Every finding on record at The Laurels of Pender

Based on observations, manufacturer's instructions, and staff interviews, the facility failed to record an opened date on multi-dose insulin pen injectors and an insulin vial for 3 of 4 medication carts that were reviewed for medication storage (100 and 400 hall medication carts). Findings included: a) An observation of the 400-hall medication cart on 01/14/26 at 8:20 AM with Medication Aide #3 revealed the follow medications: Humalog prefilled insulin pen was opened with no opened dateLantus prefilled insulin pen was opened with no opened date. The manufacturer's instructions for both the Humalog and Lantus insulin pens read to discard after 28 days once opened. An interview with Medication Aide #3 on 01/14/26 at 8:12 AM revealed nurses and medications aides were responsible for checking the medication carts to make sure there were no expired medications. Medication Aide #3 stated that as a Medication Aide she cannot administer insulin and she did not check the dates on them. An interview with Unit Manager #2 on 01/14/26 at 8:12 AM stated the nurses should be checking the medication carts to make sure there were no expired medications and all insulin pens were dated once opened. The Lantus Insulin Pen and the Humalog Insulin pen were received on 01/12/26 as was indicated on the pharmacy labels adhered on the insulin pens. She stated they had been used and should have been dated once opened in order to determine how long the pens were good for according to the manufacturer's instructions. how did she know they were received on 1/12? b) An observation of the 100 - hall long term care medication cart on 01/14/26 at 8:40 AM with Nurse #10 revealed the following medications: Tresiba prefilled insulin pen was opened with no opened date. The manufacturer's instructions for Tresiba read to discard after 56 days once opened. Lispro Insulin vial was opened with no opened date. Insulin Glargine prefilled insulin pen was opened with no opened date. The manufacturer's instructions for the Lispro insulin vial and the Insulin Glargine prefilled insulin pen read to discard after 28 days once opened. An interview with Nurse #10 on 01/14/26 at 8:45 AM revealed all nurses were responsible for checking their medication carts to make sure there were no expired medications and that all the insulin pens and vials were dated when opened. Nurse #10 stated the Tresiba insulin pen, the Lispro vial of insulin and the Insulin Glargine should have had a date on it when it was opened so nursing staff would when it should be used by. Nurse #10 stated she should have checked the insulins at the start of the shift to be sure they were all dated. Nurse #10 stated she would discard the insulin pens and vial. c) An observation of the 100 - hall skilled care medication cart on 01/14/26 at 9:11 AM with Medication Aide #1 revealed the following medications: Lantus prefilled insulin pen was opened with no opened date. The manufacturer's instructions for Lantus prefilled insulin pen read to discard after 28 days once opened. An interview was conducted with the Medication Aide #1 on 01/14/26 at 9:11 AM revealed all nurses and medication aides were responsible for checking the medication carts to make sure there were no expired medications. Medication Aide #1 stated that as a Medication Aide she cannot administer insulin and she did not check for opened dates on the insulin pens. An interview with Unit Manager #1 on 01/14/26 at 9:11 AM stated she should have checked the medication carts to be sure all the insulin pens were dated once opened. Unit Manager #1 stated she was overseeing Medication Aide #1 since she cannot administer insulin and Unit Manager #1 should have checked the medication cart at the start of the shift. Unit Manager #1 stated all nurses and medications aides should be checking their carts at the start of their shift to check for expired medications, and to be sure all insulin was dated once opened. An interview was conducted with the Director of Nursing (DON) on 01/15/26 at 11:10 AM. The DON reported her expectation was that once an insulin pen or vial was opened the nurses should be putting am opened date on them. She stated insulins pens and vials have a manufacturer's instruction to discard after so many days once opened and without having the initial opened date recorded on the vial or the pen, nurses would not be able to determine if the medication was still good for use.

Based on observations and staff interviews, the facility failed to label and date opened packages of food in 2 of 2 freezers (the front freezer and the outside freezer), label and date opened packages of food in 1 of 1 dry goods storage room, and discard expired foods stored for use in 2 of 2 nourishment room refrigerators (100 and 400 hall nourishment rooms). This deficient practice had the potential to affect the food served to the residents.The findings included:An initial tour of the kitchen was conducted on 1/12/26 at 9:25 AM in the presence of the Dietary Manager.a). At 9:35 AM on 1/12/26 an opened plastic bag containing bread sticks and an opened plastic bag containing biscuits were observed in the kitchen front freezer without an opened date or expiration date.At 9:40 AM on 1/12/26 an opened plastic bag of garlic bread without an opened date or expiration date was observed in the large freestanding freezer located outside the kitchen. b). At 9:45 AM on 1/12/26 an opened package of hamburger buns and an opened loaf of bread that were not in the original packaging were observed in the dry goods storage room without an opened date or expiration date. An interview was completed with the Dietary Manager on 1/12/26 at 9:55 AM. The Dietary Manager stated that all opened foods stored in the freezer and the dry goods storage room should be labeled and include the date the item was opened and the expiration date. c). An observation of the 400-hall nourishment room was conducted on 1/12/26 at 10:05 AM in the presence of the Dietary Manager. There was an opened container of a nectar consistency nutritional supplement with no opened date or expiration date. The label on the nutritional supplement indicated that the manufacturer recommended that the product be consumed within 4 days after it was opened. A disposable food container with a resident name, no date received and no expiration date was observed in the 400-hall nutrition room. An observation of the 100-hall nourishment room was conducted on 1/12/26 at 10:10 AM in the presence of the Dietary Manager. There was a disposable food container with a resident name on it dated 1/1/26.An interview was completed with the Dietary Manager on 1/12/26 at 11:05 AM. The Dietary Manager stated there was not supposed to be any expired food in the nutrition rooms. She indicated that the staff were not paying close attention to the dates. The Dietary Manager stated that food brought in by outside sources was to be labeled, dated and discarded after three days. The Dietary Manager indicated that the nursing staff were responsible for labeling food brought in from outside with the resident name and date it was brought in. The dietary staff were responsible for monitoring the expiration dates and discarding expired food and supplements. An interview was completed with the Administrator on 1/13/26 at 8:40 AM. The Administrator stated that he expected the kitchen staff to check for expired food in the kitchen and nutrition rooms and to discard them. He further stated he expected the staff to label and date food stored in the kitchen and nutrition rooms.

Based on record review, Nurse Practitioner and staff interviews, the facility failed to obtain and document consent for treatment with psychotropic medications and review with the resident or resident representative in advance of the risks versus benefits of psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) prior to administration of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #98). Findings included: Resident #98 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, dementia and anxiety. Resident #98's physician orders dated 01/07/26 revealed orders for the following psychotropic medications: Amitriptyline (antidepressant/psychotropic medication) 25 milligrams give 2 tablets in the evening for bipolar disorder, Depakote Sodium Extended Release (an anticonvulsant and mood stabilizer used to treat several conditions including bipolar disorder) 500 milligrams give 3 tablets in the evening for dementia, and Seroquel (antipsychotic/psychotropic medication) 300 milligrams give one tablet in the evening for dementia. The Medication Administration Record (MAR) from 01/07/26 through 01/15/26 indicated Resident #98 was administered Seroquel, Depakote, and Amitriptyline as ordered.The Minimum Data Set admission assessment dated [DATE] revealed Resident #98 was cognitively intact and Resident #98 received antipsychotic, anticonvulsant, and antidepressant medications during this assessment period. A review of Resident #98's medical record revealed no documentation that Resident #98 or the resident's representative consented to or were informed in advance of the risks versus benefits of receiving Seroquel and Amitriptyline. An interview was conducted with Unit Manager #2 on 01/14/26 at 4:30 PM. Unit Manager #2 stated when a resident was admitted , the admitting nurse was given an admission packet. She stated within the packet was a checklist of all the areas the admitting nurse needed to address. Unit Manager #2 stated #6 on the checklist was the consent form for psychotropic medications which should be reviewed and signed and was located in the electronic record. At this time, Unit Manager #2 reviewed Resident #98's electronic medical record to see if the consent was reviewed and signed by Resident #98. Unit Manager #2 confirmed there was no documentation to support this consent, or the risks verses benefits were reviewed with Resident #98 and signed. An interview was attempted with Nurse #7 who was the admitting nurse for Resident #98 via phone and a message was left for a return call on 01/15/26 at 11:30 AM. Nurse #7 did not return the call. An interview was conducted with the Nurse Practitioner on 01/14/26 at 4:35 PM. The Nurse Practitioner stated the psychotropic medication consent form should have been completed upon admission for Resident #98. He stated it was important for the nurse to inform the resident of the risks verses benefits of each psychotropic medication to ensure Resident #98 was aware prior to administration of the medication. An interview was conducted with the Director of Nursing (DON) on 01/15/26 at 11:00 AM. The DON reported that the psychotropic consent form should have been done while completing the assessment by the admitting nurse when the resident was admitted on [DATE]. She stated it was important for the consent to be reviewed and risks versus benefits to be discussed with the resident about each of the psychotropic medications that were ordered and should have been done prior to administration of the medications.

Based on observation, record review, and staff, and the Medical Director's interview, the facility failed to follow the physician's order for the care of a surgical wound for 1 of 2 residents reviewed for wound care (Resident #33).Findings included: The hospital Discharge summary dated [DATE] for Resident #33 revealed; Aquacel (a wound dressing that promotes a moist healing environment) to remain in place to the left surgical wound for seven days and replace with new Aquacel. Resident #33 was admitted to the facility on [DATE] with diagnoses including a left femur fracture with surgical repair. A physician's order dated 1/1/26 entered by the Wound Nurse for Resident #33 revealed to cleanse the wound to the left lateral thigh with generic wound cleanser. Apply protective barrier to the peri wound, then apply silicone foam with silver (wound care that uses silver for antimicrobial protection, a foam core to absorb drainage, and a silicone adhesive for secure placement) every seven days and as needed. A care plan dated 1/2/26 revealed Resident #33 had the potential for complications from the surgical wound of the left thigh. The goal of care included the wound would heal without signs of infection. Interventions included to observe for signs of infection (i.e. redness, swelling, temperature increases, increased drainage or odor), report abnormal findings to the physician, and provide wound treatments as ordered The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #33 had moderately impaired cognition. He had no behaviors and rejection of care occurred 1-3 days. Resident #33 had a surgical wound and no wound care. Review of the Treatment Administration Record (TAR) dated January 2026 for Resident #33 revealed on 1/7/26 Nurse #6 documented that wound care was not performed with code 5 indicating to see progress notes. Further review of the TAR from 1/1/26 through 1/13/26 revealed no documentation that wound care was provided to the left femur surgical wound. Review of the progress notes dated 1/7/26 revealed no documentation as to why Nurse #6 did not provide wound care to Resident #33's surgical wound on 1/7/26. Further review of the progress notes from 1/1/26 through 1/13/26 revealed no documentation that wound care was provided to the left femur surgical wound for Resident #33. During an interview on 1/15/26 at 3:00 PM Nurse #6 stated Resident #33 refused wound care for her on 1/7/26 and she reported the refusal that day to the Wound Nurse. Nurse #6 stated she did not provide wound care to Resident #33 at any time since his admission. During an interview on 1/13/26 at 1:30 PM Nurse Aide #3 indicated Resident #33 would refuse care but if you redirect or reapproach him later he would allow you to provide his care. During an interview on 1/13/26 at 10:30 AM the Wound Nurse stated Resident #33 admitted to the facility on [DATE] following a femur fracture repair. The Wound Nurse stated wound care had not been completed to Resident #33's surgical wound because he refused on 1/7/26. She stated Resident #33's wound care was not due again until 1/14/26. A wound care observation was conducted on 1/13/26 at 11:00 AM with the Wound Nurse. Resident #33 was lying in bed. He was in no distress and verbalized no pain. The Wound Nurse removed the left hip dressing dated 12/31/25 that was applied at the hospital. The incision site included 14 intact staples with slight redness noted on the edges of one end of the incision. There was no drainage or odor noted. The Wound Nurse cleaned the area with wound cleaner, applied skin prep, and covered with a silicone foam dressing. During a second interview on 1/14/26 at 2:00 PM the Wound Nurse stated she entered an order on 1/1/26 for weekly dressing changes for Resident #33. She reported that the assigned nurse on 1/7/26 (Nurse #6) stated Resident #33 refused care that day and that was why wound care was not done. The Wound Nurse stated she asked Resident #33 one day last week if he would let her change the dressing and he refused but she did not document that refusal. The Wound Nurse stated she was responsible for wound care Monday through Friday when she was in the facility and on the weekends either the charge nurse or the assigned nurse was responsible for wound care. The Wound Nurse stated that wound care should have been provided on 1/7/26 which was day 7 following admission. She stated she should have made efforts to get the wound care done later on 1/7/26 or the following days and she didn't do that and it was done in error. The Wound Nurse stated she should not have waited 13 days following admission to provide wound care to Resident #33's surgical site. During an interview on 1/14/26 at 3:45 PM the Director of Nursing (DON) stated Resident #33's wound care should have been provided according to the physician's order. The DON stated that if Resident #33 refused wound care on 1/7/26 attempts should have been made later that day and the following days and documented in the medical record but that did not occur. The DON stated wound care should have been provided to Resident #33's surgical wound sooner than 13 days after admission. During an interview on 1/14/26 at 4:15 PM the Medical Director stated Resident #33's wound care should have been provided according to the order and wound care should have been done sooner than 13 days after admission to assess for complications including signs of infection. The Medical Director indicated no concerns had been brought to him regarding Resident #33 having any change in condition or any concerns regarding the left femur surgical site.

Based on observations, record review, resident and staff and Nurse Practitioner interviews, the facility failed to obtain orders to assess and manage a new arterial venous (A/V) fistula (A surgical connection of an artery to a vein, usually in the arm, to create a long-lasting access point for dialysis needles) that was maturing for 1 of 1 resident reviewed for dialysis (Resident #7). Findings included: A history and physical assessment from the hospital dated 12/08/25 revealed Resident #7 was admitted to the hospital with possible gastrointestinal bleed. The hospital note further indicated Resident #7 had an A/V fistula in place since October 2025 in anticipation for dialysis to the right upper extremity that was positive for bruit and thrill (whooshing sound heard with a stethoscope and a vibrating sensation felt with fingers on the A/V fistula; both signs that an access was working and had good blood flow) but has not matured and a permacath (a catheter inserted into the chest used for dialysis) was placed during this hospitalization. Resident #7 was admitted to the facility on [DATE]. He was discharged to hospital on [DATE] and readmitted on [DATE]. Diagnoses included end stage renal disease with dependence on renal dialysis. A skilled care note written by Nurse #8 on 12/17/25 revealed Resident #98 had permacath to right upper chest, and dialysis site to right upper extremity was positive for bruit and thrill. On 01/15/26 at 3:53 PM a phone interview was attempted with Nurse #8 who admitted Resident #98 on 12/17/25. Nurse #8 did not return the call. The Minimum Data Set admission assessment dated [DATE] revealed Resident #7 was moderately cognitively impaired and was coded as receiving dialysis services. Review of Resident #7's care plan dated 12/17/25 revealed a plan of care was in place for at risk for complications related to requiring dialysis due to end stage renal disease. The goal was that Resident #7 would have immediate interventions should any signs or symptoms or complications from dialysis occur through the next review. Interventions included, in part, do not draw blood or take blood pressure in the arm with fistula (arterial venous fistula), observe for signs or symptoms of infection to access site to include redness, swelling, warmth or drainage/bleeding, palpate for presence of thrill and listen for bruit, and report abnormalities to physician. Physician orders written for Resident #7 revealed an order written on 12/18/25 for dialysis treatments every Tuesday, Thursday and Saturday and to observe dialysis catheter site for any signs of bleeding and infection and to make sure caps (covering port sites) were intact. There were no orders in place to assess the A/V fistula to right arm. A progress note written by the Nurse Practitioner on 12/18/25 revealed Resident #98 had the right chest permacath in place and was on a Tuesday, Thursday, and Saturday dialysis schedule. The progress note indicated under assessment and plan that a right A/V fistula was placed in October 2025 and that it was not yet mature and a permacath was placed during the most recent hospitalization. A skin assessment note written by the Wound Treatment Nurse on 12/18/25 revealed a double lumen permacath to right chest, old dialysis access to right upper arm. The Medication Administration Record (MAR) for December 2025 revealed the catheter (permacath) site was being assessed from 12/18/25 through 12/31/25. The MAR did not include any orders to assess the A/V fistula to right arm. A progress note written on 01/01/26 revealed Resident #98 was sent to the hospital for a low hemoglobin (a lab value to measure oxygen in the blood). Resident #98 was readmitted back to the facility on [DATE]. Review of the physician orders written on 01/11/26 revealed orders to include dialysis treatments every Tuesday, Thursday and Saturday and to observe dialysis catheter site for any signs of bleeding and infection and to make sure caps (covering port sites) were intact. There were no orders in place to assess the A/V fistula to right arm. A skilled care note written by Nurse #9 on 01/11/26 revealed resident with temporary permacath placement as A/V fistula placed in October 2025 was not mature, and receiving dialysis on Tuesday, Thursday, and Saturday. An interview was conducted with Nurse #9 on 01/15/26 at 10:22 AM. Nurse #9 stated she was the nurse who started the admission for Resident #98 on the evening of 01/11/26. Nurse #9 stated usually the Unit Manager put in orders called batch orders whenever a resident had an A/V fistula. She added the batch orders included to assess fistula for bruit and thrill, monitor for signs of infection, and do not take blood pressures or do lab draws from the extremity the access site was on. Nurse #9 stated she assessed the A/V fistula site, and it was positive for a bruit and thrill, but she did not put any orders in. Nurse #9 stated that Nurse #8 took over the remainder of the admission process from Nurse #9 when she finished her shift at 7:00 PM. On 01/15/26 at 3:53 PM a phone interview was attempted with Nurse #8 and Nurse #8 did not return the call. A skilled care note written by Nurse #8 on 01/11/26 revealed dialysis site to right arm positive for bruit and thrill; dialysis days Tuesday, Thursday, and Saturday and pick up time was at 10:30 AM. A skin assessment note written by the Wound Treatment Nurse on 01/13/26 revealed double lumen permacath to right chest, dialysis access to right upper arm. The Medication Administration Record (MAR) for January 2026 revealed the catheter site (permacath) was documented as being assessed on 01/12/26, 01/13/26, 01/14/26, and 01/15/26. The MAR did not include any orders to assess the A/V fistula to right arm. An interview was conducted with Resident #98 on 01/12/26 at 9:00 AM. Resident #98 stated he was getting dialysis and pointed to his permacath to his right chest. Resident #98 stated he had a fistula to his right arm, but it was not in use at this time. Resident #98 could not recall why it was not in use or how long he had the A/V fistula. An observation of Resident #98 on 01/12/26 at 9:00 AM revealed an A/V fistula to his right upper arm and a permacath to his right chest. An interview was conducted with Unit Manager #2 on 01/15/26 at 9:30 AM. Unit Manager #2 stated she did not realize the A/V fistula to Resident #98's right arm was maturing. She knew that it existed, but she thought it was not functioning and that was why he had the permacath because that had been what he had been dialyzing through since admission. She reviewed the history and physical from the hospital at this time from 12/17/25 and confirmed he had a new A/V fistula inserted in October 2025 and that the access site was positive for bruit and thrill, but the access was not mature yet. She stated she did not assess Resident #98's site for bruit and thrill, or check for any redness, swelling or warmth and there should have been orders in place to assess the access site upon initial admission and readmission. Unit Manager #2 stated the admitting nurses should have initiated orders for the A/V fistula which would have included: no blood pressures or lab draws in the right arm, assess for signs and symptoms of infection such as bleeding, redness, swelling, and check for bruit and thrill. An interview was conducted with the Wound Treatment Nurse on 01/15/26 at 2:00 PM. The Wound Treatment Nurse stated she completed a skin assessment on Resident #98 on 12/18/25 and on 01/13/26 and saw that he had an A/V fistula. She stated she thought it was an old access site that was not in use and that was why Resident #98 had the permacath. The Wound Treatment Nurse stated she did not assess the A/V fistula site. The Wound Treatment Nurse stated she would not have put orders in the electronic record for the A/V fistula and that the admitting nurse would have initiated those orders. The Wound Treatment Nurse stated she was responsible for any dressing treatments to the permacath site or an A/V fistula site. A follow up interview was conducted with Unit Manager #2 on 01/15/26 at 11:00 AM. Unit Manager #2 stated the admitting nurses should have implemented batch orders for the A/V fistula access site and that it was not the sole responsibility of the Unit Manager. Unit Manager #2 stated she was primarily responsible for verifying orders. An interview with the Nurse Practitioner on 01/15/26 at 11:07 AM revealed he was aware Resident #98 had the A/V fistula to the right arm and mentioned it in his admitting progress note that it was maturing. He stated he would have expected the nursing staff to initiate batch orders for the A/V fistula since it was maturing and not old. He stated it was important to assess the bruit and thrill to make sure the access was not clotted (no blood flow), to check for signs and symptoms of infection, and to make sure no blood draws or blood pressures were being done from that arm. An interview was conducted with the Director of Nursing (DON) on 01/15/26 at 11:17 AM. The DON stated the admitting nurses should have initiated the batch orders for the A/V fistula access site for Resident #98 on 12/17/25 and on 01/11/26. She stated the Unit Managers verified the orders by double checking all admission orders to be sure all orders were put in place. The DON stated the orders to assess the A/V fistula site were not entered on both admissions and should have been.

Based on record review, and staff and the Consultant Pharmacist's interviews, the Consultant Pharmacist failed to identify and report a medication irregularity during 2 consecutive monthly medication regimen reviews (MRR) (November and December 2025) for 1 of 6 residents reviewed for unnecessary medications (Resident #72). Findings included: Resident # 72 was admitted to the facility on [DATE] with diagnosis which included orthostatic hypotension (a sudden drop in blood pressure upon changing positions).A review of Resident #72's physician orders revealed an order dated 11/6/25 to give midodrine 2.5 milligrams (mg) twice per day for hypotension (low blood pressure). The order indicated to hold the medication for a systolic blood pressure (SBP) reading over 120 millimeters per mercury (mm/Hg) or diastolic blood pressure over 80 mm/Hg. A review of Resident #72's medication administration record (MAR) for November 2025 revealed an entry which indicated to administer the medication midodrine 2.5 mg. Hold the medication if SBP is over 120 mm/Hg or diastolic blood pressure is over 80 mm /Hg. The MAR revealed the following: 11/9/25 6:00 PM the blood pressure was recorded as 124/53 mm/Hg and the midodrine was signed off by Nurse #1 as administered.11/10/25 6:00 PM the blood pressure was recorded as 124/68 mm/Hg and the midodrine was signed off by Nurse #4 as administered.11/15/25 9:00 AM the blood pressure was recorded as 129/54 mm/Hg and the midodrine was signed off by Nurse #5 as administered.11/17/25 6:00 PM the blood pressure was recorded as 129/56 mm/Hg and the midodrine was signed off by Nurse #3 as administered.The Consultant Pharmacist's MRR dated 11/18/25 documented that Resident #72's medication regimen contained no new irregularities. The medication regimen review did not address that Resident #72's medication midodrine was documented as administered outside the ordered parameters. A review of Resident #72's medication administration record (MAR) for December 2025 revealed an entry which indicated to administer the medication midodrine 2.5 mg. Hold the medication if SBP is over 120 mm/Hg or a diastolic blood pressure is over 80 mm /Hg. The MAR revealed the following: 12/4/25 9:00 AM the blood pressure was recorded as 122/67 and the midodrine was signed off by Nurse #2 as administered.12/9/25 at 6:00 PM the blood pressure was recorded as 121/66 and the midodrine was signed off by Nurse #2 as administered.12/11/25 at 6:00 PM the blood pressure was recorded as 132/60 and the midodrine was signed off by Nurse #1 as administered.12/14/25 at 6:00 PM the blood pressure was recorded as 121/60 and the midodrine was signed off by Nurse #2 as administered.12/17/25 at 6:00 PM the blood pressure was recorded as 121/67 and the midodrine was signed off by Nurse #2 as administered. The Consultant Pharmacist's medication regimen review dated 12/18/25 documented that Resident #72's medication regimen contained no new irregularities. The medication regimen review did not address that Resident #72's medication midodrine was documented as administered outside the ordered parameters. 12/19/25 at 6:00 PM the blood pressure was recorded as 122/61 and the midodrine was signed off by Nurse #1 as administered.12/20/25 at 6:00 PM the blood pressure was recorded as 124/62 and the midodrine was signed off by Medication Aide #2 as administered.12/23/25 at 9:00 AM the blood pressure was recorded as 128/61 and the midodrine was signed off as administered by Nurse #2 as administered.12/23/25 at 6:00 PM the blood pressure was recorded as 131/72 and the midodrine was signed off by Nurse #2 as administered.12/24/25 at 9:00 AM the blood pressure was recorded as 139/74 and the midodrine was signed off by Nurse #2 as administered.12/24/25 at 6:00 PM the blood pressure was recorded as 124/69 and the midodrine was signed off by Nurse #2 as administered.12/26/25 at 6:00 PM the blood pressure was recorded as 134/68 and the midodrine was signed off by Nurse #1 as administered. 1/9/26 at 9:00 AM the blood pressure was recorded as 126/66 and the midodrine was signed off by Medication Aide #1 as administered.1/9/26 at 6:00 PM the blood pressure was recorded as 127/70 and the midodrine was signed off by Medication Aide #1 as administered. During a phone interview on 1/15/26 at 11:20 AM the Consultant Pharmacist who was the pharmacist for the facility during November 2025 through January 2026 stated when he conducted his monthly reviews he reviewed the current MAR and the prior month's MAR for any irregularities including any medication administered outside of the parameters ordered. The Consultant Pharmacist stated a blood pressure medication should be documented as held when the blood pressure reading at the time of administration was outside the ordered parameter. The Consultant Pharmacist stated that he should have addressed Resident #72's documentation of the medication midodrine being administered outside the ordered parameter on his medication regimen reviews completed in November 2025 and December 2025. He stated that it was human error that he missed the medication administered outside the parameters when he reviewed Resident #72's MARs. An interview was conducted with the Director of Nursing (DON) on 1/15/26 at 3:15 PM. The DON stated that the Consultant Pharmacist completed a monthly review of each residents' medications. The DON stated that as part of the medication regimen review, the Consultant Pharmacist should have addressed that Resident #72's hypotension medication (midodrine) was documented as administered outside the designated parameter on the November and December 2025 MARs.

Based on record review and staff interviews, the facility failed to maintain accurate documentation on the Medication Administration Record (MAR) the administration of a medication for 1 of 6 residents reviewed for medications (Resident #72). Findings included:A review of Resident #72's physician orders revealed an order dated 11/6/25 to give midodrine 2.5 milligrams (mg) twice per day for hypotension (low blood pressure). The order indicated to hold the medication for a systolic blood pressure (SBP) reading over 120 millimeters per mercury (mm/Hg) or diastolic blood pressure over 80 mm/Hg. A review of Resident #72's medication administration record (MAR) for November 2025 revealed an entry which indicated to administer the medication midodrine 2.5 mg. Hold the medication if the SBP is over 120 mm/Hg or diastolic blood pressure is over 80 mm/Hg. The MAR revealed the following: 11/9/25 6:00 PM the blood pressure was recorded as 124/53 mm/Hg and the midodrine was signed off by Nurse #1 as administered.11/15/25 9:00 AM the blood pressure was recorded as 129/54 mm/Hg and the midodrine was signed off by Nurse #5 as administered. A review of Resident #72's medication administration record (MAR) for December 2025 revealed an entry which indicated to administer the medication midodrine 2.5 mg. Hold the medication if SBP is over 120 mm/Hg or a diastolic blood pressure is over 80 mm /Hg. The MAR revealed the following: 12/11/25 at 6:00 PM the blood pressure was recorded as 132/60 and the midodrine was signed off by Nurse #1 as administered.12/19/25 at 6:00 PM the blood pressure was recorded as 122/61 and the midodrine was signed off by Nurse #1 as administered.12/20/25 at 6:00 PM the blood pressure was recorded as 124/62 and the midodrine was signed off by Medication Aide #1 as administered.12/26/25 at 6:00 PM the blood pressure was recorded as 134/68 and the midodrine was signed off by Nurse #1 as administered. A review of Resident #72's MAR for January 2026 revealed an entry which indicated to administer the medication midodrine 2.5 mg. Hold the medication if SBP is over 120 mm/Hg or a diastolic blood pressure is over 80 mm /Hg. The MAR revealed the following: 1/9/26 at 9:00 AM the blood pressure was recorded as 126/66 mm/Hg and midodrine was signed off by Medication Aide #1 as administered.1/9/26 at 6:00 PM the blood pressure was recorded as 127/70 mm/Hg and midodrine was signed off by Medication Aide #1 as administered. An interview was conducted with Nurse #5 on 1/15/26 at 9:25 AM. Nurse #5 was assigned to Resident #72 on 11/15/25 from 7:00 AM to 3:00 PM shift. Nurse #5 stated that midodrine was prescribed to raise the blood pressure. Nurse #5 indicated that on the electronic MAR when there was a check mark and initials it indicated that the medication was administered. Nurse # 5 stated she documented incorrectly that she administered Resident #72's midodrine on 11/15/25 and that she did not administer the medication. An interview was conducted with Nurse #1 on 1/15/26 at 9:40 AM. Nurse #1 stated that midodrine was used to raise the blood pressure in a resident with hypotension or low blood pressure. Nurse #1 was assigned to Resident #72 on 11/9/25 at 6;00 PM, 11/26/25 at 9:00 AM, 11/27/25 at 9:00 AM and 6:00 PM, 11/28/25 at 9:00 AM, and 12/11/25 at 6:00 PM, and 12/19/25 at 6:00 PM. Nurse #1 stated that initials and a check mark on the electronic MAR indicated that the medication was administered. Nurse #1 stated that if Resident #72's blood pressure was outside the parameter, he held the medication and he documented in error that he administered it. Nurse #1stated he understood that it was important to document correctly. An interview was conducted with Medication Aide #1 on 1/15/26 at 10:10 AM. Medication Aide #1 stated that midodrine was administered for low blood pressure. Medication Aide #1 stated that she was aware that Resident #72 had parameters to hold the medication midodrine. Medication Aide #1 stated that she documented in error that she administered the medication midodrine to Resident #72 on 1/9/26 at 9:00 AM and 6:00 PM. During an interview with the Director of Nursing (DON) on 1/15/26 at 3:15 PM she stated that she expected that medications be administered and documented accurately. The DON stated that when a medication was held, it was to be documented as held with the indication why. The DON indicated that Resident #72's medication midodrine was not documented accurately and that accurate documentation was important for evaluation of the resident's medical condition.

Based on observations, record review, and staff interviews and Nurse Practitioner interviews, the facility failed to 1.) implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to a resident (Resident #4) with a tracheostomy (a surgical opening into the trachea that provides an airway for breathing.), a gastrostomy tube (a feeding tube placed through the abdominal wall into the stomach and used to provide essential nutrition) and a Stage IV pressure ulcer on the sacrum. This occurred with 2 of 10 staff members (Nurse Aide #1 and Nurse Aide #2) observed for infection control practices 2.) implement the infection control policy for Tuberculosis control by not completing Tuberculosis skin testing following admission for 1 of 5 residents reviewed for infection control practices (Resident #24). Findings included: 1.) The Infection Control Policy dated 2/28/25 revealed Enhanced Barrier Precautions referred to an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms that employed targeted gown and glove use during high contact resident care activities. During an observation on 1/14/26 at 10:00 AM Resident #4 was observed lying in bed. An Enhanced Barrier Precaution sign was observed on the door of Resident #4's room. A PPE (personal protective equipment) supply bag with supplies including gloves and gowns were hanging on the door of Resident #4's room. Nurse Aide #1 and Nurse Aide #2 were observed completing incontinence care. Nurse Aide #1 and Nurse Aide #2 were wearing gloves but did not don a gown prior to providing direct care to Resident #4.During an interview on 1/14/26 at 10:00 AM Nurse Aide #1 stated she did not know that she had to wear PPE when providing care including incontinence care to Resident #4. She stated she gets confused on what PPE was to be used for residents on enhanced barrier precautions. Nurse Aide #1 stated she had received infection control training on enhanced barrier precautions. During an interview on 1/14/26 at 10:00 AM Nurse Aide #2 stated she did not know she had to wear PPE when providing care to Resident #4, and stated she was not clear on why residents needed enhanced barrier precautions. Nurse Aide #2 stated she had received infection control training on enhanced barrier precautions. During an interview on 1/15/26 at 2:00 PM the Infection Control Preventionist Nurse stated staff had received infection control training on enhanced barrier precautions. She stated staff were required to complete monthly infection control in-services through an online platform. She stated Nurse Aide #1 and Nurse Aide #2 should have worn gowns along with gloves when providing direct care to Resident #4. During an interview on 1/15/26 at 2:05 PM the Director of Nursing (DON) stated staff received infection control training and should be following the infection control guidelines and wearing PPE when providing direct care to residents on enhanced barrier precautions. 2.) The facility policy titled Tuberculosis Control Plan dated 2/28/25 revealed in part; to minimize employee and resident exposure to, and subsequent infection with tuberculosis the facility will enforce the recommendations of the Centers for Disease Control and Prevention (CDC) regarding prevention of transmission of tuberculosis among employees and residents. All first time residents will be screened for tuberculosis on admission. Screening will consist of a Tuberculin Skin Test (Mantoux) using 5 units of Purified Protein Derivative (PPD) injected intradermally. Skin testing will employ the two step procedure. (If the reaction from the first test is less than 10 millimeters (mm), a second test will be given approximately 1-3 weeks after the first test was read.) A positive second test is indicative of a boosted reaction and not a new infection. If the second test remains negative, the person is classified as uninfected. Resident #24 was admitted to the facility on [DATE]. Review of Resident #24's electronic medical record on 1/14/26 revealed Step 1 of the two-step tuberculosis skin test was administered to Resident #24 on 5/23/25. The test was negative, and measured 0.1 mm. Further review revealed Step 2 was not administered to Resident #24 within 1-3 weeks following the first skin test. Step 2 was administered on 9/11/25 to Resident #24. During an interview on 1/15/26 at 2:00 PM the Infection Control Preventionist Nurse stated the tuberculin skin test was administered to residents on admission and Step 2 was to be administered within 1 to 3 weeks after Step 1. She stated Resident #24's Medication Administration Record (MAR) dated June 2025 revealed Resident #24 refused the Step 2 skin test on 6/6/25. The Infection Control Nurse stated that although Resident #24 refused the skin test on 6/6/25 staff should have offered the test again, but it looked as though that was not done. She stated she did not know why Step 2 was not offered again until 9/11/25. During an interview on 1/15/26 at 3:30 PM Resident #24 who was cognitively intact stated she did not recall refusing the skin test or why she would have refused Step 2 of the tuberculin skin test. Resident #24 stated maybe she felt bad on 6/6/25 the day it was offered to her, but she could not recall. She stated she would have agreed to complete Step 2 of the skin test if it was offered to her. During an interview on 1/15/26 at 3:45 PM the Nurse Practitioner stated Resident #24 was at baseline and had no respiratory symptoms, unexplained fever, or weight loss. The Nurse Practitioner indicated the recommended guidelines regarding Two step Tuberculin skin testing should be followed. During an interview on 1/15/26 at 4:00 PM the Director of Nursing (DON) stated Step 1 of the tuberculin skin test was offered on admission then Step 2 was to be given within 1-3 weeks after Step 1. The DON stated if Resident #24 refused Step 2 on 6/6/25 she should have been offered again within the required timeframe and that did not occur.

Based on record review and resident, staff, Responsible Party/Power of Attorney, North Carolina Nursing Assistant Registry investigator, former Director of Nursing and law enforcement interviews, the facility failed to protect a resident's (Resident #1) right to be free from misappropriation of property when Nursing Assistant (NA) #1 used Resident #1's bank account information, without Resident #1's permission, to create a Cash App account (Cash App is an app on your phone that works like a digital wallet; it is connected to your bank account and can be used to send or receive money instantly between users as well as be used to pay bills or for services) in Resident #1's name and then used that Cash App account to transfer money to her adult son, fiance, and mother on several occasions. NA #1 was alleged to have spent approximately $8022.84 (estimated) from November 2024 through March 2025. Resident #1 said it made her mad and that it hurt here (indicating her heart by patting the center of her chest) knowing NA #1 had stolen her money. This deficient practice occurred for 1 of 1 resident reviewed for abuse, neglect and misappropriation of resident property (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic diastolic (congestive) heart failure, chronic kidney disease stage 2, generalized anxiety disorder, and major depressive disorder. Resident #1's Care Plan included a need of impaired mobility related to hemiplegia following cerebrovascular disease (a stroke) affecting right side, initiated on 7/19/24. The quarterly Minimum Data Set (MDS), dated [DATE], coded Resident #1 as cognitively intact. A review of the facility's Summary of admitted Charges from Staff Member, listed the transactions on Resident #1's bank statements from 11/12/24 through 3/20/25 that totaled $8,022.84. The Initial Allegation Report, dated 3/27/25 and completed by the Administrator, was reviewed. It indicated the facility became aware on 3/27/25 at 8:30 AM that Resident #1 allegedly gifted NA #1 money. NA #1 had been suspended pending an investigation for misappropriation of resident property. Local law enforcement was notified on 3/27/25 at 9:30 AM. The Department of Social Services was notified on 3/27/25. A fax receipt indicated the Division of Health Service Regulation was notified on 3/27/25 at 9:41 AM. The Investigation Report, dated 4/2/25 and completed by the Administrator, was reviewed. The report indicated the facility did not substantiate the allegation of misappropriation of resident property. It stated the incident did not result in injury/harm or mental anguish to Resident #1. It indicated the new estimated amount was $8102.84 based on their follow-up interview. Per this report, law enforcement for this incident did not result in any charges against NA #1. Further review of the facility's 5-day summary revealed the facility had become aware of some concerns regarding Resident #1's bank account when a family member of hers brought in Resident #1's bank statement into the Business Office Manager (BOM) on 3/26/25. The family member told the BOM that someone is getting Resident #1. After some research, there had been a correlation between some transactions on the bank statement to NA #1 as she shared the same last name with the names listed on the Cash App transactions listed on the statement. The Administrator brought in NA #1 on the morning of 3/27/25 and NA #1 admitted to accepting financial gifts from Resident #1 and the transactions were completed via Cash App accounts in the names of her mother and son; NA #1 initially denied any transaction tied to her fiance. The summary listed the total of the transactions in her son and mother's names as $5825.15. A follow-up interview with NA #1 revealed an admission by NA #1 that she had, with Resident #1's permission, covered bills from Rent-A-Center and Spectrum. A follow-up interview with Resident #1 on 4/1/25 indicated Resident #1 changed her story in that she never gifted any staff gratuities or that she ever agreed to use her card to process any bill payments for staff. The summary included the facility updating the local police department's officer of these new details. The summary concluded as follows: Based on the investigation which includes the identified staff member's admitting of accepting monies from [name of Resident #1] and processing payments for herself with her alleged permission from [name of Resident #1] and [name of Resident #1] giving conflicting statements over multiple interviews, the allegation of misappropriation is unsubstantiated. The employee has been terminated effective 4-2-2025 for facility policy violation related to accepting gratuities. The Burgaw Police Department Incident/Investigation Report, incident number 2025-00671, completed by a Patrol Officer for the police department on 3/27/25 was reviewed. The report indicated the officer went to the facility and had been informed by the facility Administrator that Resident #1 had deposited money into several Cash Apps accounts that were tied to NA #1 (her own, her mother's, and her child's) over the past 4 months, totaling an amount of $5825.15 that was stolen from Resident #1. The officer stated the Administrator explained to him that the situation had been brought to their attention by Resident #1's family member (an aunt) who received mail at her address from Resident #1's bank and had noticed numerous Cash App transactions. The officer wrote that the Administrator went on to explain that when he questioned Resident #1 and NA #1, he had been informed those transactions were gifts and that the Administrator had also informed him that the facility's investigation was still ongoing. An attempt to contact the Burgaw Police Department's patrol officer via telephone was unsuccessful on 8/20/25 at 3:27 PM as the officer was not on duty on this date. A telephone interview with a Detective Sergeant of the Supportive Services Division at the Burgaw Police Department on 8/21/25 at 8:30 AM revealed the case was closed however, a warrant had been taken out against NA #1 by a Corporal within the department. The Detective Sergeant suggested this surveyor speak with the Corporal of the Police Department. A telephone interview with the Corporal of the Burgaw Police Department was conducted on 8/21/25 at 8:51 AM. The Corporal explained he was not on duty and did not have the paperwork of the case in front of him and therefore unable to give specifics in regard to dates and amounts but was able to offer what he knew of the details of the case. He explained the facility's Administrator had reported the incident to the patrol officer who, in turn, reported the case to him. The Corporal stated he went to the facility and talked with the Director of Nursing (DON) who provided him with information regarding the incident. This information included how NA #1 had Resident #1's banking account information and attached that to several Cash App accounts within her family and then used those accounts to pay for things such as bills and furniture. The Corporal stated the DON informed him that Resident #1 was not able to make decisions based on her BIMS (brief interview for mental status, an assessment tool used to determine a resident's mental cognition) score and that the DON had explained to him what a BIMS score was as well as having informed him of their policy about employees not being able to take tips or gratuities from residents. The Corporal went on to say that he had spoken to NA #1 who told him that Resident #1 had given her permission to use Resident #1's money to pay her bills. The Corporal gave examples of what some of those Cash App accounts had been used to pay for, such as pizza, birthday cake, a birthday planner, getting nails done at a spa, among other places. He said NA #1 had told him that other employees had done it in the past as well. He said NA #1 said times were tight and that she admitted to him that she had taken advantage of Resident #1, that she knew it was wrong even though Resident #1 had given her permission to do so. The Corporal stated he asked NA #1 about the facility's policy about not being allowed to take tips or gratuities from residents and that NA #1 denied knowledge of that policy and explained to him that she did not have a good orientation when she had been hired. The Corporal stated how this all came to light was that Resident #1's aunt had been made aware of these Cash App transactions after Social Security had made an overpayment of $10,000 in Resident #1 payments and had sent a letter explaining the overpayment would have to be paid back and that the aunt had gone to the facility to discuss that matter as well as the matter of all those Cash App transactions on Resident #1's bank account statements. The Corporal stated NA #1 was charged with exploitation of an elder and has been served with that process and now the case is in the hands of the court. He explained she had her first court appearance last month and may be on her second or third court appearance by now. He stated once NA #1 had been served, he submitted all of his evidence to the [NAME] County District Attorney (DA) and to NA #1's defense attorney. He recalled NA #1 telling him that she would pay everything back to Resident #1. The Corporal stated what NA #1 did was considered a felony and that she could serve time in jail but admitted she could also get probation, which is sometimes usual in cases like this. The Corporal added that he had spoken with Resident #1 who stated that she never gave NA #1 permission to use her bank account information; he stated he also talked with Resident #1's aunt, who agreed that Resident #1 would never have given NA #1 her permission to access that money in her bank account and that Resident #1 would not have been able to create a Cash App account. An interview was conducted with Resident #1 on 8/20/25 at 3:10 PM. Resident #1 recalled NA #1 referring to her as her mother, like in a friendly way at first, but stated she was not related to NA #1 at all. She said once, they started talking about Chinese food and she told NA #1 that if she would go and pick her up some Chinese food that she would buy some for her as well. Resident #1 said she gave NA #1 a $20 bill and confirmed she never gave NA #1 her debit card. Resident #1 stated that when NA #1 returned from the restaurant and put the change in the top drawer of the dresser beside her bed, she said NA #1 noticed her bank statements that were in that drawer and took them. Resident #1 stated that NA #1 then took information from those statements and set up a Cash App account in her name. Resident #1 confirmed she had never heard of Cash App before all of this happened and that the Business Office Manager (BOM) had to explain to her how it worked. Resident #1 said after she found out about all the Cash App transactions that showed up on her bank statements, she told NA #1 to return her bank statements to her or else she would call the police. Resident #1 said the police came to the facility and told her that NA #1 used her bank information to create a Cash App account in her name and then used the account for different things and that NA #1 had stolen a lot of money from her. She said after that, she saw her bank statements and all of her money was gone it made her mad and it made her hurt here, patting the center of her chest with her hand. She denied ever giving NA #1 permission to take any money from her bank account and remained adamant she had never given NA #1 her bank debit card. Resident #1 stated she wanted her money back in her bank account. A telephone interview was conducted with NA #1 on 8/19/25 at 2:04 PM. NA #1 was initially reluctant to agree to an interview and questioned whether this information would be shared with the news people. NA #1 expressed anger towards the facility and how they had handled their investigation. She complained that the Administrator slandered her name and then she decided she would like to tell her side of the story. NA #1 explained she had developed a close relationship with Resident #1 and how the resident would refer to her as a daughter and because Resident #1 had lost a child, she thought being called her daughter was sweet. She said a lot of people at the facility knew of their relationship and no one considered that a problem until a family member of Resident #1's got involved because of something to do with Social Security money. NA #1 further explained that Resident #1 had been threatened by her family and by the facility's BOM that if she did not pay back Social Security, she would be kicked out of the facility. NA #1 continued, saying that prior to the Social Security stuff, Resident #1 would do things for her and gave an example of once Resident #1 offered to do Christmas for her boys. NA #1 stated Resident #1 would cling onto her and ask her to do personal things and, in turn, Resident #1 would offer to help her financially. NA #1 said Resident #1 was in her right mind and everything was fine until Resident #1's family got involved. NA #1 acknowledged the facility was trying to say it was a lot of money but that it had only been $2000 or $3000 here and there. NA #1 denied ever having been arrested over this situation. She explained her lawyer is working with the DA and that she will have to pay restitution which would be a certain amount of money and was unable to explain further and said that she did not really understand what that meant. NA #1 continued to tell her side of the story and said around 3 months after everything had happened, she received a call from the [NAME] County Sheriff's office and then they came to her house and then she had to speak to the DA. She said the DA told her she was not being charged with anything dealing with fraud, but then said she had been charged with misappropriation of elderly something and could not remember fully what it was called, and thought it might have to do with the fact they said I took advantage of her because they had looked at her record and saw Resident #1 was incompetent and then said, but Resident #1 holds her own bank cards and stuff and makes her own financial decisions. NA #1 stated she would not have to go to jail and talked again about the restitution and said that until that is paid, the case would be pending but that when restitution is paid off, the case would be dismissed. An interview was conducted with the BOM on 8/19/25 at 2:52 PM. The BOM explained that around the 25th or 26th of March 2025, Resident #1's Responsible Party (RP)/next of kin came to see her and had brought in one of Resident #1's bank statements. The RP informed her that someone is getting her and showed her the bank statement which listed several Cash App transactions. The BOM stated she then went with the RP and another staff member to Resident #1's room to talk with her. Once in the room, she stated they asked Resident #1 what all those Cash App transactions were and who were the people she had been Cash Apping. The BOM stated Resident #1 did not know what they were talking about. She explained that at that point, she left the resident's room to go and get her phone, and the RP had opened the drawer to her dresser and looked at other bank statements she found there. She stated that they saw these Cash App transactions had been going on for a long time and with Resident #1's permission, she called the bank, explained what they had seen, and got Resident #1's bank card canceled and requested copies of all of her bank statements. The BOM stated Resident #1 had given permission to the bank for them to send her those statements. The BOM explained how she did not recognize the names associated with the Cash App transactions on the bank statement but that the last name of those listed shared the same last name of one of their employees, NA #1. She further explained that she pulled that NA #1's personnel file and also looked at her Facebook account and noticed that the emergency contacts listed in the personnel file matched the names on the Cash App transactions on the bank statements and noticed that the Facebook account listed the name of another name associated with the Cash App transactions - the employee's son. The BOM stated the transactions ranged in amounts from $20 to $1200. The BOM stated the only reason the RP had opened up and looked at Resident #1's bank statement was because of a letter from Social Security that explained Resident #1 had been overpaid by $10,000 over the course of a 2-3 year period and a letter from Social Security had been sent which stated they would be garnishing her wages in order to recoup the overpayments. The BOM stated at that point, she informed the Administrator. She explained she and the Administrator interviewed Resident #1 and that Resident #1 informed them that she liked to give gratuities to staff for a good job but that she admitted she had never given permission for any staff to use her bank card. The BOM continued and said that Resident #1 stated she knew NA #1 had taken a picture of her debit card because she heard the snap of a phone camera. The BOM said she and the Administrator met with NA #1 the following morning and said that at the beginning of the meeting, NA #1 denied using Resident #1's bank card but then later admitted to agreeing on amounts of money for Resident #1 to tip her and said that NA #1 stated she did not have Resident #1's bank card info stored on her phone. The BOM stated during their investigation, they pulled NA #1's timecards and noticed that 75% of the time observed on the Cash App transactions that NA #1 was not working and that they had asked her about that and NA #1 denied knowledge about that. The BOM stated there were multiple Cash App transactions for Spectrum [an internet/cable provider], Airbnb [a hospitality platform], Rent-A-Center, Progressive Insurance, [NAME] Financial to name a few. The BOM said the police were later called. A second interview with the BOM was conducted via telephone on 8/28/25 at 8:29 AM. The BOM stated if Resident #1 would not be able to meet her Patient Monthly Liability (PML) because of the Social Security Administration's garnishment of Resident #1's monthly benefits check secondary to having received overpayment in her monthly benefits check, then there would be a risk for her being discharged from the facility. The BOM provided a copy of the letter from Social Security Administration's letter to Resident #1 dated 3/14/25. A review of the letter Resident #1 received from the Social Security Administration (SSA), dated 3/14/25, revealed an overpayment of $9099 from September 2023 through February 2025. The letter indicated that if the SSA did not receive a refund of the amount of the overpayment from Resident #1 within 30 days, they would withhold 10 percent of her total monthly benefit or $10 (whichever is more) starting with the payment she would receive on or about 7/3/25. An interview with the Administrator was conducted on 8/19/25 at 3:46 PM. The Administrator explained that he had been informed by the BOM about a situation involving Resident #1, NA #1 and multiple Cash App transactions showing up on Resident #1's bank statements and he stated it had been brought to the BOM's attention by Resident #1's family member. He further explained that the BOM had mentioned the possible relationship of the names associated with the Cash App transactions being tied to one of their employees, NA #1. He stated he then reached out to NA #1 and asked her to come in to meet with him. Present for the interview was himself, the former Director of Nursing (DON), the BOM and NA #1. He stated he questioned NA #1 about the Cash App transactions and that NA #1 explained that Resident #1 had insisted she take and receive money from her. The Administrator stated those transactions were in concerning amounts but that they were not even close to the total amount they would later discover. He stated NA #1 accepted some responsibility that some of the charges related to her were at the resident's insistence and she was suspended at that time pending their investigation. He stated he made notifications to the State and to the police and to Adult Protective Services. He stated he did follow-up interviews with Resident #1 and noted her story changed to having never given any money to anyone and told him that if anyone said that they were lying. The Administrator stated that because they could not get a consistent story from Resident #1 and they could not prove that staff took money from her and therefore he could not substantiate the allegation. The Administrator presented a summary of his investigation, all the notebooks of his investigation, and asked for this to be considered at past noncompliance. A second interview with the Administrator was conducted via telephone on 8/28/25 at 9:31 AM. The Administrator stated while there had never been a discussion with anyone about the facility repaying the money stolen from Resident #1's bank account by NA #1 prior to the start of this investigation, he had spoken from someone at the corporate level on this date, and assured this surveyor that the facility would restore the full amount stolen by NA #1 to Resident #1's account. He also clarified that Resident #1 would not be at risk of being discharged from the facility due to inability to meet her PML. A telephone interview was conducted with the former Director of Nursing (DON) on 8/22/25 at 10:26 AM. The former DON stated she had been in her office when Resident #1's family member came to the facility and talked with the BOM. She explained the BOM then came to her and informed her that the family member had brought bank statements which showed a bunch of Cash App transactions that the family member did not understand that. She said the BOM had looked at the names on those transactions, she tied them to one of their staff, NA #1. She stated she recalled the names on the Cash App transactions were the names of NA #1's mother, her adult son, and her fiance and they knew those names were associated with NA #1 because of the emergency contacts listed in her personnel file and from having looked at NA #1's Facebook account and saw they were associated there as well. The former DON stated she had been present for a couple of the interviews the Administrator did with NA #1. During the first interview, NA #1 initially denied the allegations. Then, on the second interview, the former DON said NA #1 admitted to the Cash App transactions but told them that Resident #1 had given her gifts and that she thought if a resident was alert that it was okay to take the gifts. The former DON said that NA #1 knew better than that and that it was never okay to take money from a resident. She stated that NA #1 tried saying that her mother had cancer and had lost her house. The former DON said that NA #1 told them that Resident #1 already had a Cash App account and told them that Resident #1's phone was not working and had given NA #1 her debit card to get some food. The former DON said they believed NA #1 had taken Resident #1's debit card and created a Cash App account in Resident #1's name on NA #1's phone and then used that Cash App account to transfer money to all those different places. The former DON said that they also believed that in addition to Resident #1's bank card, NA #1 had to have a lot of Resident #1's personal information in order to create that Cash App account and then she stole thousands and thousands of dollars from Resident #1's bank account. The former DON stated that it was sad because Social Security would be wanting Resident #1 to pay back all that money that had been overpaid and because of what NA #1 had stolen from Resident #1 that Resident #1 did not have that kind of money to pay Social Security back. A telephone interview was conducted with Resident #1's family member and Power of Attorney (POA) on 8/21/25 at 8:30 AM. The POA explained that after she became Resident #1's POA, she had opened up a bank statement and saw all kinds of transactions like a nail salon in [NAME], an Airbnb, a cell phone place, Spectrum bill and stuff like that. The POA said at that time, it totaled around $7000 worth of charges. The POA stated she had also opened up a letter from Social Security talking about back payment and stated she was confused about both and went to the facility to talk with Resident #1 about it but first stopped by to speak with the BOM. The POA stated she had asked the BOM if Resident #1 had to pay for TV at the facility because she had seen that Spectrum transaction on that bank statement. She was confused because there had also been a transaction about a cell phone bill but that it was a different provider than the one Resident #1 used for her cell phone. She said she and the BOM went to talk with Resident #1 together and asked to see other bank statements she had which were just kept in the top drawer of her dresser beside her bed. She said that Resident #1 said something about a girl taking her bank statements and then the resident was going back and forth and stated Resident #1's memory isn't good and she's in poor health. The POA said she and the BOM knew something was not right and then the BOM called Resident #1's bank and got her debit card cancelled and got them to send her another card. The POA said the BOM explained to Resident #1 that she could not keep all that stuff just out in her room and took it all and locked it up. The POA explained those bank statements showed a lot of transactions, and she knew that Resident #1 had not made them because she had been at the facility a long time. She explained the BOM told her the facility would investigate and also call the police. The POA said the DA also got involved and that she calls the DA every month trying to find out what is going on with the case. She explained Social Security wants their money back and that they are taking money every month out of her check to get that money back. When asked how much money had been taken from Resident #1's bank account, the POA said she thought it was around $22,000. A telephone interview with an investigator from the North Carolina Nursing Assistant Registry was conducted on 8/25/25 at 10:40 AM. The investigator stated during her investigation of the allegation of NA #1 stealing money from Resident #1, she conducted many interviews including ones with the BOM, Resident #1, NA #1, and the Administrator. The investigator stated that during her interview with Resident #1, she found her to be very alert and oriented, and that all Resident #1 wanted was her money back so that she could pay back Social Security for the overpayment of benefits. The investigator stated that she informed the Administrator they needed to help Resident #1 with this and said this prompted the Administrator to contact the police and conduct an investigation of the matter. The investigator stated she obtained copies of Resident #1's bank statements which showed Cash App transactions to NA #1's mother, son and fiance. During her interviews with NA #1, the investigator stated NA #1 informed her that all the transactions were small ones and denied some of the larger ones. The investigator said she definitively proved Cash App transactions made by NA #1 in the amount of $9162.15 and closed her case on 6/10/25. A telephone interview was conducted with the Administrator and Director of Nursing (DON) on 8/22/25 at 11:14 AM. The Administrator stated he could not say why NA #1 did what she did to Resident #1 as he did not get into the whys of it, that he was more concerned that they took the right actions after they had been made aware. He stated NA #1's employment with the facility was terminated on 4/2/25. Both the Administrator and the DON stated it was their expectation that staff not accept gratuities from residents and that they expect all staff to follow their policies and procedures. The Administrator submitted the following Corrective Action Plan: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Deficient Practice: NA #1 misappropriated Resident #1 funds and there was no negativePsychosocial or mental outcomes to Resident #1. The deficient practice occurred because NA #1 did Not follow page #14 of the employee handbook specific to Gratuities and Loans. NA #1 acknowledged receipt of the employee handbook on 10-15-2024. NA #1 was suspended 3-27-25 pending investigation. Local law enforcement was notified 3-27-25 at 9:30am, Adult Protective Services (APS) at 11:00am on 3-27-25, facility providers were notified at 10:23am on 3-27-25, Division of Health Service Regulation (DHSR) was notified by submission of the Initial Allegation Report on 3-27-25 at 9:41am by the Nursing Home Administrator (NHA), and family member of Resident #1 was notified on 3-27-25. Resident #1 was interviewed by the Nursing Home Administrator and Business Office Manager (BOM) on 3-27-25. Resident #1 stated that she liked to tip staff. With permission, Resident #1's purse was searched and loose blank checks and financial cards were found by the BOM. With permission, those items were taken and given to Resident #1's aunt by the BOM. Resident #1 was given a new locked box by the BOM on 3-27-25. Resident #1 has a Patient Trust Account and a deposit was made based on cash found with permission. A mood assessment was completed on 3-27-25 by the Social Worker (SW) for Resident #1 she was assessed to be at her baseline. Mood assessments were completed 3 times a week for two weeks beginning 4-1-25 through 4-12-25 for Resident #1 by the Social Worker and Resident #1 remained at baseline. On 5-14-2025, the administrator followed up with local law enforcement to seek out updated information regarding criminal and restitution actions.To make the resident whole, a restitution judgement was made against NA #1 by the [NAME] District Court for the State of North Carolina on 8-13-2025 for Resident #1 in the amount of $14,481.05. This restitution judgment will be managed by the [NAME] District Court for the State of North Carolina. The family for Resident #1 was made aware of local law enforcement notifications made by the Business Office Manager and the Administrator as it relates to pursuing criminal actions and restitution through local law enforcement against NA#1 for Resident #1 beginning on 3-27-2025. Resident #1's ability to stay at the facility, as it relates to Resident #1s Patient Monthly Liability, has not and will not be affected by the event caused by NA #1 per the Administrator.2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.100% of interviewable residents were interviewed, offered a lock box, and educated by the Social Work department beginning on 3-27-25 and completed on 3-28-25 related to misappropriation and no other residents were affected. Interviews, offering a lock box and education related to gifts, gratuities and misappropriation of funds were completed by the BOM with responsible parties of 100% non-interviewable residents on 3-28-25 and no residents were affected. 100% of employee file audits were completed on 3-27-25 by the Human Resources (HR) Director related to abuse education, healthcare registry review, and background check verification. Newly admitted residents are offered a lock box by the admission Director or designee when completing the new admission paperwork.3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.All facility-employed staff education related to abuse and misappropriation began on 3-27-25 and was completed on 3-27-25 by Human Resources and designees. The education covered the facility's Abuse Prohibition Policy that covers physical abuse, verbal abuse, sexual abuse, exploitation, mental abuse, neglect, with an emphasis on misappropriation of resident property, to include examples of allegations of misappropriation of resident property and exploitation . The education was completed in person and via telephone by the HR Director and designees. No facility staff worked until they were educated, and this was va[TRUNCATE

Based on records reviews and staff interviews, the facility failed to have advance directives in the resident's records for 1 of 7 sampled residents. (Resident #52). Findings included: Resident #52 was admitted to the facility on [DATE]. A review of Resident #52's admission's Notice of Acknowledgments dated 01/04/2023 revealed no note that the resident wanted to formulate an advance directive or refused. Significant change Minimum Data Set (MDS) dated [DATE] indicated Resident #52's cognition was severely impaired. Review of the computerized clinical record for Resident #52 revealed no advanced directive noted in the resident's medical record. During the interview with Social Worker (SW) on 05/02/23 at 10:42 AM, she acknowledged there was no indication in the medical record if Resident #52's representative wanted to formulate an advance directive or refused to formulate one. During the interview with Director of Nursing (DON) on 05/03/2023 at 01:04 PM, she stated that the Admission's Coordinator or SW was responsible for reviewing the advance directive forms with the residents or responsible party during the admission to the facility. The DON further indicated she did not find the advance directive in Resident #52's medical record and there was no documentation found that stated the resident or responsible party refused. She added that the expectation was that the advanced directive should have been completed and scanned in Resident #52's computerized clinical record or a note indicating the refusal to formulate an advance directive. During the interview with the Administrator on 05/04/2023 at 10:30 AM, He stated the advanced directives should have been completed and scanned in Resident #52's clinical record or a note indicating refusal. The Administrator further stated he would ensure the residents' advanced directives were placed in the medical records if a resident had formulated one.

Based on record review and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of level II Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident (Resident # 78) identified as PASRR Level II. Findings included: Resident #78 was admitted to the facility on [DATE] and most recently readmitted on [DATE] after hospitalization with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change MDS assessment dated [DATE] was left blank to question A1500 which asked if Resident #78 had been evaluated by a level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition. Record review indicated Resident #78 had a Preadmission Screening and Resident Review (PASRR) Level I Screen completed dated 9/14/21 for a change in condition review. Record review indicated Resident #78 had a Preadmission Screening and Resident Review (PASRR) Level II Determination Notification dated 9/16/21. An interview was conducted with the Social Worker (SW) on 1/27/22 at 10:40 AM. The SW explained Mr. [NAME] had a completed Level II PASRR in file. The Social Worker was not aware it was not coded in the MDS data files. The Social Worker stated she usually sends an email when PASRR comes in and informs staff of the changes. She provided a copy of the updated Level II PASRR Determination Notification dated 9/16/21. An interview was conducted with the MDS Nurse on 1/27/22 at 11:35 AM. The MDS Nurse was not aware of the Level II PASRR for Resident #78 was not updated. The MDS Nurse stated she was aware of the PASRR Level II, and the care plan was updated, but it did not get updated in the MDS data. She stated she would immediately do a change in the MDS data file. An interview was conducted on 1/27/22 at 12:00 PM with the Director of Nursing and the Facility Consultant regarding PASRR II documentation. The Director of Nursing explained the Social Worker sends in the PASRR changes and notifies staff via email after receiving the updates. Resident #78 was updated in the care plan but was not updated on his MDS documentation. The Director of Nursing stated Resident #78 was missed; but should have been coded with a significant change update in the MDS data. During a telephone interview with the Administrator on 1/28/21 at 1:00 PM. He explained he had been informed about the Level II PASRR coding and it was being corrected. He stated it should have been coded with a significant change when the Level II PASRR Determination Notification was returned.

Based on record review and staff interviews the facility failed to refer a resident for screening for a level II Preadmission Screening and Resident Review (PASARR) after a new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #80 was admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] had Resident #80 coded as severely cognitively impaired and needed extensive assistance for activities of daily living (ADL). The comprehensive care plan dated 12/31/2021 had focus' of risk for pain and/or has chronic pain related to (r/t) emotional distress hallucinations, depression, delusions, and decreased mobility, arthritis, is at risk for adverse reactions and side effects r/t receiving multiple [CONDITION(S)] medications. Resident takes an antidepressant for depression and a antipsychotic ([MEDICATION(S)]) for dementia with behaviors. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The NC PASARR I screen dated 11/01/2021 had major depressive disorder as one of the mental health diagnoses. The January Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the Social Worker (SW) was conducted on 01/27/2022 at 10:35 AM. The SW stated Resident #80 was diagnosed with hallucinations, and a delusional disorder on 11/12/2021. On 12/20/2021 a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the Administrator was conducted on 01/27/2022 at 10:07 AM. The Administrator stated the facility had been working on PASARR's and expects all new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and staff interviews, the facility failed to make a referral for the re-evaluation of a Pre-Admission Screening and Resident Review (PASARR) II for 1 of 4 residents reviewed for PASARR. (Resident #66) The findings included: A review of the PASARR level I screen dated 4/8/16 had mental health [DIAGNOSES REDACTED]. Resident #66 was admitted [DATE], the medical [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] had Resident #66's [DIAGNOSES REDACTED]. Resident #66 was coded as needing total dependence for bed mobility, transfer and toilet use, extensive assistance with personal hygiene, and dressing and independent with eating and received an antidepressant and antianxiety medication for the 7 days during the look back period. The admissions MDS dated [DATE] had [DIAGNOSES REDACTED]. The care plan dated 9/7/19 had focuses of Actual Behavior Problem AEB abusive language and threatening behavior towards staff, Affective Disorder: Depression, Anxiety and [MEDICAL CONDITION] illness with history of mood cycles and frequent crying, a [DIAGNOSES REDACTED]. She prefers to stay in her room, but enjoys being read to, and conversing with others and has potential for worsening behaviors problem evidenced by yelling and screaming at staff and cursing/using abusive language related to dx of [MEDICAL CONDITION] disorder, anxiety and [MEDICAL CONDITION] left [MEDICAL CONDITION]. A review of the PASRR level 1 determination notification dated 04/08/2016 read: PASRR number ending in an A and without an expiration date, did not need further screening unless a significant change occurs with the individual's status which suggests a [DIAGNOSES REDACTED]. A review of the Medication Administration Record [REDACTED]. Reviewed psychotherapy progress note dated 9/11/19 read: treatment goals focused on during the session were: [MEDICAL CONDITION] symptoms and anxiety, to reduce anxiety, and monitor for symptoms of escalations of mood towards mania. Reviewed nurses note dated 7/31/19 read: Yelling/Screaming, allowed time for venting and redirected. During an interview with social worker on 10/09/19 at 10:42 AM, the social worker stated there should have been a referral for a PASARR level II for Resident #66 that included all of her mental health diagnoses. During an interview with the Director of Nursing (DON) 10/09/19 at 10:24 AM, the DON stated there should have been a referral for a PASARR level II for Resident #66 and there will be a full audit to assure all [DIAGNOSES REDACTED]. During an interview with Administrator on 10/09/19 at 10:36 AM, the Administrator stated according to the diagnoses, there should have been a referral for a PASARR level II for Resident #66 and there will be a full audit and education to assure all [DIAGNOSES REDACTED].

Based on record review, staff and Nurse Practitioner (NP) interview the facility failed to follow the Physicians' order for two low blood sugar levels for 1 of 1 resident reviewed. (Resident #1) Findings included: May 2019 Medication Administration Record [REDACTED]. Record review dated 02/03/2019 noted Resident #1's blood sugar level as 64. There was no documentation stating the Physician was called. Record review dated 03/07/2019 noted Resident #1's blood sugar level as 62. There was no documentation stating the Physician was called. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED].#1 coded as cognitively intact needing supervision with eating and extensive assistance with transfer, bed mobility, dressing, toilet use and personal hygiene for activities of daily living (ADL). The comprehensive care plan dated 05/04/2019 with focus of risk for fluctuation blood sugars related to Diabetes Mellites (DM). Reviewed a Nurses note by Nurse #1 dated 2/3/2019 16:10:06 read: BS 64 eating banana. During a telephone interview with Nurse #1 on 05/23/2019 at 1:20 PM, Nurse #1 stated she did write the note on 02/03/2019 and she did recheck and called the Physician about the low blood sugar but did not document it. During an interview with Nurse #2 on 05/23/2019 at 11:26 AM, Nurse #2 stated she did recheck Resident #1's blood sugar, didn't remember what the value was and did not call the Physician because she was not aware she needed to call if it was under 70 but knew to call if it was over 450. During an interview with the Director of Nursing (DON) on 05/23/2019 at 12:12 PM, the DON stated she expects her nursing staff to follow Physicians orders. During an interview with the Nurse Practitioner (NP) on 05/23/2019 at 12:23 PM, the NP stated her expectation are for orders to be followed and will clarify Resident #1's order to make it more individualized.

Based on observation, record review and staff interviews, the facility failed to prevent 1 of 1 cognitively impaired residents with wandering and exit-seeking behaviors (Resident #128) from exiting the facility on 3 separate occasions. Immediate jeopardy began on 10/10/16 when Resident #128 exited the facility unattended by facility staff and was observed standing in the grass between a ditch and a road in front of the facility. Immediate jeopardy is present and ongoing. Findings Included: Resident #128 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had an admission Minimum Data Set (MDS) on 6/12/16. A review of Resident #128's Care Plan, last updated on 07/27/16, indicated Resident #128 was a wanderer and an elopement risk related to his aimless wandering, impaired safety awareness and history of attempts to leave the facility unattended. The Care Plan indicated the facility was to identify his pattern of wandering by questioning if the wandering is purposeful, aimless or escapist. The Care Plan included an intervention of monitoring Resident #128's location every 15 minutes to ensure his whereabouts and to document his wandering behavior and attempted diversional interventions in the behavior log. The Care Plan indicated Resident #128 had a Wander Guard bracelet applied to his left wrist. (A Wander Guard is a device worn by a resident that signals an exit door to lock when approached by the resident wearing it or sounds an alarm if a resident wearing one exits the door). The resident was discharged from the facility to home on 8/8/16. The resident was admitted to the facility on [DATE]. The resident was assessed as a new resident on this admission. A review of Resident #128's admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #128 was severely cognitively impaired with behaviors that included inattention, disorganized thinking, and wandering. The MDS indicated Resident #128's wandering placed him at significant risk of getting into a potentially dangerous place. The MDS indicated Resident #128 needed limited assistance with walking in his room and in the corridor and his balance during transitions and walking was not steady and only able to stabilize with staff assistance. The MDS indicated Resident #128 used a cane as a mobility device and had a fall in the last month prior to admission. A review of Resident #128's Care Area Assessment (CAA), dated 10/13/16, indicated Resident #128 had cognitive loss and dementia and was easily distracted. The CAA indicated Resident #128 had behavioral symptoms which included daily wandering, resistance to care, pacing and physically abusive at times. The CAA indicated Resident #128 was an immediate threat to himself and an immediate intervention was required. On 08/24/17 at 9:14 a.m., the Director of Nursing (DON) was asked to provide a copy of the behavior log mentioned in Resident #128's Care Plan. The DON stated there was no log because they do not do that type of log at this facility. A review of the Daily Skilled Nursing Notes indicated Resident #128 exhibited wandering behaviors on October 7, 10, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 29, 30 of 2016. Record review indicated Resident #128 exited the facility unattended by staff on 10/10/16, 11/02/16 and 11/06/16. A review of an Incident Report of the elopement written by Nurse #3 on 10/12/16 indicated Resident #128 was found ambulating in the street on 10/10/16 at 4:15 p.m. The report included a witness statement by Nurse #2 which stated, I was driving down road in front of V(NAME) (The Village of Campbell which was the previous name of this facility) and resident was walking across the street from driveway on 100 Hall of V(NAME). I stopped and assisted resident into vehicle and brought him back to the parking lot of V(NAME) and assisted resident inside facility. Resident was pleasant and talkative. No harm or injury noted. The incident report indicated an Elopement Assessment was performed and a Wander Guard was placed on the resident's left wrist. The incident report indicated the root cause of the incident to be a history of dementia and recent hospitalization for delirium. The incident report was signed by the Director of Nursing (DON) on 10/13/16 indicating she was aware of the elopement. During an interview with Nurse #2 on 08/24/17 at 12:04 p.m., Nurse #2 stated on 10/10/16 she was driving in to work and noticed Resident #128 standing in the grass between the ditch and the road near the facility sign. Nurse #2 stated she did not think he had jumped the ditch but rather walked out of the parking and the down to an area between the road and ditch near the facility sign. Nurse #2 stated the only way she could maneuver the resident was to get him in her car as if they were going somewhere. Nurse #2 stated she pulled into the parking lot near the 400 Hall and Nurse #3 assisted her in getting the resident back in the facility. Nurse #2 stated she and Nurse #3 walked with the resident to his assigned nurse, Nurse #4. Nurse #2 stated under normal situations, the resident's elopement would have been discussed the following morning at their stand-up meeting. Nurse #2 stated the facility was in a bit of chaos following the aftermath of Hurricane Matthew therefore the resident's elopement of 10/10/16 did not get discussed until 10/12/16. A Risk of Elopement Review form, completed on Resident #128 on 10/12/16 by Nurse #3, indicated Resident #128 was cognitively impaired with poor decision making skills, had a pertinent [DIAGNOSES REDACTED]. The assessment indicated Resident #128 was at risk for elopement as evidenced by having left the facility without informing staff on 10/10/16 and a Wander Guard bracelet was placed on his left wrist with staff to check the placement of the bracelet every four hours with daily signal checks to be placed in the log. During an interview with the DON on 08/24/17 at 12:02 p.m., the DON stated she did not recall being made aware of Resident #128's 10/10/16 elopement because she was out of the state. During an interview with the former Administrator on 08/25/17 at 9:28 a.m., the former Administrator stated she did not complete an investigation of the 10/10/16 elopement or put a Plan of Correction (P(NAME)) in place. The former Administrator stated a Wander Guard had been placed on the resident and she had hoped it would prevent future elopements. When asked how the resident exited the building, she stated he just walked out. During an interview with Nurse #2 on 08/25/17 at 10:30 a.m., Nurse #2 stated she thought Resident #128 exited the facility on 10/10/16 through the 100 Hall front door because he resided on that hall. An observation of the distance from the 100 Hall front door to the point where the resident was picked up was made on 08/25/17 at 10:30 a.m. Accompanied by Nurse #2 and using a measuring wheel provided by the therapy department, the distance the resident traveled equaled 223 feet. Wunderground.com, an affiliate of the Weather Channel, indicated the outside temperature on 10/10/16 was 68 degrees Fahrenheit with a wind speed of 15 mph. A review of a Nurse Progress Note, written on 11/02/16 at 7:00 p.m. by the DON, revealed Resident #128 had exited the facility and a search had been started. The note indicated the resident had been found in the woods approximately a block from the facility. During an interview with the former Social Worker (SW) on 08/25/17 at 8:49 a.m., the former SW stated she had become aware Resident #128 was missing from the facility after she noticed the former Staff Development Coordinator (SDC) looking for him on the 100 Hall. The former SW stated she and the former SDC went out the exit door at the end of the 100 Hall, near room 130, and began calling Resident #128's name. The former SW stated they heard Resident #128 respond and they both kept calling his name and followed his voice to get to him. The former SW stated the resident was found lying on his back in a wooded area and the nursing staff (who had already arrived) along with the help of a police officer, assisted Resident #128 to a standing position. Wunderground.com, an affiliate of the Weather Channel, indicated the outside temperature on 11/02/16 was 75 degrees Fahrenheit with a wind speed of 6 mph. Per the former SW, the resident was dressed with pants, shoes and a jacket which he wore all the time regardless of the weather. The former SW stated Resident #128 was taken to the hospital by Emergency Medical Services (EMS). During an interview with Nurse #5 on 08/25/17 at 9:11 a.m., Nurse #5 stated she had been in a resident's room providing care with the door closed on 11/02/16. Nurse #5 stated when she exited the resident's room, she noticed one or two police cars outside behind the facility. Nurse #5 stated she went outside and asked the police officers if everything was okay and stated they told her they had been called because of a missing resident. Nurse #5 stated she and the two police officers walked the back woods line in an attempt to find a way to where she thought she saw someone. Nurse #5 stated she found entry into the woods on the side of the parking lot and by the time she made it to Resident #128's location in the woods other facility staff were already there. Nurse #5 stated Resident #128 had vines wrapped around his feet and one of the police officers had to take out his pocket knife and cut the vines from around his feet. During an interview with the DON on 08/24/17 at 1:25 p.m., the DON stated a Nursing Assistant (NA) came to her office and told her a resident was trying to get out of the building or he may already be out. The DON stated she went to the dining room door that leads to the back of the facility and started out the door. She stated she and the former SW ran for over a good block. The DON stated the resident was cutting across yards. When asked how she thought Resident #128 had gotten out of the locked and alarmed door, she stated she assumed Resident #128, who was a very observant man, must have known if he held the door long enough the lock would release. The DON stated the former Administrator was in her car trying to head him off. The DON stated there was a wooded area about 1 to 1½ blocks away from the facility and stated they could hear him yelling. The DON stated once they got to the wooded area where Resident #128 was, his feet were tangled in some ground vines and he could not get free. The DON stated after the resident was assisted, he walked out of the woods and was taken by EMS to the hospital for evaluation of possible injuries. The DON stated she sent a staff member over to the hospital to remain with the resident. The DON stated when the resident returned to the facility, she placed him on 1:1 the duration of his stay at the facility. When asked, the DON stated there had been no incident report filed related the Resident #128's elopement of 11/02/16. The DON stated there was no investigation of the elopement documented. The DON stated they had placed him on 1:1 and an attempt was made to find Resident #128 placement in a locked or memory care unit at another facility. During an interview with the former Administrator on 08/25/17 at 9:28 a.m., the former Administrator stated on 11/02/16 she had already left the facility for the day when she received a phone call from facility staff who informed her Resident #128 had exited the facility. The former Administrator stated by the time she returned to the facility, the resident had already been found. The former Administrator stated the decision was made to send Resident #128 to the hospital to get checked out as he had some scratches from being tangled in the vines. The former Administrator stated she sent a facility staff member over to the hospital to sit 1:1 with him and once Resident #128 returned to the facility later the evening of 11/02/16, he remained on a 1:1 observation. The former Administrator was interviewed on 08/25/17 at 9:28 a.m. She stated after Resident #128's elopement on 11/02/16, she went back into the facility and staff reported to her the door the resident exited from had not alarmed. The former Administrator stated all front and side doors at the facility had been equipped with the Wander Guard system except for the back doors. She stated the door Resident #128 exited had a button at the top of the door and once someone pressed the button, the door could be opened and it would not alarm. The former Administrator stated only staff knew about this button and the door was used for deliveries. She stated after inspecting the door, it had been determined the automatic closure had been set to have the door close slowly which did not create enough force to have the door latch properly. The former Administrator stated if the door was not latched and someone exited through it, the alarm would not sound. She stated she had the maintenance director adjust the automatic door closure which corrected the problem. A review of an Incident Report written by Nurse #7 on 11/06/16 indicated Resident #128 had exited the facility at 5:30 p.m. The incident report indicated resident on 1:1 observation with aide (NA #2), no falls noted, aide went to bathroom and resident went out side door, alarms went off, on 100 Hall. The incident report was signed by the DON and the former Administrator. During an interview with the DON on 08/24/17 at 1:35 p.m., the DON stated Resident #128 had been assigned NA #2 for his 1:1 observation on 11/06/16. The DON stated the resident exited the facility when NA #2 left Resident #128 unattended to use the bathroom. When asked how Resident #128 exited the facility, the DON stated she thought it was an instance similar to his 11/02/16 elopement when she thought Resident #128 had pushed on the door long enough for it unlock and he then exited the facility. During an interview with NA #2 on 08/24/17 at 2:15 p.m., NA #2 stated she was assigned to work 1:1 with Resident #128 on 11/06/16. NA #2 stated Resident #128 was focused on wanting to leave and did not want to eat supper. NA #2 stated she and Resident #128 sat on a couch in an alcove near the main dining room. NA #2 stated Resident #128 began to doze on and off and stated when he fell asleep she walked across the hall to use the bathroom. NA #2 stated when she was finished and opened the door, Resident #128 was no longer sitting on the couch. NA #2 stated she immediately went into the main dining room and asked if anyone had seen Resident #128. NA #2 stated she left the dining room and walked down the service hall to the 100 Hall in search of Resident #128. NA #2 stated she noticed Nurse #8 bringing Resident #128 back into the building through an exit door to the right of the nurses' station. During an interview with Nurse #8 on 08/24/17 at 3:02 p.m., Nurse #8 stated she could not remember an incident involving Resident #128's elopement on 11/06/16 therefore could neither confirm nor deny Resident #128's elopement. During an interview with the former Administrator on 08/25/17 at 9:28 a.m., the former Administrator stated she had been informed Resident #128 had been observed by staff at all times when he exited the facility on 11/06/16. The former Administrator stated she did not consider the incident an elopement therefore she did not complete an investigation or a P(NAME). During an interview with NA #3 on 08/25/17 at 11:50 a.m., NA #3 stated she had been working on 2nd shift on 11/06/16. NA #3 stated she and Nurse #8 heard the alarm of the exit door by the 100 Hall nurses' station sound. NA #3 stated she and Nurse #8 investigated the alarm and saw Resident #128 standing outside under the awning. NA #3 stated Resident #128 never walked past the awning. NA #3 stated Nurse #8 went outside and assisted Resident #128 back into the building. During an interview with the (current) Administrator on 08/25/17 at 11:44 a.m., the Administrator stated another corporation owned the facility during Resident #128's elopements. The Administrator stated it was his expectation the staff follow the current corporation's policy for the elopement of a resident and all the delineations within the policy. An observation was made on 08/25/17 at 12:10 p.m. of the distance from the exit door near the 100 Hall nurses' station to the end of the awning of the outside. The distance equaled 15 feet. Wunderground.com, an affiliate of the Weather Channel, indicated the outside temperature on 11/06/16 was 61 degrees Fahrenheit and there was no wind. The resident was discharged to another facility on 11/17/16. The Administrator was notified of the Immediate Jeopardy on 08/24/17 at 6:00 p.m.

Based on observation, staff and resident interviews, and record review the facility failed to provide a written grievance decision regarding a resident's complaint about the use of a wander guard for 1 of 1 residents reviewed for wander guard use (Resident #110). Findings included: Review of a Power of Attorney form dated 5/6/16 revealed Resident #110 had a family member appointed to be his Power of Attorney. Resident #110 was admitted to the facility on [DATE]. His active [DIAGNOSES REDACTED]. Review of Resident #110's quarterly Minimum Data Set assessment dated [DATE] revealed the resident was assessed as cognitively intact. Resident #110 was also assessed to exhibit no behaviors of wandering. Review of Resident #110's quarterly Minimum Data Set assessment dated [DATE] revealed the resident was assessed as cognitively intact. Resident #110 was also assessed to exhibit no behaviors of wandering. Review of Resident #110's most recent Minimum Data Set assessment dated [DATE], coded as an annual assessment, revealed the resident was assessed as cognitively intact. Resident #110 was also assessed to exhibit no behaviors of wandering. Review of Resident #110's risk for elopement assessment signed 6/1/17 revealed he was assessed as no risk for elopement. Review of Resident #110's behavior monitoring sheet for 7/25/17 through 8/23/17 revealed the resident had not exhibited any behaviors including wandering. Review of the facility's Grievance Log from September 2016 to August 2017 revealed there were no recorded grievances for Resident #110. During observation on 8/22/17 at 9:00 AM Resident #110 was observed to have a wander guard on his right ankle. During an interview on 8/22/17 at 9:01 AM Resident #110 stated when he first entered the facility he had no real short term memory because of a stroke and tried to leave because he did not understand how much help he needed. He further stated that was over a year ago and he had not attempted to leave since. He stated a wander guard was put on his ankle but he was alert and oriented now and understood why he needed the help. He further stated he had told the facility he was not going to leave the facility and would like to have the wander guard off. Resident #110 stated he asked to have the wander guard taken off months ago and was told to speak with the Director of Nursing and file a complaint with her. He stated the Director of Nursing simply told him no she could not take it off and did not give him a reason. He further stated that he understood why his family member was his legal guardian. Resident #110 further stated that he wanted his family member to continue being his legal guardian and did not want that changed. During an interview on 8/23/17 8:14 AM Nurse Aide #5 stated that Resident #110 had requested to have his wander guard removed and she had told the resident to talk to his nurse. During an interview on 8/23/17 8:22 AM Nurse #5 stated he had behaviors in his past but she had not had any concerns with his behaviors lately. She further stated when he first came to the facility in June he went out with his sister and got a beer and went behind the store to drink and the police had to bring him back. A wander guard was put in place after this and he did pull it off a few times. She stated they had to watch his wander guard to make sure to put a new wander guard on but that he had not tried to get out when the wander guard was off. She further stated he asked about getting his wander guard off every day and she had told the resident it is not up to her and directed him to the Director of Nursing. During an interview on 8/23/2017 at 8:42 AM the Director of Nursing stated they placed a wander guard on Resident #110 in June of 2016 after he left his Power of Attorney during an outing. The Director of Nursing stated that Resident #110 often asked to have his wander guard removed but the facility systematically evaluated residents with wander guards yearly. She further stated she did not evaluate wander guards based on request. The Director of Nursing stated that she did not have an answer for why she did not include him in an evaluation earlier when he requested to have the wander guard removed or when he was assessed as no risk for elopement in May 2017. She stated the facility did not see his verbal complaint as a grievance and she did not do an investigation of his concern. During an interview on 8/24/17 at 8:33 AM Resident #110's Power of Attorney stated she agreed Resident #110 had the right to be informed why the wander guard was still in place and if there was an in depth assessment, she would be perfectly fine with the facility revisiting the use of his wander guard. She further stated she had not been notified of any reevaluation of his wander guard placement since June of 2016.

Based on observations, record review and staff interviews, the facility failed to promote a resident's dignity by allowing the resident, who was totally dependent on staff for feeding assistance, to eat a pureed meal with her fingers for 1 of 1 residents observed (Resident #18). Findings Included: Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #18's significant change Minimum Data Set (MDS), dated [DATE], indicated resident #18 was moderately cognitively impaired. A review of Resident #18's MDS, dated [DATE] revealed Resident #18 required total dependence on staff for eating. The MDS indicated resident had impairment on both side of her upper and lower extremities. A review of Resident #18's Care Plan, last updated 05/17/17, revealed Resident #18 required staff to feed her for all meals. During an observation of Resident #18 on 08/21/17 at 6:15 p.m., Resident #18 was observed to be lying in her bed with the head of the bed elevated at a 45 degree angle and she was leaning to her right. Resident's divided plate containing pureed food items had been placed on her over-bed table which was positioned across the bed. Resident #18 was observed using the fingers of her left hand to scoop and drag the food off of the plate, across a portion of the over-bed table and into her mouth. Resident #18 was observed to have pureed food on her right cheek, right neck and chest area, and on her blouse. During an interview with Nursing Assistant (NA) #1 on 08/24/17 at 4:05 p.m., NA #1 stated she had been assigned to care for Resident #18 on 08/21/17 for the 3:00 p.m. to 11:00 p.m. shift. NA #1 stated she had brought Resident #18's supper tray in to her, set it up and gave her a spoon so she could feed herself. NA #1 stated Resident #18 was an independent diner sometimes and a dependent diner sometimes. When asked for clarification, NA #1 stated on the days Resident #18 went to [MEDICAL TREATMENT], she is too tired to feed herself and on those days she fed her. NA #1 stated on days the resident did not go to [MEDICAL TREATMENT], she could feed herself. When asked if she was aware Resident #18 had used her fingers to feed herself on 08/21/17, NA #1 stated Resident #18 did that often even though she provided a spoon for her to use. When asked if she had noticed the pureed food on Resident #18's body and clothes, NA #1 stated she had noticed it and stated by the time she had returned to the room, Resident #18 had pulled her plate into the bed with her and she had to give the resident a shower and changed her bed linens. When asked how she would know how a resident had been assessed for feeding assistance, she stated there was a care card inside the closet door. During an observation of the Nursing Care Card, dated 05/17/17 located inside Resident #18's closet on 08/24/17 at 4:10 p.m., NA #1 pointed to the part of the card which indicated Resident #18's eating skills. The letter E was circled. When asked what E stood for, NA #1 was unable to provide an answer. Nurse #1 entered the room to offer assistance and informed NA #1 the meaning of E was extensive. NA #1 stated she had not known the resident needed extensive assistance with meals. During an interview with the Director of Nursing (DON) on 08/25/17 at 1:35 p.m., the DON stated it was her expectation the nursing staff treat the residents with dignity and respect by providing the appropriate feeding assistance. During an interview with the Administrator on 08/25/17 at 1:20 p.m., the Administrator stated it was his expectation the staff treat residents with dignity and respect.

Based on observations, record review and staff interviews, the facility failed to provide care in accordance with the plan of care for 1 of 1 resident observed (Resident #128) who required total dependence on staff to be fed. Findings Included: Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #18's significant change Minimum Data Set (MDS), dated [DATE], indicated Resident #18 was moderately cognitively impaired. A review of Resident #18's MDS, dated [DATE], revealed Resident #18 required total dependence on staff for eating. The MDS indicated resident had impairment on both side of her upper and lower extremities. A review of Resident #18's Care Plan, last updated 05/17/17, revealed Resident #18 required staff to feed her for all meals. During an observation of Resident #18 on 08/21/17 at 6:15 p.m., Resident #18 was observed to be lying in her bed with the head of the bed elevated at a 45 degree angle and she was leaning to her right. Resident's divided plate containing pureed food items had been placed on her over-bed table which was positioned across the bed. Resident #18 was observed using the fingers of her left hand to scoop and drag the food off of the plate, across a portion of the over-bed table and into her mouth. Resident #18 was observed to have pureed food on her right cheek, right neck and chest area, and on her blouse. During an interview with Nursing Assistant (NA) #1 on 08/24/17 at 4:05 p.m., NA #1 stated she had been assigned to care for Resident #18 on 08/21/17 for the 3:00 p.m. to 11:00 p.m. shift. NA #1 stated she had brought Resident #18's supper tray in to her, set it up and gave her a spoon so she could feed herself. NA #1 stated Resident #18 was an independent diner sometimes and a dependent diner sometimes. When asked for clarification, NA #1 stated on the days Resident #18 went to [MEDICAL TREATMENT], she was too tired to feed herself and on those days she would feed her. NA #1 stated on days the resident did not go to [MEDICAL TREATMENT], she fed herself. When asked if she was aware Resident #18 had used her fingers to feed herself on 08/21/17, NA #1 stated Resident #18 does that often even though she will provide a spoon for her to use. When asked if she had noticed the pureed food on Resident #18's body and clothes, NA #1 stated she had noticed it and stated by the time she had returned to the room, Resident #18 had pulled her plate into the bed with her and she had to give the resident a shower and change her bed linens. When asked how she would know how a resident had been assessed for feeding assistance, she stated there was a care card inside the closet door. During an observation of the Nursing Care Card, dated 05/17/17, inside Resident #18's closet on 08/24/17 at 4:10 p.m., NA #1 pointed to the part of the card which indicated Resident #18's eating skills. The letter E was circled. When asked what E stood for, NA #1 was unable to provide an answer. Nurse #1 entered the room to offer assistance and informed NA #1 the meaning of E was extensive. NA #1 stated she had not known the resident needed extensive assistance with meals. During an interview with the Director of Nursing (DON) on 08/25/17 at 8:05 a.m., the DON stated it was her expectation nursing staff follow the residents' Care Plans and feed them accordingly. During an interview with the Administrator on 08/25/17 at 1:20 p.m., the Administrator stated it was his expectation residents be fed according to their plan of care.

Based on observation, staff interview, and record review the facility failed to provide nail care for 1 of 4 residents reviewed for Activities of Daily Living care (Resident #66) and failed to provide feeding assistance to 1 of 4 residents reviewed for Activities of Daily Living care (Resident #18). Findings included: 1) Review of Resident #66's most recent Minimum Data Set assessment dated [DATE] revealed he was assessed as severely cognitively impaired and totally dependent on staff for personal hygiene care. He was also assessed as not rejecting care. Review of Resident #66's care plan last updated 7/22/17 revealed he was care planned to be dependent upon staff for all Activities of Daily Living related to worsening dementia with severe cognitive and communication impairment. The goal was for Resident #66 to be kept clean, dry, comfortable, and appropriately dressed and groomed daily with staff assistance. During observation on 8/22/17 at 9:10 AM Resident #66 was observed to have long fingernails. During observation on 8/23/17 at 2:35 PM Resident #66 was observed to still have long fingernails. During an interview on 8/23/17 at 3:18 PM Nurse Aide #6 stated that residents who are totally dependent on staff for personal hygiene are supposed to have their fingernails clipped every other day. She stated that any diabetic residents have to have the podiatrist clip their toenails but the Nurse Aides clip their fingernails. She stated that she had performed nail care on Resident #66 but that she could not remember the last time and that she would look into it. During an interview on 8/23/17 at 3:23 PM the Director of Nursing stated that either the treatment nurse or other staff will clip the fingernails of residents including diabetic residents. She stated it was her expectation that dependent residents have their nails trimmed regularly and that staff would do this as needed. The Director of Nursing observed Resident #66 ' s fingernails during the interview and stated that Resident #66 did have long fingernails and that she would have a nurse clip them immediately. 2. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #18's significant change Minimum Data Set (MDS), dated [DATE], indicated Resident #18 was moderately cognitively impaired. A review of Resident #18's MDS, dated [DATE], revealed Resident #18 required total dependence on staff for eating. The MDS indicated resident had impairment on both side of her upper and lower extremities. A review of Resident #18's Care Plan, last updated 05/17/17, revealed Resident #18 required staff to feed her for all meals. During an observation of Resident #18 on 08/21/17 at 6:15 p.m., Resident #18 was observed to be lying in her bed with the head of the bed elevated at a 45 degree angle and she was leaning to her right. Resident's divided plate containing pureed food items had been placed on her over-bed table which was positioned across the bed. Resident #18 was observed using the fingers of her left hand to scoop and drag the food off of the plate, across a portion of the over-bed table and into her mouth. Resident #18 was observed to have pureed food on her right cheek, right neck and chest area, and on her blouse. During an interview with Nursing Assistant (NA) #1 on 08/24/17 at 4:05 p.m., NA #1 stated she had been assigned to care for Resident #18 on 08/21/17 for the 3:00 p.m. to 11:00 p.m. shift. NA #1 stated she had brought Resident #18's supper tray in to her, set it up and gave her a spoon so she could feed herself. NA #1 stated Resident #18 was an independent diner sometimes and a dependent diner sometimes. When asked for clarification, NA #1 stated on the days Resident #18 went to [MEDICAL TREATMENT], she was too tired to feed herself and on those days she would feed her. NA #1 stated on days the resident did not go to [MEDICAL TREATMENT], she fed herself. When asked if she was aware Resident #18 had used her fingers to feed herself on 08/21/17, NA #1 stated Resident #18 does that often even though she will provide a spoon for her to use. When asked if she had noticed the pureed food on Resident #18's body and clothes, NA #1 stated she had noticed it and stated by the time she had returned to the room, Resident #18 had pulled her plate into the bed with her and she had to give the resident a shower and change her bed linens. When asked how she would know how a resident had been assessed for feeding assistance, she stated there was a care card inside the closet door. During an observation of the Nursing Care Card, dated 05/17/17, inside Resident #18's closet on 08/24/17 at 4:10 p.m., NA #1 pointed to the part of the card which indicated Resident #18's eating skills. The letter E was circled. When asked what E stood for, NA #1 was unable to provide an answer. Nurse #1 entered the room to offer assistance and informed NA #1 the meaning of E was extensive. NA #1 stated she had not known the resident needed extensive assistance with meals. During an interview with the Director of Nursing (DON) on 08/25/17 at 8:05 a.m., the DON stated it was her expectation nursing staff provide feeding assistance to meet the resident's Activities of Daily Living (ADLs) needs. During an interview with the Administrator on 08/25/17 at 1:20 p.m., the Administrator stated it was his expectation staff meet the residents' ADL needs for meal assistance.

Based on observation and staff interviews the facility failed to discard expired medications on 1 of 3 medication carts reviewed and 1 of 2 medication storage rooms reviewed (100 hall skilled medication cart, 100 hall medication storage room). Findings included: 1) During an observation on 8/24/17 at 9:46 AM, two blister packs of 120 Glycopyrrol 1 milligram tablets, which expired on 6/30/17, were in the 100 hall skilled cart stock drawer. During an interview on 8/24/17 at 9:46 AM, Nurse #9 stated the 120 Glycopyrrol 1 milligram tablets had expired on 6/30/17. She stated none of the expired medication had been used to her knowledge. She further stated no expired medications should be on the medication cart. During an interview on 8/24/17 at 10:18 AM the Director of Nursing stated it was her expectation that medication stock be rotated, reviewed, and discarded before the expiration date. She further stated the Glycopyrrol 1 milligram tablets should not have been in the skilled medication cart on the 100 hall. 2) During an observation on 8/24/17 at 9:54 AM an opened bottle of Senna 8.6 milligram tablets with the expiration date of 3/17 was observed in the 100 hall medication room. During an interview on 8/24/17 at 9:55 AM Nurse #1 stated the bottle of Senna 8.6 milligram tablets expired on 3/17. She further stated no expired medications were supposed to be in the medication storage cabinet. Nurse #1 stated that they reviewed the medication room for out of date medications multiple times each month and they must have missed the bottle that expired in March. She stated she did not know if any doses had been given from the bottle since the expiration date. During an interview on 8/24/17 at 10:18 AM the Director of Nursing stated it was her expectation that medication stock be rotated, reviewed, and discarded before the expiration date. She further stated that the bottle of Senna 8.6 milligram tablets should not have been in the medication storage room.

Based on record review and staff interview, the facility failed to implement protective measures to protect 1 of 1 resident (#7) from 1 of 1 resident (#3) from sexually inappropriate behavior. Immediate Jeopardy began on 1/6/15 and was identified on 3/6/15 at 3:30 PM. Immediate Jeopardy was removed on 3/7/15 at 5:15 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete training on abuse for 100% of the staff and to implement the monitoring of its corrective action. The findings included: A document titled "Abuse Prevention Program Guidelines" update 10/14/14 read in part: "Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion." The document also read that the abuse prevention program included protection of residents during investigations by the following measures: 1. If the alleged abuse involved another resident, the accused resident will not be permitted to make visits to other residents ' rooms unattended. 2. If resident to resident abuse is observed, the aggressor will be removed from the situation and a plan of care developed to prevent the recurrence of such incidents. Resident #7 was admitted to the facility on [DATE] from the community with [DIAGNOSES REDACTED]. Review of the most recent Annual MDS dated [DATE] and the most recent Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 was presently moderately cognitively impaired. The MDS revealed the Resident required limited assistance with bed mobility and transfers. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed Resident #3 was moderate cognitively impaired. The MDS revealed the Resident required extensive one person assistance in transfer and limited one person assistance in locomotion on unit. No observations were made of Resident #3 walking. He was impaired on one side in upper and lower extremities. Review of the most recent quarterly MDS dated [DATE] revealed Resident #3 was moderate cognitively impaired. The MDS revealed the Resident required limited one person assistance for transfer, locomotion on unit and walking in room and corridor. He was impaired on one side in upper and lower extremities. The Resident used a wheelchair or walker to ambulate. Review of the first report titled, " Situation, Background, Assessment, Recommendation/Response " (SBAR) dated 1/6/15 revealed Resident #3 was found in Resident #7 room grabbing and trying to tear Resident #7 ' s brief off. Resident #3 was observed fondling her breast and trying to push her on the bed into a lying position. Resident #3 was removed from Resident #7 room and brought back to Resident #3 ' s room. Review of the Director of Nursing (DON) summary report dated 1/8/15 revealed on 1/6/15 at 7:45 AM Nursing Assistant (NA) #1 heard Resident #7 yelling out for help. NA #1 entered the room and Resident #3 was observed with his hands on her breast and pulling at her brief. NA #1 called out help and Nurse #1 entered the room. Nurse #1 immediately removed Resident #3 from the room. Nurse #1 then ensured Resident #7 was safe and went to alert administrative staff. The nursing staff were advised to initiate 1:1 supervision on Resident # 3 but before the staff could initiate one-on-one supervision Resident #3 was observed in Resident #7 room with his hand in Resident #7 genital area as per witness statement by NA #2. NA #2 removed Resident #3 from the room and he remained with a staff member after this time. His room was also changed from across the hall from Resident #7 to a private room by the Nurses station for closer monitoring. During an interview on 3/7/15 at 10:04 AM, the FNP stated her expectations of the facility staff would be to have removed Resident #3 from the area, follow the facility's protocol and provide one on one staff care. During an interview on 3/6/15 at 9:15 AM the DON stated on 1/6/15 around 8:10 AM the night shift (11-7 nurse) met her at the entry to the facility and informed her about the incident with Resident #3 and Resident #7. The DON stated staff reported that Nurse #1 left Resident #3 and went back into Resident #7 ' s room to make sure she was safe with no immediate injuries. The DON stated Nurse #1 was in the process of notifying administrative staff concerning the incident. The DON instructed Nurse #1 to immediately place Resident #3 on one-on-one supervision. Nurse #1 went back down to arrange the one-on-one supervision and was called back to Resident #7 room by NA#2. NA#2 reported that she went into Resident #7 room to check on her and Resident #3 was again at her bedside and his hand was on genital area. He was observed in his wheelchair and was removed out of Resident #7 room. The DON stated that NA#2 remained with Resident #3 until NA #1 relieved her for one-on-one supervision. The DON stated Resident #3 was moved to private room. The DON stated she would expect her staff when there was a resident to resident altercation to have immediately done 1 on 1 with Resident #7. The DON also stated that NA #1 stayed with Resident #7 while Nurse #1 took Resident #3 to his room. NA #1 left Resident #7 to pass out breakfast trays. There was no staff watching Resident #3 after the first incident. The DON stated she would expect her staff in a case like that to have immediately done 1 on 1 with Resident #3. They thought since they were all on the hall they would have enough people to closely supervise until directed to do something. Facility did immediate in-service on the facility's abuse protocol for the nurses at the facility at that time. DON stated that the facility had not done a full plan of correction after the resident to resident abuse on 1/6/15 or have any discussion of the incident in their monthly QA meeting. The administrator was notified of the immediate jeopardy on 3/6/15 at 3:30 PM. Immediate jeopardy was removed on 3/7/15 at 5:15 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: For Resident #7, Resident #3, and All Other current in-house and future residents that may have been/may be affected: *On January 6, 2015 Charge LPN, and Floor LPNS (3) responsible for care of Residents #3 and #7 at time of incident in serviced by Director of Nursing on facility policy Abuse Prevention Program Guideline, to include resident to resident abuse and the removal of the accused resident from the situation, and the keeping of the accused resident from making visits to other residents rooms unattended until the development of a plan of care to prevent reoccurrence. *Floor LPN #1 responding to residents at time of first incident involving Resident #7 and Resident #3 will be counseled by Director of Nursing on March 7, 2015 for failure to implement fully facility policy Abuse Prevention Program Guidelines as related to resident to resident abuse, with additional disciplinary action as deemed appropriate. *In servicing of all facility staff initiated by Director of Nursing/Designee on March 6, 2015 of facility policy Abuse Prevention Program Guideline, to include resident to resident abuse and the removal of the accused resident from the situation, and the keeping of the accused resident from making visits to other residents rooms unattended by providing one on one monitoring by staff of accused resident until the development of a plan of care to prevent reoccurrence. Any facility staff not in serviced by March 7, 2015 will be in serviced via phone or in person by Director of Nursing/Designee at beginning of their next scheduled shift. *All newly employed staff will be educated during Employee Orientation by Staff Development Coordinator/Designee on facility policy Abuse Prevention Program Guideline, to include resident to resident abuse and the removal of the accused resident from the situation, and the keeping of the accused resident from making visits to other residents rooms unattended by providing one on one monitoring by staff of accused resident until the development of a plan of care to prevent reoccurrence. *Area Ombudsman to be contacted by Administrator/Designee on March 7, 2015 for scheduling of Resident Rights/ Resident Abuse Staff in-service with ongoing Resident Rights/Resident Abuse in servicing of staff at least annually thereafter by Director of Nursing/Staff Development Coordinator/Designee. *All alert and oriented interviewable in-house residents interviewed by Director of Nursing/Designee on 3/6/2015 for any potential previously unreported allegations of Resident to Resident Abuse as it may relate to the January 6, 2015 incident. Any reported allegations of abuse from these interviews will be investigated per facility abuse policy. *Audit of all in-house residents Medical Records to be conducted by Director of Nursing/Designee on March 7, 2015 for review of Significant Change Documentation/SBAR Documentation from January 6, 2015 thru March 7, 2015 for indication of reports of resident to resident abuse to ensure implementation of facility policy Abuse Prevention Program Guideline. *Facility Grievance Logs and 24/5 day reports for January 7, 2015 thru March 7, 2015 will be reviewed by Administrator/Designee on March 7, 2015 for indication of reports of resident to resident abuse to ensure implementation of facility policy Abuse Prevention Program Guideline. Immediate Jeopardy was lifted on 3/7/15 at 5:15 PM. On 3/6/15, the facility provided evidence of all staff presently working had been in-serviced on the facility ' s Abuse Prevention Program Guideline policy, to include resident to resident abuse and the removal of the accused resident from the situation, and the keeping of the accused resident from making visits to other residents rooms unattended by providing one on one monitoring by staff of accused resident until the development of a plan of care to prevent reoccurrence. Any facility staff not in-serviced by March 7, 2015 will be in-serviced via phone or in person by the Director of Nursing/Designee at the beginning of their next scheduled shift. Alert and oriented residents were interviewed regarding feeling safe in your living environment and there were no issues identified. Interviews with all staff involved in resident care presently working at the facility on 3/6/15 at revealed they were aware of the Abuse policy that included implementing supervision for a resident identified with inappropriate behaviors.

Based on record review, police report review, resident, Family Nurse Practitioner and staff interviews the facility failed to implement interventions to prevent reoccurrence of sexually inappropriate behavior for one of one resident with sexually inappropriate behaviors (Resident #3) toward one of one resident (Resident #7). Immediate Jeopardy began on 1/6/15 when staff became aware Resident #3 acted sexually inappropriately toward Resident #7. The administrator was notified of the immediate jeopardy on 3/6/15 at 3:30 PM. Immediate jeopardy was removed on 3/7/15 at 5:15 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete training on abuse for 100% of the staff and to implement the monitoring of its corrective action. The findings included: Resident #7 was admitted to the facility on [DATE] from the community with [DIAGNOSES REDACTED]. Resident #7 was in the facility at the time of the survey. Review of the most recent Annual Minimum Data Set ((MDS) dated [DATE] and the most recent Quarterly MDS dated [DATE] revealed Resident #7 was moderately cognitively impaired and required limited assistance with bed mobility and transfers. The Care Area Assessment Summary (CAAS) dated 8/20/14 for Communication revealed the resident could verbally make her needs known and although she could not see, she would turn towards vocalization. The Resident stated she could see light in the room and could see some shapes but was unable to see detail. The Care Area Assessment for Activities of Daily Living (ADL) revealed the Resident required limited assistance with bed mobility and was able to ambulate with her walker with the assistance of one person. The Resident ' s Care Plan most recently updated on 2/11/2015, revealed Resident #7 required supervision and cueing with daily decision making related to her dementia and blindness. She required limited to extensive assistance with her ADLs related to blindness and limited mobility. Resident #3 was admitted to the facility on [DATE] and discharged from facility 1/7/15 with [DIAGNOSES REDACTED]. A review of the Annual MDS dated [DATE] revealed Resident #3 was moderate cognitively impaired. The Resident had no psychosis, moods, delirium or acute change of behavior during the 7 day observation period. He required extensive one person assistance in transfer and limited one person assistance in locomotion on unit. He was impaired on one side in upper and lower extremities. The Care Area Assessment Summary dated 4/28/2014 for cognitive loss/dementia revealed Resident #3 had cognitive deficit and impaired short term memory. He had slurred speech but was able to make himself understood. He answered questions appropriately but required some coaxing to answer detailed questions. The Care Area Assessment for ADL revealed Resident #3 had declined in functional mobility and ability to complete ADL ' s as a result of new CVA. He had left sided weakness. He was able to turn and reposition himself in the bed for the most part and rise from lying to sitting position without assistance. He required one person assistance for sit to stand and transfers to and from his wheelchair. A review of the most recent quarterly MDS dated [DATE] revealed Resident #3 was moderate cognitively impaired. The Resident had no psychosis, moods, delirium or acute change of behavior during the 7 day observation period. He required limited one person assistance for transfer, locomotion on unit and walking in room and corridor. He required extensive assistance with bed mobility. He was impaired on one side in upper and lower extremities. The Resident used a wheelchair or walker for mobility. The Care Plan dated 5/5/14 and last updated 12/17/14 revealed Resident #3 required cueing to enhance daily decision making skills related to his CVA with short term memory loss. Review of the first report titled, " Situation, Background, Assessment, Recommendation/Response " (SBAR) revealed that on 1/6/15 at 7:50 AM Resident #3 was found in Resident #7 room grabbing and trying to tear Resident #7 ' s brief off. Resident #3 was observed fondling Resident #7 ' s breast and trying to push her on the bed into a lying position. Resident #3 was removed from Resident #7 ' s room and brought back to Resident #3 ' s room. Review of the second report titled, " Situation, Background, Assessment, Recommendation/Response " (SBAR) revealed that on 1/6/15 at 8:20 AM Resident #3 was observed in Resident #7 ' s room with his hand on Resident #7 ' s vagina and trying to push her down. Resident #3 was removed from Resident #7 ' s room and was placed on 1 on 1 supervision. A review of Resident #7 ' s Weekly Skin Observation on 1/3/15 on 7 AM to 3 PM shift revealed she had no redness or bruising to her breast or perineal area. A review of Resident #7 ' s Weekly Skin Observation on 1/6/15 at 8:30 AM done by Nurse #1 and Nurse #2 revealed she had redness and a slight abrasion to her pubic area and redness at the bottom of her left breast. Review of Family Nurse Practitioner (FNP) assessment note dated 1/6/15 at 2:14 PM revealed Resident #7 was seen by the FNP for a follow-up of report from staff that she had been found with a male resident ' s hand in her brief and had tried to push her back in bed. The report revealed she had redness under her left breast and in her upper perineum. Upon examination the resident had redness under and on the bottom of her left breast with no bruising. Her Genitourinary area had redness on her upper labia and clitoris/urethral area with no pain on exam. There was no vaginal drainage or broken skin or bleeding. Review of the incident report dated 1/6/15 (no time documented) revealed Nurse #1 documented that Resident # 3 was observed in Resident #7 ' s room with his hands on her vagina after he tore her briefs off of her. The report also stated Resident # 7 was observed yelling for help and trying to stop him. The report revealed no injury to Resident #3. Review of NA #1 ' s Record Statement of Witness she documented that on 1/6/15 (No time on statement) she went down to the Skilled Hall to get Resident #3 for breakfast and heard Resident #7 screaming for help and her room door was observed to be closed. NA #1 opened the door and observed Resident #3 in front of Resident #7 who was sitting up on the side of the bed. NA #1 documented that she observed Resident #3 trying to pull off Resident #7 ' s brief and that Resident #7 was holding onto her brief with her legs tightly closed. NA #1 documented that she immediately called for Nurse #1 ' s assistance. A review of the witness statement by NA #2 dated 1/6/15 at 8:20 AM revealed she was passing out breakfast to the residents on the skilled hall and she heard a female resident (Resident #7) yelling for help. NA #2 first went to check to see if Resident #3 was in his room. He was not and then she immediately went to Resident #7 ' s room. The door was observed to be closed. NA #2 opened the door and observed Resident #3 touching Resident #7. Resident #3 was observed with his hands inside her brief. Resident #7 was observed screaming and trying to push his hand away. Review of the Director of Nursing (DON) summary report dated 1/8/15 revealed on 1/6/15 at 7:45 AM, Nursing Assistant (NA) #1 heard Resident #7 calling for help. NA #1 entered the room and Resident #3 was " observed with his hands on her breast and pulling at her brief. " NA #1 called for help and Nurse #1 entered the room. Nurse #1 immediately removed Resident #3 from the room. Nurse #1 then ensured Resident #7 was " safe and went to alert administrative staff. " The nursing staff were advised (by DON) to initiate 1 on 1 supervision on Resident # 3 but before the staff could initiate 1 on 1 supervision, Resident #3 was observed in Resident #7 ' s room with his hand in Resident #7 ' s genital area as per witness statement by NA #2. The DON summary report stated Resident #3 saw NA #2 entering the room and removed his hand. NA #2 removed Resident #3 from the room and he was supervised by staff continually after the incident. Resident #3 room was changed from across the hall from Resident #7 to a private room on a different hall near the Nurses station for closer monitoring. The report also revealed that the Police Department was notified and an investigation initiated. On 1/6/15 at 8:30 AM Resident #7 received a head to toe assessment from Nurse #1 and Nurse #2. The report stated they noted redness to her pubic area as well as redness to her left breast. The Family Nurse Practitioner (FNP) assessed Resident #7 on 1/6/15 and noted there were no penetrating injuries. The DON stated in her report that Resident #3 was assessed as alert and oriented with periods of confusion. He could recall the incident when questioned by facility staff and reported to Nurse #1 that he was trying to help Resident #7 button her blouse. When law enforcement interviewed Resident #3, he stated he did go into Resident #7 room to talk to her but did not touch Resident #7. Resident #3 ' s wife was notified of the incident and law enforcement was involved. The DON summary stated that the Police Department notified the facility that they had a warrant for Resident #3 ' s arrest (regarding incident on 1/6/15) and picked Resident #3 up and brought him to jail. Resident #3 returned to the facility the evening of 1/6/15 with an unsecured bond and 1 to 1 supervision was reinstated. Resident #3 was issued an immediate discharge notice to maintain safety of other residents. He was picked up by his family to attend his court hearing on 1/7/15 and discharged from the facility with home health services on 1/7/15 in care of his family. Review of the Police Report submitted 1/6/15 at 11:41 AM, revealed a complaint was called into dispatch on 1/6/15 at 8:20 AM, regarding a male subject (Resident #3) who sexually assaulted a female subject (Resident #7) 1/6/15 at 7:30 AM. The last time known that everything was okay was 1/6/15 at 7 AM. Resident #7 had minor injuries. Resident #7 was listed as a victum of second degree sexual offense and sexual battery. The suspect (Resident #3) used personal weapons (hands, feet, teeth etc). The Police Report stated that on 1/6/15 at approximately 9:36 AM, an officer went to the facility in reference to an assault. The Officer interviewed the DON, Resident #3, Resident #7, NA #1, and NA #2. The social progress note on 1/6/15 at 4:45 PM, stated that an immediate discharge notice was given to Resident #3 and family due to the incident on 1/6/15. The social progress note on 1/7/15 at 2:30 PM, stated the wife and son of Resident #3 were given discharge information and all questions and concerns were addressed. During an interview on 3/6/15 at 10:00 AM, NA #1 stated she was a Restorative Aid and on 1/6/15 she was going to assist Resident # 3 in restorative dining. She stated on 1/6/15 between 7:30 to 8:00 AM Resident #3 was observed in his wheelchair at the nurses station. NA#1 further stated when the breakfast food trays came out she went to look for him and he was not in his room. She stated she heard Resident #7 yelling for help. When she entered Resident #7 ' s room she observed Resident #3 sitting in his wheelchair and he was grabbing on Resident #7 ' s brief near her pubic area. Resident #7 was observed sitting up on the side of her bed facing the door. Resident #3 ' s back was observed facing the door while he was sitting in his wheelchair. NA #1 stated she immediately backed out of the room into the doorway and immediately called Nurse #1 in the hallway for assistance. NA #1 stated after Nurse #1 entered the room to handle the situation, she left the room to go assist in the restorative dining on the opposite hall. NA #1 further stated that later that morning, Resident #3 was brought to restorative dining to eat and NA #1 had to sit with him one on one. During an interview on 3/6/15 at 9:15 AM, the DON stated on 1/6/15 around 8:10 AM, the night shift (11-7 nurse) met her at the entry to the facility and informed her about the incident with Resident #3 and Resident #7. The DON stated NA #1 had heard Resident #7 yelling for help at 7:45 AM. NA #1 entered Resident #7 ' s room and observed Resident #3 in her room with his hand on her breast and pulling at her briefs. Resident #7 was observed sitting on the side of her bed. NA #1 called for help for Nurse #1 from the doorway. NA #1 and Nurse #1 entered the room together and Nurse #1 escorted Resident #3 back to his room across the hall. The DON stated staff reported Nurse #1 left Resident #3 in his room and went back into Resident #7 ' s room to make sure she was safe with no immediate injuries. The DON stated Nurse #1 was in the process of notifying administrative staff concerning the incident when the DON entered the facility. The DON instructed Nurse #1 to immediately place Resident #3 on one on one supervision. Nurse #1 went back down to arrange the one on one supervision and was called back to Resident #7 room by NA #2. NA#2 reported that she went into Resident #7 room to check on her and Resident #3 was again at her bedside and his hand was on Resident #7 ' s genital area. He was observed in his wheelchair and was immediately removed from Resident #7 ' s room. The DON stated that NA #2 remained with Resident #3 until NA #1 relieved her for one on one supervision. The DON stated the FNP, Police Department and family members were notified and Resident #3 was transferred to a private room. The DON stated she would expect her staff when there was a resident to resident altercation to have immediately done 1 on 1 with Resident #3. During an interview on 3/6/15 at 10:32 AM, Nurse #1 stated on 1/6/15, she heard NA #1 yelling out for help in Resident #7 ' s room. She went in and saw Resident #3 in his wheelchair wheeling away from Resident #7 ' s bed. NA #1 informed Nurse #1 that Resident #3 had his hands on Resident #7 ' s brief and she had been yelling for help. NA #1further informed Nurse #1 she had heard yelling and had gone into Resident #7 ' s room to see what was happening. Nurse #1 stated she wheeled Resident #3 back into his room across the hall. Nurse #1 stated she transferred Resident #3 back to his bed and instructed Resident #3 to stay in his bed until they could figure out what to do. Nurse #1 stated that Resident #3 agreed to stay in his room. During the interview Nurse #1 stated Resident #3 had been seen getting out of bed and into his wheelchair by himself in the past and could easily do so. Nurse #1 stated she returned to Resident #7 ' s room and observed her breathing hard and panicky. Resident #7 requested Nurse #1 to stay with her. While talking with her, Nurse #1 said Resident #7 revealed she was sitting up and Resident #3 was trying to push her back to a laying position. Resident #3 was grabbing at her brief and fondling her breast. Nurse #1 stated after she had felt Resident #7 was safe she left the room and went to notify the DON and Family Nurse Practicioner (FNP). Nurse #1 further stated that she thought she told someone to stay with Resident #7 but could not recall who. Nurse #1 stated she would have placed one on one care immediately if she had known Resident #3 was going to get up and go back into Resident #7 ' s room again. During an interview on 3/6/15 at 11:51 AM, NA #2 stated that on 1/6/15 between 8:15 to 8:25 AM, she had heard Resident #7 yelling for help. She checked to see if Resident #3 was in his room and he was not. Resident #7 ' s door was closed and NA #2 opened the door and found Resident #3 ' s hands inside of Resident #7 ' s brief and Resident #7 was yelling for help. NA #2 further stated she called for help and stayed in the room. NA #2 asked Resident #3 what he was doing and he removed his hand out of Resident #7 ' s brief. NA#2 stated Nurse #1 came and removed Resident #3 from Resident #7 ' s room. During an interview on 3/7/15 at 10:04 AM, the FNP stated she was called by the facility and informed that a male resident (Resident #3) had put his hands on a female resident ' s (Resident #7) female parts and it had happened twice that she recalled. The FNP stated that she was not trained to do rape exams but did a superficial exam on Resident #7 on 1/6/15. Upon assessment the FNP revealed that Resident #7 had no vaginal drainage or redness at the opening of vagina. She did have redness on her left breast and her labia/clitoris. The FNP further revealed that Resident #7 had told the FNP that Resident #3 had not penetrated her vagina and that she (Resident #7) kept trying to push him (Resident #3) off of her. The FNP stated that her expectations of the facility staff would be to have removed Resident #3 from the area, follow the facility's protocol and provide one on one staff care. On 3/6/15 at 4:30 PM, Resident #7 was interviewed and had no recall of being touched inappropriately or of recent events. The administrator was notified of the immediate jeopardy on 3/6/15 at 3:30 PM. Immediate jeopardy was removed on 3/7/15 at 5:15 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Resident #7 Resident #3 For Resident #7: *On January 6, 2015, at approximately 7:50am Resident #3 was removed from room of Resident #7 by floor CNA ' s and was redirected to his room. * On January 6, 2015, at approximately 8:20 am Resident #3 was removed from room of Resident #7 by floor CNA and Resident #3 was immediately placed on one on one observation by Director of Nursing, and remained on this observation status until discharge on [DATE], not being allowed to visit Resident #7's room or any other resident ' s room. *Resident #3 also had an immediate room change following the 8:20 am incident for relocation into another wing of facility, removed from room area of Resident #7. * Floor LPN for Resident #7 notified Attending Physician/Medical Director of incident on January 6, 2015 at approximately 8:30 am, with examination of resident by Attending Physician immediately following notification, new orders received. Communication by Attending Physician with Responsibility Party regarding visit/examination occurred on January 6, 2015 as documented in visit note. Follow-up visit by Attending Physician on January 8, 2015 with new orders received and implemented, to include Mental Health Consult, with continued follow-up by Attending Physician as needed *Responsible Party was notified of incident by Nursing Home Administrator and Director of Nursing on January 6, 2015 of incident. *24 Hour report submitted to Health Care Personnel Registry by Director of Nursing/Designee on January 6, 2015, with completed 5 Day Investigation Report submission on January 8, 2015 by Director of Nursing/Designee. *Local Law Enforcement notified of incident and responded to facility on January 6, 2015, initiating legal investigation. *Resident #3 was discharged from facility to care of Responsible Party on January 7, 2015. For Resident #3: *On January 6, 2015, at approximately 8:20 am Resident #3 was removed from room of Resident #7 by floor CNA and Resident #3 was immediately placed on one on one observation by Director of Nursing, and remained on this observation status until discharge on [DATE] not being allowed to visit Resident #7's room or any other resident ' s room. *Resident #3 also had an immediate room change following the 8:20 am incident to relocation into another wing of facility, removed from area of Resident #7. *floor LPN notified Attending Physician of incident on January 6, 2015 at approximately 8:30 am. Resident was assessed by Attending Physician following notification. *Responsible Party was notified of incident by Nursing Home Administrator and Director of Nursing on January 6, 2015. *24 Hour report submitted to Health Care Personnel Registry by Director of Nursing/Designee on January 6, 2015, with completed 5 Day Report submission on January 8, 2015 by Director of Nursing/Designee. *Local Law Enforcement notified and responded to facility on January 6, 2015, initiating legal investigation. *Resident #3 was discharged from facility to care of Responsible Party on January 7, 2015. For Resident #7, Resident #3, and All Other current in-house residents that may have been affected: *Resident #3 placed on one-on-one observation until discharge from facility on January 7, 2015. *On January 6, 2015 Charge LPN, and Floor LPNS (3) responsible for care of Residents #1 and #2 at time of incident in serviced by Director of Nursing on facility policy Abuse Prevention Program Guideline, to include resident to resident abuse and the removal of the accused resident from the situation, and the keeping of the accused resident from making visits to other residents rooms unattended until the development of a plan of care to prevent reoccurrence. *24 Hour report submitted to Health Care Personnel Registry by Director of Nursing/Designee on January 6, 2015, with completed 5 Day Report submission on January 8, 2015 by Director of Nursing/Designee. Floor LPN #1 responding to residents at time of first incident involving Resident #7 and Resident #3 will be counseled by Director of Nursing on March 7, 2015 for failure to implement fully facility policy Abuse Prevention Program Guidelines as related to resident to resident abuse, with additional displinary action as deemed appropriate. *All alert and oriented interviewable in-house residents interviewed by Director of Nursing/Designee on 3/6/2015 for any potential previously unreported allegations of Resident to Resident Abuse as it may relate to the January 6, 2015 incident. There were no allegations of Resident to Resident Abuse. *Audit of all in-house residents Medical Records to be conducted by Director of Nursing/Designee on March 7, 2015 for review of Significant Change Documentation/SBAR Documentation from January 6, 2015 thru March 7, 2015 for indication of reports of resident to resident abuse to ensure implementation of facility policy Abuse Prevention Program Guideline. Audit did not identify any indications of reports of resident to resident abuse. *Audit of all in-house residents Medical Records to be conducted by Director of Nursing/Designee on March 7, 2015 for review of Significant Change Documentation/SBAR Documentation from January 6, 2015 thru March 7, 2015 for indication of tendency toward verbal or abusive behaviors by resident. Audit did not identify any indications of these behaviors. *Facility Grievance Logs and 24/5 day reports for January 7, 2015 thru March 7, 2015 will be reviewed by Administrator/Designee on March 7, 2015 for indication of reports of resident to resident abuse to ensure implementation of facility policy Abuse Prevention Program Guideline. No Grievances or 24/5Day reports indicated reporting of resident to resident abuse. *In servicing of all facility staff initiated by Director of Nursing/Designee on March 6, 2015 of facility policy Abuse Prevention Program Guideline, to include resident to resident abuse and the removal of the accused resident from the situation, and the keeping of the accused resident from making visits to other residents rooms unattended by providing one on one monitoring by staff of accused resident until the development of a plan of care to prevent reoccurrence. Any facility staff not in serviced by March 7, 2015 will be in serviced via phone or in person by Director of Nursing/Designee at beginning of their next scheduled shift. *All newly employed staff will be educated during Employee Orientation by Staff Development Coordinator/Designee on facility policy Abuse Prevention Program Guideline, to include resident to resident abuse and the removal of the accused resident from the situation, and the keeping of the accused resident from making visits to other residents rooms unattended by providing one on one monitoring by staff of accused resident until the development of a plan of care to prevent reoccurrence. *Area Ombudsman to be contacted by Administrator/Designee on March 7, 2015 for scheduling of Resident Rights/ Resident Abuse Staff in-service with ongoing Resident Rights/Resident Abuse in servicing of staff at least annually thereafter by Director of Nursing/Staff Development Coordinator/Designee. Immediate Jeopardy was lifted on 3/7/15 at 5:15 PM. On 3/6/15, the facility provided evidence of all staff presently working had been in-serviced on the facility ' s Abuse Prevention Program Guideline policy, to include resident to resident abuse and the removal of the accused resident from the situation, and the keeping of the accused resident from making visits to other residents rooms unattended by providing one on one monitoring by staff of accused resident until the development of a plan of care to prevent reoccurrence. Any facility staff not in-serviced by March 7, 2015 will be in-serviced via phone or in person by the Director of Nursing/Designee at the beginning of their next scheduled shift. Alert and oriented residents were interviewed regarding feeling safe in your living environment and there were no issues identified. Interviews with all staff involved in resident care presently working at the facility on 3/6/15 at revealed they were aware of the Abuse policy that included implementing supervision for a resident identified with inappropriate behaviors.

Based on record review, observation and interview the facility failed to provide full visual privacy when providing direct care for 1 of 3 residents (Resident #47) observed receiving personal care. Findings include: A review of the facility policy for Quality of life - "Perineal Care" dated September 15, 2011 read in part, "5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. 6. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body." Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] and annual MDS dated [DATE] revealed on his brief interview for mental status (BIMS) he scored a 12 meaning he was alert and oriented and was interviewable. Resident #47 required extensive assistance for toilet use and had a catheter for urine elimination due to [MEDICAL CONDITION]. Review of Resident # 47's Care Area Assessment (CAA) summary dated 4/16/12 reveled he required extensive assistance with activities of daily living (ADL). Resident #47 was involved in his personal care and was incontinent of bowel and had a urinary catheter in place for [MEDICAL CONDITION]. He could alert staff of toileting needs, however when staff went into assist him, he would have already had an incontinent episode. A review of the resident care plan dated 4/23/12 revealed he required extensive assistance with ADL care. An intervention was to check Resident #47 every 2 hours to ensure he was comfortable and well positioned and to provide assistance for all toileting needs. On 9/19/12 at 4:08 pm Resident #47 was observed in his room with a strong urine odor. Resident #47 was asked if he was dry and he stated he was. The resident's nursing assistant (NA#1) was observed entering the resident's room. Resident #47 was observed lying on his back and NA#1 was observed pulling up the resident' s gown to his chest and pulling the covers down exposing his genital area down to his legs. NA#1 was observed cleaning the resident's front including his genital area with a wash cloth and then rinsing and drying the resident with a towel. Nursing Assistant #2 was observed knocking on the door and immediately entering the resident's room at 4:19 pm. When he opened the door NA #1 did not cover the resident exposing his genital area down to his legs. Other facility staff were observed walking down the hall while the door was opened. NA #2 was observed helping NA#1 roll the resident on his right side to clean his bottom. NA#1 washed his bottom and rinsed him. NA #1 stated she did not have enough wash cloths and was observed walking out of the resident's room. The door was opened and facility staff were observed walking down the hall. The resident remained uncovered while the door was opened. NA#1 was observed re-entering the resident's room with the resident remaining uncovered. During an interview on 9/19/12 at 4:50 pm NA#1 stated she did leave the resident uncovered when she left the room and when NA #2 entered the room. During an interview on 9/20/12 at 9:05 am, Resident #47 stated, "It was quite embarrassing to be exposed to so many people." During an interview on 9/20/12 9:35am, the Director of Nursing (DON) stated she expected staff to maintain patient privacy. Whenever staff are providing care, a resident should be covered to avoid unnecessary exposure of the resident's body. During an interview on 9/21/12 at 9:30 am, NA#2 stated he knew to provide privacy when entering a room, but there were so many staff coming in and out he did not have time to cover the resident.