale and his weight was 253.0 pounds. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #90 was alert and cognitively intact. He had no weight loss. Resident #90's care plan dated 5/15/24 stated he was to have dysphagia (difficulty swallowing) advanced meats and mechanically altered diet for all food categories. The interventions included to provide and serve supplements as ordered and provide and serve diet as ordered. On 4/24/24 Resident #90 was weighed using a total mechanical lift and his weight was 229.4 pounds. 5/28/24 Resident #90 was weighed using a total mechanical lift and he weighed 215.8 pounds. Resident #90 had a physician order stating that Resident #90 was at risk for malnutrition and ordered double protein and fortified pudding with meals starting 6/6/24. On 6/9/24 at 10:33 AM an interview was conducted with Resident #90. Resident #90 stated he did not like to eat bread at his meals and the ground food didn't taste good. Resident #90 stated he had lost some weight. On 6/10/24 at 12:21 PM observation was made of Resident #90's lunch tray and ticket. The tray had chocolate ice cream but no fortified pudding. A single portion of protein was observed on the tray. The lunch ticket did not list fortified pudding or double protein. The resident ate approximately 50 % of his meal. On 6/10/24 at 12:30 PM an interview and observation was conducted with the Registered Dietitian (RD). The RD checked Resident #90's lunch ticket and noticed that it did not have the double portion of protein, nor the fortified pudding listed. The RD stated that she will need to check the ticket system to see why it was not correct and she will fix it. The RD stated that the fortified pudding and double protein was to increase caloric intake due to weight loss and pressure ulcer. On 6/10/24 at 3:38 PM an interview was conducted with the Medical Director (MD). The MD stated she just spoke to the RD about Resident #90 last week. The MD stated that some of the weights listed for him were fluid overload. The MD stated that the RD did her own orders. The MD stated Resident #90 had a poor prognosis. The MD was not aware of the fortified pudding or double protein but agreed that if it was ordered he should be receiving it. The MD did not believe there was any negative impact on weight loss and pressure ulcer with the order not starting on 6/6/24. On 6/11/24 at 2:57 PM an interview was conducted with the Unit Manager who confirmed the order for fortified pudding and double protein for Resident #90. The Unit Manager thought that once she confirmed the order then the RD finished the process to get the order started by sending an email. On 6/11/24 at 3:30 PM a second interview was conducted with the RD. The RD stated that Resident #90 had poor intake and was barely eating a single portion of the protein and did not feel him missing a double portion would make much difference with his weight loss or on his pressure ulcer. On 6/11/24 at 4:09 PM an interview was conducted with the Dietary District Manager (DDM) and Dietary Manager (DM). The DDM displayed her email chain on the computer. The email chain showed she received an email on 6/3/24 and the next one was on 6/10/24. The DDM stated she never received the 6/6/24 email regarding the diet order and that is why the ticket was incorrect. The DDM stated that the 6/6/24 order did not start when it should have. On 6/12/24 at 11:35 AM an interview was conducted with the DON. She stated the RD did her own orders and the orders are then confirmed usually by the Unit Manager. The facility had a meeting each week called the At-Risk Meeting to go over any resident with weight loss issues. The meeting was usually on Monday. This past Monday the facility did not have the meeting because of the survey going on. If they had the meeting, then they would have caught the diet order change for Resident #90. On 6/12/24 at 2:40 PM an interview with the Administrator was conducted. The Administrator stated that the RD would send out an email when there is a diet order change. The facility would look through the system to make sure dietary orders are not being missed.

Based on record reviews and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for 2 of 2 residents (Resident #80 and Resident #86) reviewed for PASRR. The findings included: 1. Resident #80 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. A review of Resident #80's medical record indicated bipolar disorder was added to her diagnoses list effective 6/5/23. There was no information in Resident #80's medical record regarding PASRR. An interview with the Social Services Director (SSD) on 6/12/24 at 9:13 AM revealed she started working at the facility in November 2023, and she was responsible for PASRR. The SSD stated she knew Resident #80 had been at the facility for a while even before she started working at the facility. During the interview, the SSD searched for PASRR information in Resident #80's medical record and agreed that she could not find any. She looked up Resident #80's PASRR from the North Carolina Medicaid Uniform Screening Tool website and found a PASRR Level I Determination Notification letter dated 11/30/22. The SSD stated the application for PASRR was submitted on 11/30/22 with dementia as the primary diagnosis and with no mental disorder. She further stated that there was an issue with the psychiatric provider letting her know about mental diagnoses, and that she would have submitted an application for PASRR Level II if she had known about Resident #80's diagnosis of bipolar disorder. The SSD added that she recently asked the psychiatric provider to let her know of any new mental health disorders. She further shared that there had been a breakdown in communication, and as she continued in her current position, she had been finding things that should have been done by the previous Social Worker. An interview with the Minimum Data Set (MDS) Coordinator on 6/12/24 at 10:41 AM revealed Resident #80 had been diagnosed with bipolar disorder by the psychiatric provider on 6/5/23. The MDS Coordinator stated that the psychiatric provider was supposed to communicate with the Social Worker, and the Social Worker was supposed to apply for a PASRR Level II for the new mental health disorder diagnosis. An interview with the Administrator on 6/12/24 at 2:24 PM revealed he could not speak as to why the PASRR Level II was missed for Resident #80, but that they were now doing a full audit of all residents. The Administrator stated that this was another system that they needed to work on. 49000 2. Resident #86 was readmitted to the facility on [DATE] with the diagnosis of anxiety disorder and bipolar disorder. The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #86 was moderately cognitively intact. She was not depressed, and she displayed no behaviors. Resident #86 had a diagnosis of anxiety and bipolar disorder. On 6/11/24 at 10:06 AM an interview was conducted with the Social Services Director (SSD). The SSD stated she started working at the facility in November 2023. She has been reviewing and going through the Preadmission Screening and Resident Reviews (PASRR) for each resident to ensure they are correct. She printed off the PASRR for Resident #86. The PASRR was dated September 7, 2023. The PASRR stated that no further PASRR screening was required unless a significant change occurs with the resident's status which suggests a diagnosis of mental illness or mental retardation. The SSD stated she has not yet uploaded The PASRR Level I into the Point Click Care (PCC) but would do so today. On 6/12/24 at 11:39 AM a second interview with the SSD was conducted. The SSD stated that the level II PASRR for Resident #86 should have been done back on 9/7/23. She is going through them now and making sure they are correct. On 6/12/24 at 2:44 PM an interview with the Administrator was conducted. He was unable to speak to the PASRRs or what happened, but he did speak to the SW and he knows she will be very diligent in looking into all the PASRRs and ensure they are correct.

Based on observations and staff interviews the facility failed to remove expired food, and to date and label opened food in 1 of 3 kitchen refrigerators. The facility failed to remove expired resident food in 1 of 2 nourishment refrigerators (nourishment room [ROOM NUMBER]). Additionally, the facility failed to maintain a clean wall behind the dish machine free of black matter and maintain and repair a leaking dish machine pipe. This practice had the potential to affect food served to residents. The findings included 1. On [DATE] at 8:15 AM an observation of the walk-in refrigerator in the kitchen revealed multiple stored food items that were expired or stored without a use by date. The Dietary Manager was not present at the time of the observation. The second shelf of the walk-in refrigerator contained as followed: 1 opened bag of French toast not dated. 2-quart plastic container of lettuce dated ,d+[DATE] and use by ,d+[DATE]. 2-quart container of chicken broth dated ,d+[DATE] and use by ,d+[DATE]. 1 plastic bag with Swiss written on it and dated ,d+[DATE] use by ,d+[DATE]. 1 plastic bag containing sliced cheese not dated. 1 opened plastic bag containing shredded cheese not dated. 1 plastic bag containing ham not dated. 3-quart container of cooked rice half full dated ,d+[DATE] to ,d+[DATE]. 3.5-quart container of salsa dated ,d+[DATE] use by ,d+[DATE]. 3.5-quart container half full of ketchup dated ,d+[DATE] use by ,d+[DATE]. 2-quart container of lime gelatin dated ,d+[DATE] use by ,d+[DATE]. 3.5- quart chicken salad dated ,d+[DATE] use by ,d+[DATE]. 1 plastic bag containing turkey dated ,d+[DATE] and use by ,d+[DATE]. On [DATE] at 8:40 AM a dietary aide reported there were new staff that worked the previous weekend and overlooked the items in the walk-in refrigerator. She stated that all dietary staff normally dated items and checked expiration dates of food in the refrigerators. On [DATE] at 10:32AM the District Dietary Manager stated that all food in the walk-in refrigerator should have been dated and removed if expired. The manager should have checked for dates and expired food, but also any dietary staff should have checked for dates when in the walk-in refrigerator. 2. A follow-up visit to the kitchen on [DATE] at 10:19 AM revealed the wall area directly behind the dish machine contained an approximately 24 by 12 inch splotchy blackish matter that was crumbly to touch in some areas. On [DATE] at 10:32 AM the District Dietary Manager in training stated the dish machine area was assigned to be cleaned every Tuesday night by the dietary staff. She said the dietary staff assigned to clean the area the previous day (Tuesday) did not clean it as assigned by the cleaning schedule. 3. On [DATE] at 10:19AM an observation in the kitchen with the District Dietary Manager revealed a leaking hot water pipe with a steady drip on the top of the dish machine. The dish machine was identified as a high temperature machine that used hot water to sanitize the dishes. The dish machine water temperature gauge revealed a wash temperature of 170 degrees Fahrenheit and a rinse temperature of 195 degrees Fahrenheit with both exceeding the minimum temperature requirements (150 and 180 degrees respectively). On [DATE] at 10:32 AM the District Dietary Manager stated she was unaware of the leaking pipe and did not know how long it had been leaking. The District Dietary Manager was covering for the Dietary Manager who was on vacation. The Maintenance Director was interviewed on [DATE] at 4:10 PM and stated he was unaware of the leaking pipe on the dish machine. He made rounds in the kitchen daily to check for any maintenance issues and the kitchen staff would inform him of any maintenance issue they had. 4. On [DATE] at 11:00 AM an observation of nourishment room [ROOM NUMBER] with the District Dietary Manager revealed a resident's container of watermelon was dated use by [DATE]. The container of watermelon was removed and disposed of by the District Dietary Manager. The District Dietary Manager stated the dietary aides check the nourishment rooms 3 times daily for expired items and to restock any needed items. The container of watermelon should have been removed by a dietary aide. The Administrator stated on [DATE] at 5:13 PM that any expired food in refrigerators should have been thrown out by the kitchen staff and food should have been dated and labeled. The dish machine area should have been cleaned by the kitchen staff and the dish machine should have been maintained and repaired when leaking.

Based on observations, record review, and interviews the facility failed to assess the ability of residents to self-administer medications for 3 of 3 residents reviewed for self-administration of medication (Resident #35, Resident #39, and Resident #7). Findings included: 1. Resident #35 was admitted to the facility 06/17/22 with multiple diagnoses including spinal stenosis (when the spaces in the spine narrow and cause pressure on the spinal cord and nerve roots). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #35 was cognitively intact. Review of the medical record revealed no documentation that Resident #35 had been assessed for self-administration of medication. An observation of Resident #35's room on 04/03/23 at 11:32 AM revealed the following: a. a 15 milliliter (ml) bottle of carboxymethylcellulose sodium 0.5% eye drops (eye drops that help with dry eyes) sitting on the overbed table b. a 1.76 ounce (oz) tube of diclofenac sodium topical gel 1% (a topical anti-inflammatory pain-relieving gel) in a bath basin sitting on the floor by Resident #35's bed c. a box of 4% lidocaine patches (patches that help with pain relief) sitting on top of Resident #35's chest of drawers beside her bed An interview with Resident #35 on 04/03/23 at 11:32 AM revealed she put the eye drops in her eyes when she felt like she needed them, she put the diclofenac gel on her knees once a day, and placed the lidocaine patches on her lower back daily. She stated her daughter brought her the medications from home. Observations of Resident #35's room on 04/04/23 at 2:44 PM, 04/05/23 at 11:50 AM, and 04/06/23 at 4:19 PM revealed the eye drops, diclofenac gel, and lidocaine patches remained in the same locations. An interview with the Director of Nursing (DON) on 04/06/23 at 4:59 PM revealed no medications should be left at the bedside unless the resident had been assessed as safe to self-administer medications. She stated if a resident was assessed as safe to self-administer medications, then a physician's order was obtained to leave the medications in the room, including over the counter (OTC) medications. The DON confirmed Resident #35 had not been assessed to self-administer medication and should not have had eye drops, diclofenac gel, or lidocaine patches in her room. She stated she had removed multiple medications from Resident #35's room and her family kept bringing medications to her. 2. Resident #39 was admitted to the facility 11/11/22 with multiple diagnoses including non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident was moderately cognitively impaired. Review of the medical record revealed no documentation that Resident #39 had been assessed for self-administration of medication. An observation of Resident #39's overbed table on 04/03/23 at 11:42 AM revealed a tube of triamcinolone cream 0.1% (an antifungal cream) and 2 tubes of diclofenac sodium 1% gel (a topical anti-inflammatory pain-relieving gel) sitting on top of the table. Another tube of triamcinolone cream 0.1% cream and diclofenac sodium gel 1% were sitting in a storage basket beside Resident #39's bed. An interview with Resident #39 on 04/03/23 at 11:42 AM revealed he put the triamcinolone cream on his toes for fungus and he put the diclofenac gel on his knees for pain. An observation of the storage basket sitting beside Resident #39's bed on 04/04/23 at 2:18 PM revealed a tube of triamcinolone cream 0.1% and a tube of diclofenac sodium gel 1% were sitting in the basket. An observation of Resident #39's overbed table on 04/05/23 at 11:51 AM revealed 2 tubes of diclofenac sodium gel 1% and 1 tube of triamcinolone cream 0.1% were sitting on top of the table. An observation of the storage basket sitting beside Resident #39's bed revealed a tube of triamcinolone cream 0.1% was sitting in the basket. An interview with the Director of Nursing (DON) on 04/06/23 at 4:59 PM revealed no medications should be left at the bedside unless the resident had been assessed as safe to self-administer medications. She stated if a resident was assessed as safe to self-administer medications, then a physician's order was obtained to leave the medications in the room, including over the counter (OTC) medications. The DON confirmed Resident #39 had not been assessed to self-administer medication and should not have had diclofenac gel and triamcinolone cream in his room. She stated she had removed multiple medications from Resident #39's room and his family kept bringing medications to him. 3. Resident #7 was admitted to the facility 02/15/23 with diagnoses including diabetes and arthritis. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was moderately cognitively impaired. Review of the medical record revealed no documentation that Resident #7 had been assessed for self-administration of medication. An observation of Resident #7's overbed table on 04/03/23 at 9:30 AM revealed a 10 milliliter (ml) bottle of carboxymethylcellulose sodium 1% gel eye drops (eye drops that help with dry eyes) was sitting on the table. An interview with Resident #7 on 04/03/23 at 9:30 AM revealed nursing staff put the drops in his eyes because he didn't have the hand strength to open the bottle and apply the drops. An observation of Resident #7's overbed table on 04/05/23 at 11:48 AM revealed a 10 milliliter (ml) bottle of carboxymethylcellulose sodium 1% gel eye drops (eye drops that help with dry eyes) was sitting on the table. An interview with the Director of Nursing (DON) on 04/06/23 at 4:59 PM revealed no medications should be left at the bedside unless the resident had been assessed as safe to self-administer medications. She stated if a resident was assessed as safe to self-administer medications, then a physician's order was obtained to leave the medications in the room, including over the counter (OTC) medications. The DON confirmed Resident #7 had not been assessed to self-administer medication and should not have had eye drops in his room. She stated she had removed eye drops from Resident #7's room on multiple occasions and his family kept bringing him more eye drops.

Based on observations, staff and resident interviews, and record review the facility failed to secure medication for 1 of 1 resident (Resident #10) observed with medication at bedside. The findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses including a stage 3 pressure ulcer. A review of Resident #10's physician's orders revealed an order dated 12/16/22 to clean wound with wound cleaner and apply zinc with collagen every shift and as needed. The annual Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. On 11/25/22 Resident #10's self-administration of medication assessment documented Resident #10 was not able to self-administer medications. An observation of Resident #10's room and interview were conducted on 4/3/23 at 10:09 AM. The Resident was alert and lying in bed. A container labeled zinc oxide with collagen paste was on the overbed table. The Resident stated the zinc oxide with collagen paste was left on her overbed table a lot of the time. Nurse # 1 stated in an interview on 4/3/23 at 10:45 AM the zinc oxide with collagen paste was left on the overbed table after application earlier in the morning. She said it should have been locked up in the treatment cart after use and the paste contained 25% zinc concentration. The Director of Nursing (DON) stated on 4/6/23 at 3:13 PM that zinc oxide is labeled with the resident's name and date and should be stored in the treatment cart when not in use. It was not standard protocol to leave it in a resident's room.

Based on record review and staff and resident interviews the facility failed to correctly enter an order to obtain a speech therapy (ST) evaluation as ordered by a Nurse Practitioner (NP) for 1 of 4 residents (Resident #76) reviewed for therapy services. Findings included: Resident #76 was admitted to the facility 02/08/23 with multiple diagnoses including dysphagia (difficulty swallowing). Resident #76 had a Physician order dated 02/10/23 to receive a mechanical soft diet (a diet consisting of foods that could be swallowed safely). The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #76 was cognitively intact and received a mechanically altered diet. The nutrition care plan initiated 02/15/23 revealed Resident #76 had a nutritional problem related in part to a diagnosis of dysphagia and interventions included providing her diet as ordered and monitoring her meal intakes. NP #1's progress note revealed Resident #76 was seen for diet/swallowing on 03/07/23. The note further stated Resident #76 verbalized concern with her dietary restrictions, was requesting speech-language therapy re-evaluate her for aspiration (inhaling food or fluid into the airway), and denied difficulty chewing or swallowing food. Resident #76's orders revealed an order dated 3/08/23 for speech-language therapy to evaluate her to increase her diet consistency. Review of Resident #76's medical record did not contain any documentation that a ST evaluation was completed on or after 03/08/23. An interview with Resident #76 on 04/03/23 at 10:07 AM revealed she received a chopped meat diet and she did not have a chewing or swallowing problem and refused to eat chopped meat. She stated she had requested to have her diet changed to a regular diet but no one had changed it. An interview with the Director of Rehab on 04/05/23 at 8:18 AM revealed Resident #76 was placed on the ST case load on 02/9/23 and was discharged from ST on 03/03/23. She confirmed Resident #76 had not received any additional ST services since 03/03/23 and was not aware of any orders for a ST evaluation after 03/03/23. An interview with the Director of Nursing (DON) on 04/06/23 at 4:59 PM revealed the order for ST to evaluate Resident #76 dated 03/08/23 was placed in the computer by nursing staff as a one time order and one time orders fell off the active order list at midnight each night. She stated if the order had been entered into the computer as a routine order it would have remained on Resident #76's active orders and would have notified the therapy department Resident #76 had a new order for ST evaluation. The DON stated since the order was not entered into the computer correctly ST was not aware of the order and that is why Resident #76 did not receive a ST evaluation as ordered on 03/08/23. She stated residents should receive therapy consults as ordered.

Based on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) for a resident with a new mental health diagnosis for 1 of 1 resident reviewed for PASRR (Resident #44). Findings included: Resident #44 was admitted to the facility on [DATE]. Her diagnoses included panic disorder, major depressive disorder, and psychotic disorder with delusions due to a known physiological condition. The North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry dated 04/06/23 revealed Resident #44 had a Level I PASRR effective 10/11/22. A Psychiatrist progress note dated 01/26/23 revealed in part, Resident #44 had been having some delusions that her water was poisoned and hearing people talking to her. It was further noted Resident #44 reported feeling restless, anxious, and realized people were not in the room with her but still worried about the voices. The assessment and plan noted a new diagnosis of psychotic disorder with delusions due to known physiological condition with plans to consider medication at a future visit. Review of Resident #44's list of cumulative diagnoses contained in her medical record revealed a new diagnosis of psychotic disorder with delusions due to known physiological condition with an onset date of 01/27/23. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #44 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability. During interviews on 04/05/23 at 11:57 AM and 04/06/23 at 10:10 AM, the Social Worker (SW) explained typically the Psychiatrist or nursing staff notified him of residents with a new mental health diagnosis and he would submit a referral to PASRR requesting a Level II evaluation. The SW did not recall being notified Resident #44 was diagnosed with a new mental health condition on 01/27/23 and confirmed he had not requested a Level II PASRR evaluation for Resident #44 until 04/05/23. During an interview on 04/06/23 at 5:16 PM, the Administrator stated the SW should have been made aware when Resident #44 was diagnosed with a new mental health condition so that he could have requested a Level II PASRR evaluation.

Based on record review and resident and staff interviews, the facility failed to treat a resident in a dignified and respectful manner when Nurse Aide #1 spoke and acted in a manner that made a resident feel uncomfortable for 1 of 7 residents reviewed for dignity (Resident #21). Findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses that included left tibia (larger bone in the lower leg) and fibula (smaller bone in the lower leg) fractures. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #21 with intact cognition. Resident #21 required physical assistance of one to two staff members with transfers, bed mobility and toileting. During an interview on 04/03/23 at 10:43 AM, Resident #21 revealed on Saturday 04/01/23, NA #1 had just finished cleaning her up after an incontinence episode when within minutes she had another incontinent episode where urine leaked out from her brief onto the bed. Resident #21 stated that while NA #1 was cleaning her up the second time, NA #1 started walking back and forth around her bed telling Resident #21 that she (NA #1) was praying the devil out of her. Resident #1 stated NA #1's behavior made her feel very uncomfortable as if NA #1 thought she (Resident #21) was the devil. Resident #21 stated she reported the incident to the Administrator this morning. During a telephone interview on 04/05/23 at 12:31 PM, NA #1 stated on Saturday (04/01/23) after changing Resident #1, she started assisting her roommate with care when Resident #21 told her she had another incontinent episode. NA #1 explained she didn't realize the brief she had placed on Resident #21 was too big which caused urine to leak out onto the bed. NA #1 recalled Resident #21 was being argumentative and accusing NA #1 of not believing she had an incontinent episode even after NA #1 told her she could see the bed was wet. NA #1 stated it was possible she said to herself, Lord help me as she was providing care to Resident #21 but never told Resident #21 she was praying the devil out of her. During a follow-up telephone interview on 04/05/23 at 8:09 PM, NA #1 stated she had thought further about the incident with Resident #21 on 04/01/23 and felt Resident #21 may have misunderstood her. NA #1 explained when dealing with difficult situations, she drew on her faith and would say to herself, devil, I rebuke you in an effort to bring herself peace and not react negatively to a situation. NA #1 stated it was possible Resident #21 heard NA #1 make the comment to herself and thought it was directed at her (Resident #21). During a follow-up interview on 04/06/23 at 2:29 PM, Resident #21 clarified she had not misunderstood the situation with NA #1. Resident #21 stated when NA #1 was providing her care, NA #1 did not make the comment devil I rebuke you softly to herself but instead used a loud tone while walking around the bed and made the comment directly to Resident #21. Resident #21 stated she was never fearful of NA #1 but was bothered by NA #1's behavior because she (Resident #21) was unable to walk or get out of bed on her own to leave the room. Resident #21 restated the incident just made her feel very uncomfortable. During an interview on 04/05/23, the Administrator stated he spoke with Resident #21 the morning of 04/03/23 regarding the alleged incident with NA #1. The Administrator stated NA #1 had worked at the facility through a staffing agency for about a month and there had been no reported issues with her performance. The Administrator stated he notified the staffing agency NA #1 was suspended from working at the facility while he finished conducting an investigation. The Administrator stated disrespectful behavior, whether actual or perceived, was never acceptable. He stated residents should always be treated with respect and never made to feel otherwise.

Based on observation and staff interviews, the facility failed to protect the private health information for 1 of 1 sampled resident (Resident #14) by leaving confidential medical information unattended and exposed in an area accessible to the public for 1 of 4 medication carts. The findings included: Resident #14 was admitted to the facility on [DATE]. A continuous observation was made on 05/13/21 from 9:59 AM through 10:04 AM for an unattended medication cart in the hallway of 400 Hall. Medication Aide (MA) #1 left the medication cart with the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The screen showed a picture of Resident #14, her room number, a list of medications she was receiving, her diagnoses, and other personal or health related information. The unattended computer screen was accessible to anyone who passed by including those who were not authorized to view this confidential information. During an interview with MA #1 on 05/13/21 at 10:05 AM she explained she had about 30 residents to do medication pass that morning. She was moving too fast and had forgotten to turn on the privacy protection screen before leaving the medication cart. She acknowledged that it was not an appropriate action to leave the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Nurse #1 on 05/13/21 at 10:09 AM she stated she was the nurse for 400 Hall and MA#1 was under her supervision. She added MA #1 did not usually leave resident's confidential medical information unprotected during medication pass. Nurse #1 acknowledged that MA#1 should turn on the privacy protection screen before leaving the medication cart. During an interview with the Director of Nursing (DON) on 05/13/21 at 10:48 AM she stated MA#1 should turn the privacy protection screen on before leaving the medication cart to protect resident's confidential personal and medical information. It was her expectation for all the staff to follow the HIPAA guidelines while working in the facility. During an interview with the Administrator on 05/13/21 at 11:09 AM she stated it was her expectation for all the staff in the facility to follow HIPAA guidelines all the time.

Based on resident and staff interviews, review of the Centers for Disease Control and Prevention (CDC) guidelines and the facility's Infection Control and Personal Protective Equipment (PPE) policies and procedures, the facility failed to implement their PPE policy when 2 nurses (Nurse #1 and Nurse #2) failed to keep a mask over their mouth and nose while talking to residents in their room for 9 of 16 residents interviewed (Resident #1, #2, #3, #4, #5, #6, #7, #8 and resident #9). These failures occurred during the COVID-19 pandemic. Findings included: The CDC guidelines updated November 4, 2020 read: Implement Universal Source Control Measures. Source Control refers to use of facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Healthcare Personnel (HCP) should wear a facemask at all times while they are in the healthcare facility. The facility's PPE policy and procedure, dated October 29, 2020, included: The center should ensure that all staff are using appropriate PPE when they are interacting with residents. Masks should be worn by all center staff at all times when in the facility, when interacting with the residents and when direct care is being provided. The most recent facility in-service training, dated 11/30/20, included instructions for wearing masks and included signatures of Nurse #1 and Nurse #2. An in-service, dated 9/16/20, included instructions on proper use of masks and included signatures of Nurse #1 and Nurse #2. On 12/9/20 from 10:00 AM to 11:30 AM, interviews conducted with 16 alert and oriented residents on 1 of 6 halls (100 hall) revealed they had difficulty understanding what staff were saying through the masks. Nine of the 16 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8 and Resident #9) stated some of the staff pulled their mask down below their mouth so that they could understand what the staff were saying. The staff would then put the mask back over their nose and mouth. The residents were unable to identify specific staff. An interview, conducted on 12/9/20 at 12:30 PM with Nurse #1, revealed she cared for Resident #9, who had difficulty hearing and only read lips. She stated she lowered her mask below her mouth so that Resident #9 could read her lips. She then placed the mask back over her nose and mouth. Nurse #1 stated she thought it was alright to lower her mask while speaking to the resident since she was wearing a face shield. She could not recall how many times this had occurred. Nurse #1 stated she had been educated to wear the mask at all times when in the facility and when talking to the residents. An interview, conducted on 12/9/20 at 12:45 PM with Nurse #2, revealed she had lowered her mask to communicate with residents who had difficulty understanding her through the mask. She stated residents become frustrated when unable to understand what she is saying when speaking to them with the mask on. She could not recall how often this had occurred or with which residents. Nurse #2 stated she had been educated to wear the mask at all times when in the facility and when talking to the residents An interview was conducted on 12/9/20 at 1:45 PM with the Infection Preventionist (IP), who was also the Director of Nursing. She stated she and the unit managers monitored the staff daily for proper use of PPE, which included masks. She stated it was inappropriate for staff to lower their mask when talking to a resident. The IP stated staff have been instructed to use white boards or pen and paper to communicate with residents when residents have difficulty understanding them through the masks. There is an expectation that masks are to be worn at all times while in the facility and when talking to and providing care for the residents. An interview, conducted with the Administrator on 12/9/20 at 2:00 PM, revealed when staff are in a resident's room, they should communicate by writing on a white board or on paper. The in-service, conducted on 11/30/20, addressed wearing the mask at all times and covering the mouth and nose. It is not acceptable for staff to pull their mask down to speak to the residents when in their room. The only time staff should remove their mask is when they are in a private place with only themselves.

Based on observations, staff interviews, and medical record and facility documentation review, the facility failed to provide supervision during toileting for a resident with a history of falls for one (1) of four (4) sampled residents (Resident #120). The findings are: Resident #120 was admitted to the facility on [DATE] with a hip fracture from a fall at home. While in the facility she fell on [DATE] when she ambulated unassisted from the bathroom and sustained a second hip fracture. Her other [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had moderately impaired cognition and required extensive assistance with activities of daily living, including bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS also specified the resident used a wheelchair for mobility but was not steady moving on and off the toilet. In addition, the MDS specified the resident had one fall with injury since the previous assessment. Resident #120's Care Area Assessment (CAA) dated 04/08/11 for falls specified the resident was at high risk for falls due to a history of falls with hip fracture and a fall on 03/11/11 with a second hip fracture, dementia, osteoporosis, poor balance, and muscle weakness. Resident #120's fall care plan updated 04/08/11 specified she was at risk for falls related to declining mental status, recent fall and fracture, history of falls, balance problem when standing, decreased muscle coordination, osteoporosis and use of psychotropic medication. Approaches listed in the care plan to minimize the risk for injury related to a fall included one person assistance with transfers. Review of Resident #120's medical record revealed a document titled "Change of Condition" dated 04/28/11 at 4:35 p.m. that specified the resident fell in the bathroom when she got up unassisted and sustained a 3 centimeter laceration to the back of her head. The document also specified the post fall interventions included resident was not to be left unattended while in the bathroom. The Emergency Department reports dated 04/28/11 were reviewed and revealed a computed tomography (CT) scan of the head was performed secondary to head injury from a fall with a laceration to the back of the head. The CT results showed "subtle scalp defect in the occipital region compatible with the given history of a laceration. No acute intracranial injury." Further review of the Emergency Department report specified the resident received sutures to her head and returned to the facility on [DATE] at 2:30 a.m. Observations made of Resident #120 on 08/23/11 at 8:45 a.m. revealed she wore a personal alarm clipped to her wheelchair. She was not observed to try to stand from her wheelchair. The licensed nurse who responded to the resident on 04/28/11 was unavailable for an interview. On 08/24/11 at 12:25 p.m. the Administrator was interviewed and reported a fall investigation was conducted that concluded the nursing assistant assigned to care for Resident #120 left the resident alone in the bathroom when she fell . The Administrator stated that the resident's functional status fluctuated day to day and the best practice was for the nursing assistant not to leave the resident unattended in the bathroom. On0 8/24/11 at 1:25 p.m. Nursing Assistant (NA) #1 was interviewed and reported she was assigned to care for Resident #120 on 04/28/11. NA #1 reported she was aware of Resident #120's history of falls and stated the resident wore a personal alarm attached to her wheelchair to alert staff of unassisted transfer attempts. She added that the resident required extensive assistance with transfers. She added that at times the resident would have impulsive tendencies and attempt to stand unassisted. NA #1 also stated that her usual practice was to stand outside the bathroom door to give the resident privacy but close enough to provide immediate assistance if needed. During the interview with NA #1on 08/24/11 at 1:25 p.m. she stated that on 04/28/11 in the evening she assisted Resident #120 into bathroom and onto the toilet. During this time the NA reported she realized she did not have wash cloths to complete the resident's care. She added she made the decision to leave the resident on the toilet to retrieve wash cloths. NA #1 reported that she gave the resident her call bell and instructed her to not move from the toilet. The NA stated she left the bathroom and walked to the clean linen cart that was stored in the hallway approximately two resident room doors down from Resident #120's bathroom. The NA stated that when she returned she observed the resident in the floor with blood to the back of her head. On 8/25/11 at 10:30 a.m. NA #2 was interviewed and reported this was the first time she had cared for Resident #120. She explained she was unaware of how much assistance the resident required but would ask the licensed nurse before she assisted the resident to the bathroom. She added that she assumed the resident required extensive assistance with transfers and should not be left alone in the bathroom because the resident wore a personal alarm attached to her wheelchair. On 08/25/11 at 10:45 a.m. Licensed Nurse (LN) #1 was interviewed and reported that she had cared for Resident #120 often. She recalled an incident that occurred after Resident #120 fell on [DATE] when she assisted the resident to the bathroom and found the resident unsafe to be left alone in the bathroom. She reported the resident demonstrated impulsive actions and was quick to try to get up from the toilet unassisted. On 08/25/11 at 10:50 a.m. LN #2 was interviewed and reported she was assigned to care for Resident #120. She reported that Resident #120 was not safe to be alone in the bathroom because of poor safety awareness and impulsive tendencies.