Every finding on record at The Oaks-Brevard

Based on record review and staff interviews, the facility failed to obtain consent and inform the resident or Responsible Party in advance of the risks and benefits of psychotropic medications prior to initiation for 6 of 6 residents reviewed for unnecessary medications (Residents #3, #7, #6, #51, #2, and #10). The findings included:1. a. Resident #3 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had severe cognitive impairment. He displayed no behavioral symptoms and received antianxiety medications during the MDS assessment look-back period. Review of the March 2026 Medication Administration Record for Resident #3 revealed an active physician order dated 03/02/26 for lorazepam (antianxiety medication) 0.5 milligrams 1 tablet every 12 hours as needed for anxiety disorder. The order had a stop date of 03/16/26.Review of Resident #3's electronic medical record revealed no documentation that Resident #3's Responsible Party was informed in advance of the risks and benefits of initiating Lorazepam 0.5 mg and consented to the treatment. b. Resident #6 was admitted to the facility on [DATE] with cumulative diagnoses that included major depressive disorder, anxiety disorder, borderline personality disorder, hallucinations, and unspecified psychosis not due to a substance or known physiological condition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition. She displayed no behaviors and received antidepressant and antipsychotic medications during the MDS assessment look-back period. Review of the March 2026 Medication Administration Record for Resident #6 revealed the following active physician orders: -10/20/25 for risperidone (antipsychotic medication) 1 milligram (mg) at bedtime for borderline personality disorder. -10/21/25 for duloxetine (antidepressant medication) 60 mg once a day for major depressive disorder. -10/21/25 for lamotrigine (anticonvulsant and mood stabilizer) 100 mg once a day for vascular dementia, severe with mood disturbance. Review of Resident #6's electronic medical record revealed no documentation that Resident #6 or her Guardian were informed in advance of the risks and benefits of initiating risperidone 1 mg, duloxetine 60 mg or lamotrigine 100 mg and consented to the treatment. c. Resident #7 was admitted to the facility on [DATE] with cumulative diagnoses that included schizophrenia, anxiety disorder, bipolar disorder, and schizoaffective disorder, bipolar type. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment. She had no behavioral symptoms and received antipsychotic and antidepressant medication during the MDS assessment look-back period. Review of the March 2026 Medication Administration Record for Resident #7 revealed the following active physician orders: -10/29/25 for trazodone (antidepressant medication) 100 mg at bedtime for insomnia due to other drug disorder. -10/30/25 for venlafaxine (antidepressant medication) 225 mg once a day for bipolar disorder. -01/22/26 for quetiapine (antipsychotic medication) 50 mg once a day for schizophrenia. -02/13/26 for haloperidol (antipsychotic medication) 2 milligrams (mg) twice a day for schizoaffective disorder, bipolar type. Review of Resident #7's electronic medical record revealed no documentation that Resident #7's Responsible Party was informed in advance of the risks and benefits of initiating haloperidol 2 mg, quetiapine 50 mg, trazodone 100 mg, or venlafaxine 225 mg and consented to the treatment. During interviews on 03/04/26 at 10:13 AM and 03/05/26 at 2:13 PM, the Administrator revealed they were unable to find any psychotropic consent forms for Resident #3's lorazepam 0.5 mg, Resident #6's risperidone 1 mg, duloxetine 60 mg or lamotrigine 100mg, and Resident #7's haloperidol 2 mg, quetiapine 50 mg, trazodone 100 mg, or venlafaxine 225 mg. The Administrator stated either the Social Worker (SW) or MDS Coordinator were responsible for obtaining consents for psychotropic medication use. He was not sure why the consents weren't obtained prior to initiating the medications or where the breakdown occurred. During an interview on 03/04/26 at 11:28 AM, the MDS Coordinator confirmed that either she or the SW were responsible for obtaining psychotropic medication consents. She explained when there was a new psychotropic medication order or when a change was made to an existing psychotropic medication order a consent form was obtained from the Resident or their RP; however, she stated they were not always informed of new orders or medication changes. The MDS Coordinator verified they were not able to find psychotropic medication consent forms for Resident #3, Resident #6, or Resident #7. During an interview on 03/04/26 at 3:24 PM, the SW confirmed that she or the MDS Coordinator were responsible for obtaining psychotropic medication consents. The SW explained the Psychiatric provider exited with her after seeing residents to discuss any changes to the treatment plan, such as new orders or medication changes, and then sent her the progress notes usually within 48 hours. She stated she reviewed the psychiatric progress notes when received and if there was a new psychotropic medication order, she worked on obtaining consent. The SW stated there were times that providers would add or change psychiatric medications and not let her or the MDS Coordinator know. The SW verified they were not able to find psychotropic medication consent forms for Resident #3, Resident #6, or Resident #7 and was not sure where the breakdown occurred. During an interview on 03/05/26 at 12:55 PM, the Assistant Director of Nursing (ADON)/Interim Director of Nursing (DON) revealed she was aware of obtaining consents for antipsychotic medications but not for psychotropic medications. The ADON/Interim DON stated the SW was responsible for reviewing medications and provider notes and implementing appropriate measures to obtain the necessary consent. The ADON/Interim DON explained there had been a lot of changes within positions and obtaining the psychotropic consents just slipped through the cracks. 2. Resident #51 was admitted to the facility on [DATE] with diagnosis that included Alzheimer's disease, major depressive disorder, anxiety disorder, and insomnia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #51 was severely cognitively impaired with wandering for 1 to 3 days. The MDS indicated that she took antipsychotic, antianxiety, antidepressant, and anticonvulsant medications on a routine basis during the 7 day look back period. Review of the March 2026 Medication Administration Record for Resident #51 revealed the following active physician orders:-8/2/25 for mirtazapine (antidepressant medication) 15 milligrams (mg) 1 tablet at bedtime for insomnia. -12/25/25 for fluoxetine (antidepressant medication) 40 mg 1 capsule once a day for Alzheimer's disease and major depressive disorder. -1/13/26 for lamotrigine (anticonvulsant medication used to stabilize mood disorders and treat depression) 100 mg 1 tablet once a day for major depressive disorder.-2/13/26 lorazepam (antianxiety medication) 0.5 milligrams 1 tablet twice a day for anxiety disorder. Review of Resident #51's electronic medical record revealed no documentation that Resident #51's Responsible Party was informed in advance of the risks and benefits of initiating mirtazapine 15 mg, fluoxetine 40 mg, lamotrigine 100 mg, or lorazepam 0.5 mg and consented to the treatment. During an interview on 03/04/26 at 11:28 AM, the MDS Coordinator confirmed that either she or the SW were responsible for obtaining psychotropic medication consents. She explained when there was a new psychotropic medication order or when a change was made to an existing psychotropic medication order a consent form was obtained from the Resident or their RP; however, she stated they were not always informed of new orders or medication changes. The MDS Coordinator verified they were not able to find psychotropic medication consent forms for Resident #51. During an interview on 03/04/26 at 3:24 PM, the SW confirmed that she or the MDS Coordinator were responsible for obtaining psychotropic medication consents. The SW explained the Psychiatric provider exited with her after seeing residents to discuss any changes to the treatment plan, such as new orders or medication changes, and then sent her the progress notes usually within 48 hours. She stated she reviewed the psychiatric progress notes when received and if there was a new psychotropic medication order, she worked on obtaining consent. The SW stated there were times that providers would add or change psychiatric medications and not let her or the MDS Coordinator know. The SW verified they were not able to find psychotropic medication consent forms for Resident #51 and was not sure where the breakdown occurred. During an interview on 03/05/26 at 12:55 PM, the Assistant Director of Nursing (ADON)/Interim Director of Nursing (DON) revealed she was aware of obtaining consents for antipsychotic medications but not for psychotropic medications. The ADON/Interim DON stated the SW was responsible for reviewing medications and provider notes and implementing appropriate measures to obtain the necessary consent. The ADON/Interim DON explained there had been a lot of changes within positions and obtaining the psychotropic consents just slipped through the cracks. During interviews on 03/04/26 at 10:13 AM and 03/05/26 at 2:13 PM, the Administrator revealed they were unable to find any psychotropic consent forms for Resident #51's mirtazapine 15 mg, fluoxetine 40 mg, lamotrigine 100 mg, or lorazepam 0.5 mg. The Administrator stated either the Social Worker (SW) or MDS Coordinator were responsible for obtaining consents for psychotropic medication use. He was not sure why the consents weren't obtained prior to initiating the medications or where the breakdown occurred. 3. Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder and hallucinations. Resident #2's physician orders revealed an order dated 12/13/25 for olanzapine (an antipsychotic medication) 5 milligrams, one (1) tablet daily, for hallucinations. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had severe cognitive impairment and had received antipsychotic medications daily during the MDS look-back period. A Psychiatric Nurse Practitioner progress note dated 02/27/26 indicated Resident #2 was stable on her current medication regimen and that any reduction in the regimen would likely have risked decompensation for Resident #2. In addition, the Nurse Practitioner noted there was no indication for a gradual dose reduction of Resident #2's olanzapine 5 milligrams. Review of the Medication Administration Record (MAR) from 02/17/26 through 03/04/26 indicated an active physician order dated 12/13/25 for olanzapine 5 milligrams, one (1) tablet daily, for hallucinations. Review of Resident #2's electronic medical record revealed no documentation indicating that Resident #2's Responsible Party (RP) was informed in advance of the risks and benefits of receiving olanzapine 5 milligrams and had consented to the treatment. During an interview on 03/05/26 at 12:24 PM, the MDS Coordinator stated she was not able to locate psychotropic medication consent forms for Resident #2. She confirmed she shared responsibility for obtaining psychotropic medication consents with the Social Worker (SW). She explained that when there was a new psychotropic medication order or when a change was made to an existing order, she explained the risks and benefits of the medication with the resident or RP and then obtained a consent form. She stated she was not sure where the breakdown had occurred with Resident #2's consent for olanzapine 5 milligrams. During an interview on 03/05/26 at 12:53 PM, the SW stated she was not able to locate the psychotropic medication consent form for Resident #2. She stated she shared responsibility for obtaining psychotropic medication consents with the MDS Coordinator. The SW stated she was not sure where the breakdown had occurred with Resident #2's consent for olanzapine 5 milligrams. She stated she met with the psychiatric provider to discuss any changes to the treatment plan. In addition, she reviewed the psychiatric progress notes for new psychotropic medications and worked on obtaining consent forms for any new psychotropic medications. During an interview on 03/05/26 at 12:34 PM, the Interim Director of Nursing (DON) stated the SW was responsible for reviewing provider notes for psychotropic medication changes and for obtaining the necessary consents from residents or their RP. The Interim DON explained there had been many position changes and obtaining the psychotropic consents had slipped through the cracks. During an interview with the Administrator on 03/05/26 at 2:13 PM, the Administrator confirmed the MDS Coordinator and the SW shared responsibility for obtaining consents for psychotropic medication use. The Administrator stated they were unable to find the psychotropic consent form for Resident #2's olanzapine 5 milligrams. He stated he expected the consent to be obtained before initiating the medication and was not sure where the breakdown had occurred. 4. Resident #10 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, generalized anxiety disorder, major depressive disorder and cognitive communication deficit. A Psychiatric Nurse Practitioner order dated 09/04/25 specified Resident #10 to be administered olanzapine (antipsychotic medication) 5 milligrams (mg) once daily given at bedtime for unspecified dementia with other behavioral disturbance. A Psychiatric Nurse Practitioner order dated 09/12/25 specified Resident #10 to be administered lamotrigine (anticonvulsant medication) 100 mg once daily for unspecified dementia with other behavioral disturbance. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was severely cognitively impaired. The MDS indicated the resident received antidepressant, antipsychotic and anticonvulsant medication on a routine basis during the 7-day look back period. On 12/23/25 the Psychiatric Nurse Practitioner ordered trazadone (antidepressant medication) 50 mg once daily given at bedtime for unspecified dementia with other behavioral disturbance. The Medication Administration Record (MAR) from 03/01/26 through 03/05/25 indicated Resident #10 was administered olanzapine, lamotrigine and trazadone as ordered by the physician. A Psychiatric Nurse Practitioner progress note dated 02/13/26 indicated that Resident #10 was taking olanzapine 5 mg at bedtime for hallucinations and was stable with no medication changes needed. He was also taking lamotrigine 100 mg daily for anxiety and depression and reported his mood as pretty good. Resident #10 was taking trazodone 50 mg at bedtime for insomnia, and staff reported no sleep concerns. A review of Resident #10's medical record revealed no documentation that Resident #10's representative consented to or was informed in advance of the risks versus benefits of initiating olanzapine, lamotrigine or trazadone. An interview with the MDS Nurse was conducted on 03/04/26 at 11:28 AM. The MDS Nurse stated that when a new psychotropic medication was ordered or changed, corporate policy required the MDS Nurse or the Social Worker to obtain the psychotropic consents. She stated that new medication orders were reviewed during daily clinical meetings. She also stated that the Social Worker was responsible for reviewing the Psychiatric Nurse Practitioner progress notes. An interview with the Social Worker was conducted on 03/04/26 at 3:24 PM. The Social Worker stated that Psychiatric Nurse Practitioners hold an exit meeting with her after seeing residents to discuss any changes or new medications. The Social Worker reported that the Psychiatric Nurse Practitioners send her a copy of the progress notes within 24 to 48 hours. The Social Worker also stated that she and the MDS Nurse were responsible for obtaining consents. An interview with the Director of Nursing (DON) was conducted on 03/05/26 at 12:55 PM. The DON stated that the Social Worker was responsible for reviewing medications and provider notes and implementing appropriate measures to obtain consents. An interview with the Nursing Home Administrator was conducted on 03/05/26 at 2:13 PM. The Nursing Home Administrator stated the Social Worker and the MDS Nurse were responsible for obtaining consents and he was not sure where the breakdown occurred.

Based on observation, record reviews and resident and staff interviews, the facility failed to maintain advance directives in both locations designated by the facility for 1 of 21 residents reviewed for advance directive (Resident #23).The findings included:Resident #23 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact.During an interview on [DATE] at 10:42 AM, Resident #23 stated he was a Do Not Resuscitate (DNR) and had informed the facility upon admission he had a DNR in place. Resident #23 stated that DNR meant staff would not provide Cardiopulmonary Resuscitation (CPR) if needed.A review of Resident #23's physician orders revealed an order for an advanced directive of DNR dated [DATE].A review of Resident #23's Electronic Medical Record (EMR) revealed the advanced directive banner at the top of Resident #23's EMR page documented DNR as his advance directive.Review of the advance directive notebook kept at the nurse's station revealed there was no advance directive on file for Resident #23.On [DATE] at 2:41 PM, an interview was conducted with Nurse #1, who was assigned to Resident #23 on [DATE]. Nurse #1 explained that if she had needed to immediately determine a resident's advanced directives, she would have looked in the advance directives notebook kept at the nurse's station or in the resident's EMR on the computer. Nurse #1 indicated the Interim Director of Nursing (DON) was responsible for ensuring the code forms were in the notebook stored at the nurse's station.An observation and interview were conducted with the Interim DON on [DATE] at 2:55 PM. The Interim DON confirmed she was responsible for ensuring the advanced directives notebook matched the orders in the EMR and for obtaining the provider's signature on the DNR form for residents with DNR orders in the EMR. After review and observation of the advanced directives binder, the Interim DON confirmed Resident #23 had a DNR order in the EMR and his DNR form was not present in the advanced directives notebook. She stated the DNR form should have been in the advanced directives binder, but with all the changes at the facility, it had been missed.An interview was conducted with the Administrator on [DATE] at 2:12 PM. The Administrator stated the code status information in the advanced directives binder and the EMR should have matched. He expected staff to check for code status in the advanced directives binder or in the EMR.

Based on record review and staff interviews, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC, a form used by skilled nursing facilities to inform residents of the last day of Medicare Part A coverage and provides instructions on how to file an expedited appeal) and/or a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, a form used by skilled nursing facilities to inform residents about potential costs and coverage limitations for services that may not be covered by Medicare) prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary notification review (Residents #97 and #6).Findings included:1. Resident #97 was admitted to the facility on [DATE].Review of the Beneficiary Notice worksheet provided by the Administrator on 03/03/26 revealed Resident #97's Medicare Part A coverage for skilled services ended on 10/31/25. Resident #97 discharged home to the community on 10/31/25.Review of Resident #97's medical record revealed no evidence a NOMNC was reviewed with or provided to Resident #97 or her Responsible Party (RP).During an interview on 03/04/26 at 11:28 AM, the Minimum Data Set (MDS) Coordinator revealed she was responsible for issuing NOMNCs and SNF ABNs. She explained therapy staff informed her when a resident's Medicare Part A skilled coverage was scheduled to end and she consulted with the provider to determine whether any additional skilled services, such as wound care, were required. If no further skilled needs were identified, she completed and reviewed the applicable notices with the resident or their RP. The MDS Coordinator stated when Resident #97 discharged home, the Social Worker (SW) and Financial Counselor were covering for her while she was on vacation and the issuance of the NOMNC was overlooked. She confirmed they were unable to locate any documentation showing that a NOMNC was issued to Resident #97. During an interview on 03/05/26 at 2:13 PM, the Administrator revealed the MDS Coordinator was responsible for issuing a NOMNC at least two days in advance of skilled services ending. The Administrator stated he would have expected Resident #97 to have received a NOMNC when her Medicare Part A skilled services ended, per regulatory guidelines.2. Resident #6 was admitted to the facility on [DATE].A Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with and signed by Resident #6 on 11/13/25 which indicated her Medicare Part A coverage for skilled services would end on 11/15/25. Resident #6 remained in the facility.Review of Resident #6's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #6.During an interview on 03/04/26 at 11:28 AM, the Minimum Data Set (MDS) Coordinator revealed she was responsible for issuing NOMNCs and SNF ABNs. She explained therapy staff informed her when a resident's Medicare Part A coverage for skilled services were ending and she spoke with the provider to make sure there wasn't something else the resident could be skilled for that therapy wasn't aware of, such as wounds. If there was nothing else that could be skilled, she then completed and reviewed the applicable notices with the resident or their RP. The MDS Coordinator stated she just forgot to provide a SNF ABN to Resident #6 when the NOMNC was issued.During an interview on 03/05/26 at 2:13 PM, the Administrator revealed the MDS Coordinator was responsible for issuing a NOMNC at least two days in advance of skilled services ending and a SNF ABN if the resident remained in the facility and/or appealed the NOMNC. The Administrator stated he would have expected Resident #6 to have received a SNF ABN when her Medicare Part A skilled services ended, per regulatory guidelines.

Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation after a new serious mental illness disorder was identified for a resident previously determined to have a Level I PASRR status (Resident #71) and failed to develop a care plan that incorporated the PASRR Level II determination recommendations for a resident with an active diagnosis of a serious mental illness (Resident #6) for 2 of 3 residents reviewed for PASRR.The findings included:.1. A PASRR Determination Notification letter dated 03/01/23 revealed Resident #71 had a Level I PASRR with no expiration date that indicated no further PASRR screening is required unless a significant change occurs with the individual's status which suggests a diagnosis of mental illness or if present, suggests a change in treatment needs for those conditions.Resident #71 admitted to the facility on [DATE] with diagnoses that included anxiety disorder.A psychiatric progress note dated 05/22/24 noted in part, Resident #71's daughter reports that [Resident #71} had a past psychiatric history of PTSD related to witnessing her son die at their home. No reports of flashbacks or nightmares. No psychotropic medications are indicated at this time. Will continue to monitor for signs and symptoms of PTSD.A psychiatric progress note dated 11/22/24 revealed Resident #71 had diagnoses of major depressive disorder that was chronic and stable with the plan to continue the current dose of sertraline (antidepressant medication) 50 milligrams (mg) once a day. It was also noted she had a diagnoses of PTSD that was chronic and stable with no reported anxiety or traumatic reoccurrences with the plan to continue monitoring.The annual Minimum Data Set (MDS) assessment dated [DATE] Resident #71 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Her active diagnoses included anxiety disorder, depression (other than bipolar) and PTSD. She received antianxiety and antidepressant medication during the MDS assessment look-back period.A psychiatric progress note dated 12/05/25 revealed Resident #71 had a diagnosis of major depressive disorder that was chronic and stable with the plan to continue the current dose of sertraline 75 mg once a day. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had moderate impairment in cognition. Her active diagnoses included depression and she received antidepressant medication during the MDS assessment look-back period.The facility was unable to provide documentation that a request was submitted for a Level II PASRR evaluation for Resident #71 following the new mental illness diagnoses of major depressive disorder and PTSD.During interviews on 03/04/26 at 3:24 PM and 03/05/26 at 10:37 AM, the Social Worker (SW) revealed she was responsible for submitting requests for Level II PASRR evaluations, however, she was not always notified when a resident was diagnosed with a new mental illness. She explained the psychiatric provider typically sent her the progress notes usually within 48 hours of seeing residents and when she reviewed the progress notes, if she noticed a new mental illness diagnosis, she submitted a request for Level II PASRR evaluation. The SW stated she did not submit a request for a Level II PASRR evaluation following the new diagnoses of major depressive disorder and PTSD for Resident #71 and it was an oversight.During an interview on 03/05/26 at 2:13 PM, the Administrator stated the SW as responsible for submitting requests for Level II PASRR evaluations. The Administrator stated he would expect for the SW to abide by the regulatory guidance and submit requests for Level II PASRR evaluations with any new mental illness diagnosis or change in a resident's condition.2. Resident #6 was admitted to the facility on [DATE]. Her cumulative diagnoses included major depressive disorder, anxiety disorder, borderline personality disorder, hallucinations, and unspecified psychosis not due to a substance or known physiological condition.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had severe cognitive impairment. She displayed delusions, verbal behavioral symptoms directed toward others 4 to 6 days, and other behavioral symptoms not directed toward others 1 to 3 days during the MDS assessment look-back period.A PASRR Determination Notification letter dated 11/03/25 revealed Resident #6 had a Level II PASRR with no expiration date and noted nursing placement was appropriate with specialized services determination of psychological testing and psychiatric evaluation.Review of Resident #6's comprehensive care plan, last reviewed/revised 01/12/26, revealed no care plan that addressed the Level II PASRR specialized services determination.During an interview on 03/04/26 at 3:24 PM, the Social Worker revealed she submitted requests for Level II PASRR evaluations when needed and the MDS Coordinator was responsible for developing the care plan if a resident had a Level II PASRR.During an interview on 03/04/26 at 4:05 PM, the MDS Coordinator confirmed she was responsible for developing resident care plans. She confirmed Resident #6 had a Level II PASRR and a care plan should have been developed. The MDS Coordinator stated it was an oversight.During an interview on 03/05/26 at 2:13 PM, the Administrator revealed it was his expectation that residents with a Level II PASRR determination would have care plans developed per regulatory guidance.

Based on staff interviews, the facility failed to have a qualified professionals to direct the facility's activity program. This practice had the potential to affect all of the residents at the facility. The findings included: On 12/16/24 at 10:35 AM an interview was conducted with the Activity Director (AD). She stated that she had worked at the facility for the past several years as a nursing assistant and then became the Life Enrichment Specialist on the memory care unit around May 2023 and then moved into the AD position for the facility in December 2023 after the previous AD resigned. She stated she had never received any formal activities training from the facility, completed any state training courses, and to her knowledge was not certified. She revealed several months ago she had received an email about some state training for activities and she showed the email to the previous Administrator and was told that she did not need any training and did not have to be certified. The AD stated she had researched on-line activities for residents, reviewed the previous AD calendars and notes to assist her with making activities calendars but had received no real training on what activities should be included for residents, how to adjust her schedule so she could include evening and weekend activities, training other staff to assist her with activities, or how Resident Council minutes should be documented. She revealed the Life Enrichment Specialist who was responsible for activities in the memory care unit was also not certified and had not received any formal activities training except for the training she provided to her. The AD stated she would like to have some formal activities training and to become certified in activities so that she could provide the best activities program for her residents. On 12/17/24 at 11:15 AM an interview was conducted with the Life Enrichment Specialist for the memory care unit. She stated she began her position as the Life Enrichment Specialist for the memory care unit in December 2023 after the previous AD for the facility resigned and the previous Life Enrichment Specialist who had been working the memory care unit was moved into the facility AD position. She revealed prior to taking the Life Enrichment Specialist position she had worked at the facility as a nursing assistant. The Life Enrichment Specialist revealed the only training she received prior to taking the position was from the current AD, which consisted of how to make an activities calendar and which activities the residents preferred. She stated she had researched activities for memory care residents on-line on her own time but had never received any formal activities training from the facility, completed any state training courses, and to her knowledge was never activities certified. The Life Enrichment Specialist revealed she would like to receive formal activities training and to become certified so that she could make sure she was providing the best activities program to her residents. A telephone interview with the former Administrator on 12/17/24 at 1:45 PM revealed she was aware the current facility AD and the Life Enrichment Specialist for the memory care unit were not formally activities trained and had not received their certifications. She stated she believed that maybe they had tried to schedule those trainings, but they got cancelled and maybe they were never re-scheduled. She revealed she just really could not recall exactly what happened or why the AD and the Life Enrichment Specialist had never been formally trained or certified in activities prior to her leaving. On 12/18/24 at 2:31 PM an interview was conducted with the Administrator. The Administrator stated he began his employment at the facility on October 28, 2024, and was just recently made aware that neither the facility AD nor the Life Enrichment Specialist were trained and certified in activities. He stated although he could not speak as to why the former Administrator had not inquired about both the AD and the Life Enrichment Specialist receiving their activities training and certification, he had spoken with their regional office about setting up formal activities training for both the AD and the Life Enrichment Specialist and had also inquired about setting them up on-line for their certifications.

Based on record review, and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns and/or suggestions voiced by residents during Resident Council meetings for 12 of 14 months reviewed (October 2023, November 2023, January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, July 2024, August 2024, October 2024, and November 2024). Findings included: Review of the Resident Council Minutes for the period 10/26/23 through 11/21/24 revealed the following: a. The Resident Council meeting minutes dated 10/26/23 revealed the section for old business noted resident concerns with dietary and showers. There was no indication of the facility's response to these concerns listed under old business. Under New Business there were noted concerns from residents with residents being able to go shopping and staff being loud in hallways. b. The Resident Council meeting minutes dated 11/30/23 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held on 10/26/23 were read, approved, revised and/or resolved. Further review of Resident Council minutes revealed documented resident concerns of them still being upset with dietary related to food, resident being able to go shopping for themselves, not being able to open door to dining room, and resident bed in room needing fixed. c. The minutes from the Resident Council meeting held on 12/28/23 were not available for review due to the president and other members of the resident council being sick and the meeting was cancelled. d. The Resident Council meeting minutes dated January 2024 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held on 11/30/23 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding menus and food, night shift being short staffed, and timeliness of call lights being answered. e. The Resident Council meeting minutes dated February 2024 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held in January 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding menus, dessert portions, and making sure nourishment rooms were being stocked nightly specifically with sandwiches. f. The Resident Council meeting minutes dated March 2024 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held in February 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding menus and food, night shift being short staffed, and timeliness of call lights being answered. g. The Resident Council meeting minutes dated April 2024 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held in March 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding menus and food, night shift being short staffed, and timeliness of call lights being answered. h. The Resident Council meeting minutes dated May 2024 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held in April 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding holiday meals, mold in the shower room and on the shower curtain, and the coffee machine located in the lobby being broken. i. The Resident Council meeting minutes dated June 2024 revealed no indication that the minutes from the Resident Council meeting held in May 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding menus and food portions, and bathrooms not being large enough. j. The Resident Council meeting minutes dated July 2024 revealed no indication that the minutes from the Resident Council meeting held in June 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding menus and condiments, coffee machine located in the lobby needing to be repaired, and more outings for residents. k. The Resident Council meeting minutes dated August 2024 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held in July 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with windows and pictures needing to be cleaned and nursing staff not cleaning off toilets after a resident accident. l. The minutes from the Resident Council meeting held on September 2024 were not available for review due to members of the Resident Council being sick and the meeting was cancelled. m. The Resident Council meeting minutes dated October 2024 revealed no indication that the minutes from the Resident Council meeting held in August 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with doors to resident's rooms not staying open on their own, staff vacuuming halls during resident meals, and more activities scheduled for residents and their families. n. The Resident Council meeting minutes dated November 2024 revealed no indication that the minutes from the Resident Council meeting held in October 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under the section for old business from the previous Resident Council meeting. Further review of the resident council minutes revealed no new business. A Resident Council group interview was conducted on 12/17/24 at 3:30 PM. During the interview, Residents #4, #44, #51, and #56, who attend Resident Council meetings regularly, all stated they felt facility staff did not really address their concerns or suggestions because the only response they typically received from staff, if they received one at all, was it was being looked into but never any satisfactory resolution and some of the issues continued to happen. Resident #4, who was the Resident Council President, added they understood some of the concerns they voiced couldn't be fixed right away but it would be nice to receive some form of communication back as to what was being done. The residents all agreed they would like to know they were being heard and receive feedback from the administration on the efforts that had been made or attempted to resolve their concerns and/or suggestions. Review of facility grievance log from October 2023 through December 2024 revealed no grievances had been received from Resident Council. During an interview on 12/16/24 at 10:35 AM, the Activity Director (AD) confirmed she attended and recorded the minutes for the Resident Council monthly meetings. The AD explained that she had not received any formal training on how to conduct or record minutes from the Resident Council meetings and was not aware that she needed to document during each meeting old business and how any concerns from the previous meetings had been addressed or resolved. She stated she had asked the previous Administrator about completing a grievance form for any Resident Council concerns and the previous Administrator had informed her that when residents voiced any concerns and/or suggestions during the Resident Council meetings, the AD was to inform the Social Worker (SW), or the Director of Nursing (DON) and they would look into them. The AD stated sometimes the residents would let her know during the meetings if an issue or concern had been resolved or was improving, but she never received an actual response back from the SW or the DON as to how the concerns had been resolved. She revealed most of the same concerns were mentioned during the meetings each month and she continued to document those concerns in the Resident Council minutes and inform the SW or DON. The AD revealed moving forward she would prefer to write any concerns or suggestions from Resident Council meetings on a grievance form so she could have some form of a paper trail showing the concerns had been reviewed and were being addressed. During an interview on 12/17/24 at 10:18 AM, the Social Worker (SW) revealed the AD would come to her with concerns from Resident Council and she would usually just pass those concerns to the correct department head. She stated that she would have only completed a grievance form brought to her from Resident Council if it involved a specific resident concern and if she felt like that concern rose to the level of a grievance. She revealed once she informed the department heads of the concerns from Resident Council, she was never made aware of the resolutions, so she was never able to inform the AD of any resolutions to the concerns. The SW stated that moving forward she could see where it would be more beneficial for grievance forms to be completed during Resident Council so a resolution could be addressed and documented. A telephone interview with the former Administrator on 12/17/24 at 1:45 PM revealed she had informed the AD to notify the SW or the DON with any concerns or suggestions brought to her during Resident Council so they could be discussed with the appropriate department heads. She stated the only time a grievance would have been completed during Resident Council meetings was if a specific resident had a concern or grievance. She revealed she was not aware the AD had not been informed of the resolutions regarding the concerns from Resident Council. When asked if she had reviewed any of the minutes from Resident Council over the past year or had discussed with the AD on how to document minutes from resident council, the previous Administrator stated that she was sure she had reviewed some of the Resident Council minutes but could not recall any specific details of the minutes or how they were documented. During an interview on 12/18/24 at 1:31 PM, the Director of Nursing (DON) revealed previously the AD would bring to her or the SW any concerns from the Resident Council. She stated she would address those concerns with the department heads, but there was no written grievance of the concern and no documented resolution. She revealed she could see where it would be more beneficial to have a grievance from completed for any concerns brought up during Resident Council so those concerns could be addressed and the resolutions documented, and they could be addressed with the council during the following meeting. During an interview on 12/18/24 at 2:31 PM, the current Administrator revealed he began his employment at the facility on October 28, 2024. He stated although he could not speak to the exact process of the former Administration, he did not believe they were completing grievance forms regarding grievances from resident council. He revealed his preference would be for the AD to complete grievance forms for any concerns/suggestions brought up during Resident Council meetings. The Administrator also revealed once the grievance forms from Resident Council meetings were completed, they would be given to the SW for them to be distributed out to the responsible departments for their review. He stated he would also be notified of the grievances as he was the facility grievance official and they would also be discussed during morning meeting. The Administrator revealed once the grievances were resolved, those grievances would be distributed back to the AD for review at the following Resident Council meeting. He stated that moving forward with this process would help with making sure any grievances or suggestions from Resident Council were being addressed and the departments responsible were being held accountable.

Based on record review, and resident and staff interviews, the facility failed to ensure evening and weekend group activities were planned for the facility to meet the needs of residents who expressed that it was important to them to attend group activities for 4 of 4 residents reviewed for activities (Resident #4, #44, #51, and #56). The findings included: A review of the December 2024 activity calendar revealed group activities for the facility were only scheduled in the mornings and afternoons during the week, Monday through Friday. There were no activities scheduled for evenings or weekends at the facility except for a 10:30 AM church service every other Sunday. An interview with the Activities Director (AD) on 12/16/24 at 10:35 AM revealed she had been employed as the AD at the facility since December 2023 and typically worked Monday through Friday 8 AM to 5PM. She stated she did not have an activity assistant, so she was responsible for all the activities in the facility and since she only worked dayshift Monday through Friday, it was up to the nursing staff to assist residents with activities in the evenings and weekends. The AD stated she does have activity packets with coloring sheets, word search puzzles, and some other different worksheets available for nursing staff, so they can be set out in the dayroom for residents to do in the evenings and over the weekends. She revealed they also have a church service every other Sunday, for residents who like to attend but other than that they typically have no other scheduled group activities during the evenings or on the weekends. She revealed she has had some residents complain about not having activities on the weekend or being bored on the weekends and she will try and set up an individual activity for them when she can. She stated she knew how important activities were to the residents and agreed they could benefit from having scheduled group activities in the evenings and on the weekends and could understand why residents could feel lonely, sad, or depressed and get bored with just watching television or coloring. The Activities Director revealed she would discuss with the Administrator possibly switching up some of the schedules or times for her to be able to help cover some evening and weekend activities until they could find someone to fill an activities assistant position. a. Resident #4 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) dated [DATE] indicated Resident #4 felt that it was very important to have activities that included inside and outside of the facility and doing things in an independent and group setting. The assessment further indicated Resident #4 was cognitively intact. An interview was conducted with Resident #4 on 12/17/24 at 3:30 PM during resident council meeting revealed there had not been scheduled evening and weekend group activities at the facility for the past year. She stated the facility does offer a church service every other Sunday morning, but nothing else and she would like to have some activities scheduled for the evenings and the weekends, so they had something to do other than watch television in their rooms or the dayroom. Resident #4 also revealed not having evening and weekend activities caused her to feel bored and lonely. She stated to her knowledge they had discussed having scheduled evening and weekend activities during resident council, but nothing had changed. b. Resident #44 was admitted to the facility on [DATE]. A significant change Minimum Data Set (MDS) dated [DATE] indicated Resident #44 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #44 was cognitively intact. An interview was conducted with Resident #44 on 12/17/24 at 3:30 PM during resident council meeting revealed since she had been at the facility they have had no scheduled evening and weekend activities. She stated the facility does offer a church service every other Sunday but usually only residents that can take themselves attend the service. She revealed she felt residents would benefit from having scheduled activities in the evenings and weekends because it would give them something to look forward to and that it can get sad and lonely in the evenings and on weekends especially if you don't have any visitors and nothing to do but watch television. c. Resident #51 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #51 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #51 was cognitively intact. An interview was conducted with Resident #51 on 12/17/24 at 3:30 PM during resident council meeting revealed she enjoyed activities and there had been no activities scheduled for the evenings and weekends since she was admitted to the facility. She stated she often gets bored, lonely, and sometimes a little depressed especially when all she had to do in the evenings and on the weekends was watch television. d. Resident #56 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) dated [DATE] indicated Resident #56 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #56 was cognitively intact. An interview conducted with Resident #56 on 12/17/24 at 3:30 PM during resident council meeting revealed the facility had not offered scheduled evening or weekend activities other than a church service every other Sunday mornings. She stated she enjoyed participating in activities because it gave her reasons to get up out of bed and socialize with other residents and not having them in the evenings and on weekends, the time goes by slowly and she gets lonely, bored, and sometimes depressed. Resident #56 revealed she had not addressed her concerns with the Activities Director but had discussed them with other members of resident council and they also felt residents would benefit from having scheduled activities in the evenings and on the weekends. An interview with Nurse #2 on 12/18/24 at 10:00 AM revealed she had worked at the facility on both 1st and 2nd shift and could not recall ever seeing any scheduled group activities during the evenings or on weekends. She stated some of the residents attend a church service on Sunday mornings but other than that they can watch television in their rooms or in the dayroom, read the paper, color, or do crossword puzzles if they are able. She revealed there are not enough nursing staff on nights and weekends to assist with activities, so residents basically had to find their own activities to do. Nurse #2 stated she felt that residents get bored and depressed when they don't have activities to do and would benefit from activity staff being in the building in the evenings and on the weekends to assist with group scheduled activities. An interview with Nursing Assistant (NA) #3 on 12/18/24 at 10:45 AM revealed she worked at the facility on both 1st and 2nd shift and was not aware of any scheduled activities being offered in the evenings or weekends except for a church service on Sunday mornings. She stated most activities are scheduled during the mornings and afternoons through the week and then after that residents either had to watch television in their rooms or the dayroom or read if they are able. She revealed some of the residents have family that take them out for visits but most of them are stuck in the facility 24 hours a day and would benefit from scheduled activities in the evenings and the weekends, so they have something to pass the time and feel bored and depressed. An interview with the Administrator on 12/18/24 at 2:31 PM revealed the facility has had activity assistants, off and on, who would specifically work evenings and weekends but then they would leave and the last one they had left this past December. He stated they were currently in the process of discussing possibly hiring an activity assistant to work the evening and weekends and in the meantime would be discussing with the Activities Director about possibly changing up her schedule to see if she could cover some evening and weekend shifts and incorporate some other administrative staff to assist as well. He stated he understood scheduling resident activities for evenings and on the weekends was very important and he would try his best to accommodate those needs.

Based on observations, record review, and resident and staff interviews, the facility failed to implement their grievance policies and procedures when Resident #81 reported her dentures were missing for 1 of 3 residents reviewed for grievances. The findings included: Review of the facility grievance policy revised 1/10/2024 defines a grievance as follows: A grievance includes but is not limited to complaints with respect to care and treatment that has been furnished to a patient, as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding the patient ' s facility stay. The grievance policy procedure includes - If the grievance is taken and a response can be started, complete the Action Taken and Findings section of the Grievance/Complaint form: Healthcare centers and give it to the Administrator or designee. -If the grievance is associated with a missing item, refer to the Missing Item Policy and associated forms. The grievance policy also reads The Administrator will be responsible for overseeing the grievance process: The administrator or designee will track the grievance on the Grievance/Complaint Log Form: Healthcare Centers. This will provide a central place for all grievances; The Administrator or designee will then refer the grievance to the appropriate department for investigation if it has not already been referred. The Administrator or designee will record the date of the referral and sig the Grievance/Complaint Log Form: Healthcare Centers. The policy also reads the Administrator, or designee will be responsible for follow-up with the patient, to determine the grievance has been resolved and to ensure the grievance process is understood, The Administrator or designee will complete the Grievance/Complaint Log form: Healthcare Centers indicating whether the problem was resolved and document reactions to the resolution. The policy also reads the Grievance/Complaint should be resolved within 3 business days. Resident #81 was admitted to the facility on [DATE] and was discharged on [DATE]. Resident #81 was admitted to the facility with diagnoses that included after care following joint replacement surgery, fracture of right femur. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #81 was cognitively intact. During an interview on 12/15/2024 at 4:28pm Resident #81 stated her dentures had been missing since the day after she was admitted and wanted to know what would be done about it. Resident #81 stated she had put her dentures in a napkin on her overbed table because she did not have a denture cup. Resident #81 said she had told lots of people they were missing, and staff had looked for them, but Resident #81 wanted to know what would be done since her dentures were still missing. Resident #81 stated no one had followed up with her. Review of Resident #81's progress notes revealed a note dated 12/6/2024 written by the Social Worker that read, Resident informed Director of Nursing (DON) that she took out her dentures and put them in a napkin and is concerned that dentures have been thrown in the trash. Room searched by DON and Activity Director (AD) and unable to locate. Trash was searched and DON and AD went through recent trash in the dumpster and were not able to find dentures. Review of the grievance logs revealed there was no record of a grievance filed on 12/6/2024 or in December 2024 for Resident #81. During an interview on 12/16/2024 at 1:40pm the Social Worker (SW) stated she was aware Resident #81 had dentures missing, that Resident #81 had wrapped them in a napkin and believed they were thrown away. The SW stated the facility investigated missing items and if negligent actions were found the facility will replace the item. If it cannot be decerned what happened to an item then the facility does not have to replace the item. The SW stated the Director of Nursing (DON) and Activities Director (AD) #1 had searched dietary, and the dumpster and Resident #81's bed for the missing dentures and they were not found. The SW stated Resident #81 had been informed the facility was not liable to replace dentures due to not being able to verify how they were lost, but was unsure of the exact day Resident #81 was informed. The SW stated she had talked to her about her dentures. Further review of progress notes revealed there were no other progress notes related to discussing the result of the grievance report with Resident #81. On 12/16/2024 at 1:46pm the SW stated she was completing the grievance report right now because she had forgotten to complete it, when the grievance report for Resident #81's missing dentures was requested. During a follow up interview on 12/17/2024 at 10:07am the SW stated when a resident has lost dentures and they could not be found, it was handled differently based on each situation. The SW stated she would have started the process today (12/17/2024) of trying to get an appointment for Resident #81 with her dentist, but the resident was discharging home today. The SW stated a grievance report is normally followed up on and completed within three days and that a grievance report should be started once they have looked and can't find the missing item. The SW verified the Administrator was the facility grievance official. The SW stated the Administrator #1 was going to contact his boss regarding the policy of replacing dentures. The SW verified there was no documentation that replacement dentures were offered, no documentation of follow up with Resident #81 was documented. Review of a copy of the requested grievance report was received on 12/17/2024, and revealed the grievance report was dated as being received 12/6/2024. SW signature was dated 12/6/2024, Grievance report contained Administrator #1's signature but no date, and the SW signature that she had informed Resident #81 of completed grievance report on 12/9/2024. During an interview on 12/18/2024 at 1:40pm the Director of Nursing (DON) stated Resident #81 said she had lost her dentures. DON looked in the trash and dumpster and could not find Resident #81's upper dentures. The DON stated Resident #81 had a denture cup in her room. The DON stated for long term care residents the facility would start working to get dentures replaced, with short term situations, the DON was unaware of how it would be handled. The DON stated she expected the facility to talk to Resident #81's daughter and find out who the Dentist was and the facility would make an appointment. The DON verified Resident #81 went home with upper dentures missing. The DON stated anyone involved could fill out a grievance report once the facility knew they could not be found. During an interview on 12/18/2024 at 2:35pm the Administrator #1 stated he was aware Resident #81 was missing her upper dentures, and that he had interviewed Resident #81. The result of the interview was that Resident #81 had rolled her dentures up in a napkin because she reportedly did not have a denture cup, but the Administrator stated when talking with Resident #81 regarding her dentures a denture cup was found in Resident #81 ' s room in the bedside drawers. The Administrator stated he discussed with Resident #81 that since they could not verify how the dentures were lost, the facility was not liable to replace them. The Administrator stated he would expect a grievance report to be started immediately, and that social services normally completed the form and it was reviewed by the Administrator. The Administrator stated anyone can start the Grievance report then turn it in to the social worker to determine who needs to follow up. The Administrator verified the grievance for Resident #81 was not on the grievance log for December of 2024. The Administrator was unsure why this grievance report was not on the grievance log for December 2024, he said he had not reviewed or signed it yet. The Administrator reviewed the copy of the grievance and verified it had his signature, but the Administrator was unaware of the date he signed the grievance form for Resident #81, and thought a grievance form had been started immediately. The Administrator verified he was the facility Grievance official.

Based on record review, and staff interviews, the facility failed to implement their abuse policy and procedure in the areas of reporting to administration, completing a thorough investigation and failing to notify adult protective services, when Resident #85 reported that three staff members had held his arms down in bed and would not let him go to the bathroom and yelled at him not to ring the call light. This deficient practice occurred for 1 of 3 residents reviewed for abuse. The findings included: The facility's Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Policy revised 10/27/2020, defined abuse as the willful infliction of injury, unreasonable confinement intimidation or punishment. The facility's Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Policy revised 7/29/2019 read 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of unknown source, exploitation, mistreatment, and misappropriation of property, including injuries of unknown source, should be reported immediately to the Administrator of the provider entity, 2. Adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment including injuries of an unknown source and misappropriation of patient property. The facility's Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Policy reads The Administrator of the provider is responsible for assuring that an accurate and timely investigation is completed the policy further reads Documentation of the investigation should include, but not limited to, the following- Signed statements from pertinent parties also reads interviews should be conducted of all individuals who have relevant information, utilizing open ended questions. Written statements from any involved parties should be obtained. Statements should be gathered from the following individuals: the suspect, the person(s) making accusation(s); the patient involved; reliable patients who may have witnessed the incident and any other persons who may have information. A review of the Initial Allegation Report submitted to the state agency on 3/10/24 indicated the report was marked as an abuse investigation. The report revealed that Resident #85 had stated sometime last night or this am those 3 girls came in here and yelled at me and held my hands down and wouldn't let me go to the bathroom. One of them told me not to ring my call light again. The initial investigation report also indicated Adult Protective Services (APS) was not notified. A review of the investigation report for Resident #85 revealed there was no interview or statement of what was reported included from Resident #85, the report indicated Resident #85 reported staff had yelled at him, held his hands down and told him not to ring his call bell again, there was no statement from NA #3, there was no statement from Nurse #1 or Nurse #2, no statement from the AD #1 or the DON. Further review of the FRI revealed the AD #1 had notified the DON on 3/9/2024 at 11am by telephone, The DON interviewed Resident #85 on 3/9/2024 at 6:30pm. The DON spoke to the Administrator #2 on the phone at 9:30pm on 3/9/2024. Multiple attempts were made to contact Resident #85 for interview but were not successful. During an interview on 12/18/2024 at 1:16pm NA #3 stated she was familiar with Resident #85. NA #3 stated on 3/9/2024 Resident #85 was upset early during the shift (7am-7pm) after breakfast and reported night shift had held him down. NA #3 stated she immediately reported this to Nurse #1, who told her to notify the Activity Director (AD)#1, who was the Manager on Duty. NA# 3 stated she reported to AD #1 what Resident #85 had reported to her and saw the AD #1 go talk to Resident #85. NA #3 stated Resident # 85 had not named a specific staff member but blamed the entire shift. NA #3 stated no one interviewed her regarding what Resident #85 had reported to her, and NA #3 was not asked to give a written statement. NA #3 did not recall seeing any injuries or bruises to Resident #85. During an interview on 12/18/24 at 9:44 AM, the Activity Director (AD) #1 stated she had worked on the morning of 3/9/2024 as the manager on duty. After reviewing the daily staffing sheet from 3/9/2024, the AD #1 remembered it was NA #3 that had reported to the AD #1 on 3/9/2024. The AD #1 did not recall exactly what NA #3 had reported, but it was regarding Resident #85 had said 2 staff members had yelled at him, told him he couldn't go to the bathroom and to go to sleep, he had been up enough. The AD #1 did not recall the exact time NA #3 reported the information to her. The AD #1 stated she called the Director of Nursing (DON) and reported what Resident #85 had reported. The AD #1 stated Resident #85 was not upset when she talked to him, but he wanted to talk to the DON. The AD #1 informed Resident #85 the DON would be in later that day. The AD #1 stated as manager on duty she was not involved with the investigation, but was responsible to notify the supervisor, which is why she called the DON. The AD #1 did not recall being interviewed regarding what Resident #85 had reported to her, The AD #1 stated she did not recall writing a written statement. The AD #1 verified she had not been asked to assess Resident #85 for injuries. The AD #1 stated the DON came in later that day. During an interview with Nurse #1 on 12/18/24 at 12:06pm Nurse #1 stated she only vaguely remembered Resident #85 but had never worked with Resident #85 and had not been assigned to the hall Resident #85 had been on. During an interview on 12/18/24 at 2:02pm the DON stated the AD #1 called and said that Resident #85 was upset with night shift and reported they wouldn't let him go to the bathroom, but it can wait until you come to work tonight. The DON stated she did not go in right away because what was reported to her on the phone by the AD #1 did not require the DON to come in immediately and could wait until the DON was scheduled to come in. The DON remembered that the AD #1 had said Resident #85 had agreed to talk to the DON later that day. The DON stated she thought Resident #85 had been told he couldn't go to the bathroom alone because it wasn't safe. The DON stated if she had thought Resident #85 needed her immediately or had been abused, she would have gone to the facility immediately. The DON stated that after she was at the facility and spoke to Resident #85 she notified the Administrator #2. The DON also stated that throughout the discussion Resident #85's description of what happened changed a couple times. The DON stated she knew the accused NAs were not scheduled to be in again until 3/11/2024 and Administrator #2 thought it was not a reportable incident. The DON stated as the situation evolved the more it became evident it was a reportable incident. The DON stated the accused NAs were eventually suspended, but was not certain of the exact date the suspension was initiated. The DON stated NA# 1 and NA #2 were suspended and NA #4 turned in her resignation. The DON stated NA #1 had no previous allegations of abuse and no allegations since. The DON stated NA #2 had previous allegations regarding her demeanor and approach, but no allegations of abuse. The DON stated NA# 2 had no further allegations regarding demeanor, approach or abuse. The DON stated if there was an allegation she would call the administrator, interview alert and oriented residents. The DON stated she did not complete skin assessments on residents who are not alert and oriented. The DON stated alert and oriented residents were not interviewed until 3/11/2024, but the DON looked at residents and talked to residents, while she worked on 3/9/2024. The DON said typically a skin assessment is completed when a resident reports an allegation of abuse. The DON stated she knew to do that. The DON stated she did not notify APS. During an interview on 12/18/24 at 8:47am the former Administrator (Administrator #2) stated three third shift NAs were interviewed. The Administrator # 2 stated Resident #85 was very hard of hearing, and that Resident #85 stated NAs had held him down when he wanted to go to the bathroom. The Administrator #2 stated the 3 NAs accused were interviewed by the Administrator #2 and the DON, and NA #1 and NA #2 were suspended. The Administrator #2 stated NA #4 would have been suspended but walked out from the interview and quit. The Administrator #2 stated what she recalled from the interview with NA #2 was that NA #2 said she handed him the call bell, laid it on his chest and said to Resident #85, this is our call bell, and said to ring the call bell. The Administrator stated NA #2 denied holding Resident #85's arms down. The Administrator #2 stated she went to Resident #85's room and interviewed him the next day (did not recall the exact date). Resident #85 required help getting in and out of bed but was otherwise independent, and was stand by assist. The Administrator # 2 stated when Resident #85 was interviewed on the following Monday, she thought, Resident #85 could not remember if the alleged incident had happened over the weekend and became manipulative with the Administrator #2. The Administrator #2 further stated, she did not recall the exact dates and times from this alleged incident. The Administrator #2 stated the DON did notify her, but did not remember exactly when, just that the DON went in on a weekend to handle the complaint. The Administrator #2 stated staff was trained if there is a complaint- abuse or not- staff are trained to immediately notify the supervisor, and supervisor will determine how to proceed. The Administrator stated she would not notify APS in this instance, The Administrator stated they would only interview residents able to be interviewed or residents at risk or potential to be at risk. The Administrator #2 stated skin assessments would only be completed if the allegation was substantiated. The Administrator #2 stated normally the DON, or social worker would complete interviews of other residents. The Administrator stated she would normally interview the Nurse on the hall when the incident was reported and alleged to have happened. During an interview on 12/18/24 at 2:31pm the Administrator #1 stated he would expect protocol and policy to be followed regarding an allegation of abuse. Administrator #1 would expect an appropriate investigation to be completed and would expect law enforcement to be notified. The Administrator #1 stated an allegation of abuse required an investigation to be completed by the Administrator or designee.

Based on record reviews and interviews with staff, responsible party, the Consultant pharmacist, and the Medical Director (MD), the facility failed to have effective systems in place for the identification, storage and returning of a controlled medication (opioid) when a resident discharged home and failed to maintain the unused controlled medication for return to the pharmacy for 1 of 2 residents reviewed for pharmacy services (Resident #176). The findings included: Resident #176 was admitted to the facility on [DATE]. Resident #176 was discharged from the facility on 07/03/2024. A review of the physician's order dated 06/19/2024 revealed Resident #176 had an order to receive 1 tablet of Acetaminophen-Codeine (an opioid that acts on the central nervous system to relieve pain) 300-30 milligrams (mg) 4 times a day as needed for severe pain. The 5-day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #176 had moderately impaired cognition. The investigation report dated 07/30/2024 revealed the Assistant Director of Health Services (ADHS) became aware of the missing nacrotics for Resident #176's on 07/30/2024 at 5:00 PM when she was auditing narcotics for the monthly pharmacy review and return. The audit revealed a declining inventory sheet with 13 tablets of Acetaminophen-Codeine remaining. There was no medication card for the 13 tablets of Acetaminophen-Codeine and the 13 tablets of Acetaminophen-Codeine were unaccounted for. The final investigation report dated 08/02/2024 revealed an immediate narcotic count on all medication carts was completed on 07/30/2024 by the ADHS and all narcotics were accounted for. Staff interviews were conducted by the Director of Health Services (DHS) and the ADHS with 4 nurses who had worked on the 500 Hall medication cart for the previous 24 hours. Per the facility investigation report dated 08/02/2024, staff interviews were conducted. Nurse #4 was assigned to the 500 Hall on 07/28/2024 from 7:00 AM to 7:00 PM and stated the narcotic card was in the narcotic box on the 500 Hall medication cart but could not be specific about dates or times. Nurse #5 was in orientation and assigned to work with Nurse #4 on the 500 Hall on 7/28/2024 from 7:00 AM to 7:00 PM. Nurse #5 stated the narcotic card was in the narcotic box on the 500 Hall medication cart but did not remember anything specific including dates or times. Nurse #6 was assigned to the 500 Hall on 07/29/2024 from 7:00 AM to 7:00 PM and stated the card was in the narcotic box in the 500 Hall medication cart. Nurse #7 was assigned to the 500 Hall on 07/28/2024 and 07/29/2024 from 7:00 PM to 7:00 AM and she stated she had not seen the card in the narcotic box for some time now. A review of the declining narcotic sheet for Resident #176 was conducted on 12/17/2024 at 8:15 AM and revealed 17 tablets of Acetaminophen-Codeine had been administered and 13 tablets of Acetaminophen-Codeine remained. The facility was unable to provide the July 2024 controlled substance card count sheet for the 500 Hall medication cart. An interview was conducted with Nurse #6 on 12/17/2024 at 8:45 AM. Nurse #6 stated he remembered there was a missing medication card but did not remember anything specific. An interview was conducted with Nurse #4 on 12/17/2024 at 9:00 AM. Nurse #4 stated that she remembered an issue with a missing medication card of Acetaminophen-Codeine, but she did not remember anything else about the medication or the medication card. An interview was conducted with Nurse #5 on 12/17/2024 at 9:30 AM. Nurse #5 stated she did not remember anything about a missing medication card of Acetaminophen-Codeine . Multiple attempts to contact Nurse #7 were made and were unsuccessful. During an interview with Resident #176's responsible party (RP) on 12/17/2024 at 10:10 AM, the RP stated that the facility had notified him back in the summer that Resident #176's Acetaminophen-Codeine was missing and asked him if the facility sent the medication home with Resident #176. Resident #176's RP further stated that the Acetaminophen-Codeine was not sent home with Resident #176, but he did get a prescription for the Acetaminophen-Codeine when Resident #176 was discharged from the facility in July 2024. An interview was conducted with the ADHS on 12/17/2024 at 11:00 AM. The ADHS stated on 07/30/2024 when she was reconciling the discontinued medications with the declining inventory sheets, she had a declining inclining inventory sheet which showed 13 tablets of Acetaminophen-Codeine remaining, but she could not locate the medication card for the Acetaminophen-Codeine. The ADHS further explained that she checked all of the medication carts and called Resident #176's family to make sure the medication was not sent home with Resident #176. The ADHS revealed that she notified the DHS and the Administrator that there was a problem with the narcotic count. An interview was conducted with the DHS on 12/18/2024 at 8:00 AM. The DHS stated she collected all of the discontinued medications including narcotics and the declining inventory sheets from all of the medication carts on 07/28/2024 and placed them in the tall, locked cabinet in the [NAME] Medication Room. The DHS further explained that the ADHS was reconciling the medications with the declining inventory sheets and found the discrepancy with Resident #176's Acetaminophen-Codeine on 07/30/2024. The DHS also stated that the ADHS telephoned and informed her of the discrepancy and that she had checked all of the medication carts in the facility and all narcotics were accounted for. The DHS stated she arrived at the facility shortly after 5:00 PM and checked all of the medication carts and checked the medication storage rooms and was unable to locate the medication card containing 13 tablets of Acetaminophen-Codeine.The DHS explained that the facility did not send narcotics home with discharged residents and the pharmacy came to the facility on ce a month and collected all of the discontinued medications including narcotics. Prior to the monthly pharmacy visit, the ADHS and she would go through all of the medication carts and collect all of the discontinued medications and put them in the tall, locked cabinet in the [NAME] Medication Room and then the ADHS and she would reconcile the declining inventory sheets with the actual number of pills in the medication cards. The DHS further explained that this process was completed twice a month. The DHS also stated the pharmacist reviewed the reconciliation sheets with the actual medication cards during the monthly visit and the pharmacist would return the medications to the pharmacy. The DHS also stated that she and the ADHS were the only staff who had keys to access the tall, locked medication cabinet in the [NAME] Medication Storage Room. The DHS further explained that she believed when she collected all of the discontinued medications on 07/28/2024, she accidentally dropped the card containing the 13 tablets of Acetaminophen-Codeine in the trash can. The DHS explained that her arms were very full as she had collected medications from all 4 medication carts and in hindsight she should have collected all the medications and the declining inventory sheets from one medication cart and secured those in the tall, locked cabinet in the [NAME] Medication Storage room and then moved on to the next cart. She also stated that the facility had revised their medication process following this incident, and the medication(s) were now removed from the medication cart immediately and placed in the locked cabinet until the pharmacist picked them up. An interview was conducted with the Medical Director (MD) on 12/17/2024 at 2:30 PM. The MD stated that he was aware of Resident #176's missing Acetaminophen-Codeine. The MD also stated that he was involved in the facility's discussion of the incident. He also reported that he had received no further reports of missing narcotics. An interview was conducted with the Consultant Pharmacist on 12/18/2024 at 9:19 AM. The pharmacist stated that she was aware of the missing Acetaminophen-Codeine back in July and that she was involved in assisting the facility with a performance improvement plan to ensure safety of all controlled substances. She also stated that the 13 tablets of Acetaminophen-Codeine were never recovered, and it was her understanding that the DHS had lost them when she had collected the discontinued medications for pharmacy pick-up. An interview was conducted with the previous Administrator on 12/18/2024 at 10:19 AM. The previous Administrator stated that she recalled the incident and stated that the ADHS had reported to her that during her return medication rounds the declining inventory sheet for Resident #176's Acetaminophen-Codeine was present, but the medication card was not. The previous Administrator further stated that the facility was unable to locate the missing pills after searching all the medication carts and the medication storage areas. The previous Administrator revealed that the DHS reported to her that the last time she completed the return medication rounds, she had a lot of return medications, and her hands were full, and the DHS believed she accidentally dropped the medication card in the trash when she was placing them in the locked cabinet in the medication room. The previous Administrator further explained that a process change was made following the incident. An interview was conducted with the current Administrator on 12/18/2024 at 1:04 PM. The current Administrator revealed that he had only been with the facility for a few months but there had been no issues or concerns with narcotic counts or missing medications since he had started working there in October 2024. The current Administrator also stated that he had reviewed the information regarding the missing Acetaminophen-Codeine and further explained that the DHS had informed him that her hands were overflowing with medication cards and inventory sheets, and she believed the medication card was accidentally dropped in the trash. The facility provided the following corrective action plan with a completion date of 08/07/2024. Address how corrective actions will be accomplished for those residents to have been affected by the deficient practices: Resident #176 was discharged from the facility on 07/03/2024. There was no harm or negative impact to Resident #176. How will the facility identify other residents having the potential to be affected by the same deficient practice: All residents prescribed controlled medications have the potential to be affected by the deficient practice. On 07/30/2024 while auditing narcotics for monthly pharmacy review a discrepancy was noted by the Assistant Director of Health Services (ADHS). A descending narcotic sheet of Acetaminophen-Codeine 300-30 mg with a remaining 13 tablets was noted without the actual medication blister pack. The ADHS and Clinical Competency Coordinator immediately performed a narcotic count of all narcotics on each cart to ensure the descending inventory narcotic sheet had been reconciled and matched on 07/30/2024. No further discrepancies were noted. Interviews were conducted with all nurses that worked the 500 Hall within the 24-hour period prior to the medication being noted as missing. On 07/30/2024, a 24-hour report was sent to the North Carolina Department of Health and Human Services, a report was filed with local law enforcement (Report #2024-039-095). What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur: Re-education for all nurses on procedure for controlled substance reconciliation from shift to shift, storage, records, administration, acknowledgement/accounting for and what to do in the event of discrepancy was performed by the ADHS. The Director of Health Services (DHS) and ADHS will collect discontinued narcotics and reconcile narcotics daily and place them in the locked return narcotic box. The DHS and ADHS are the only designees to maintain access to the narcotic locked cabinet. Narcotics for short term rehabilitation residents will be released with the resident and or their RP with signed paperwork. Audits will be performed to ensure that narcotic sheets and descending narcotic sheets are accounted for and match. How will the facility monitor its corrective actions to ensure the deficient practice will not recur: The DHS and ADHS will audit each cart to ensure narcotic inventory sheet and blister pack and signatures match X 4 weeks, then X 2 months: begin date: 07/30/2024 and end date: 10/30/2024. Audit results will be presented at the facility's Quality Assurance Performance Improvement (QAPI) meeting by the DHS and ADHS and reviewed X 2 months. An Ad Hoc QAPI was held 08/05/2024. Any issues and trends identified will be addressed in QAPI by attendees as they arise, and the plan will be revised to ensure compliance. The Administrator and DHS will oversee this process until sufficient practice is maintained. Date of Compliance: 08/07/2024 The facility's corrective action plan with a correction date of 08/07/2024 was validated onsite by observations and interviews with the Administrator, DHS, and nursing staff. An observation was conducted during a shift transition for a medication cart between 2 nurses on 12/18/2024. Nurses started with counting the total number of blister cards that contained controlled medications stored in the double-locked compartment in the medication cart and verified the balance in the narcotic count log. The nurses then counted the total number of declining narcotic sheets and verified the balance in the narcotic count log. The nurses then proceeded to count each blister card of controlled medication to ensure the quantity listing in the declining narcotic count sheets were consistent with the actual pill count. After all counts were completed and without any discrepancies, the on-coming shift nurse and the off-going shift nurse signed the narcotic count logs, and the off-going shift nurse passed the medication cart key to the on-coming shift nurse. A Medication Administration observation which consisted of 26 medications, 6 different residents and 2 different nurses was conducted on 12/16/2024 and 12/17/2024. All the medications were administered as ordered without any issues. Controlled medication was retrieved from the double-locked compartment in the medication cart during the observation. The nurse documented the removal of the controlled medication on the declining narcotic count sheet. Random samples of 3 controlled medications were pulled from each medication cart for verification of accuracy. The controlled substance counts were consistent with the records documented in the declining narcotic count sheets. Interviews with the nursing staff including Licensed Practical Nurses (LPN), and Registered Nurses (RN) confirmed they had received education related to Misappropriation of Personal Property and Narcotic Process Policy. It included the process for shift-to-shift controlled medication count, narcotic storage, narcotic records, and what to do in the event of a narcotic discrepancy. The nurses were able to describe the policy and procedures and verbalized understanding of the education. Review of audit records revealed all residents receiving controlled medications were audited by the DHS and ADHS weekly for 4 weeks beginning on 07/30/2024. Then monthly for 8 weeks to ensure the narcotic count was correct on each cart, shift-to-shift count was completed appropriately, and discontinued controlled medications were removed from the medication carts and returned to the pharmacy. The finding were reported by the DHS to the QAPI committee monthly for 2 months for suggestions and/or recommendations; the quality improvement monitoring schedule will be modified based on finding of the monitoring. Interview with the Administrator and the DHS revealed the facility launched an in-service related to controlled medication process and accountability immediately after the incident to re-educate all the licensed nurses. The DHS and ADHS audited the medication carts randomly to ensure all controlled medication counts were conducted appropriately and the declining narcotic count sheets were documented properly. The Administrator and the DHS stated the interventions were successful as the facility did not have any similar issues with narcotics since then. The compliance date of 08/07/2024 was validated.

Based on observations, record review, and staff and Consultant Pharmacist interviews, the facility failed to follow the pharmacy recommendations for storing narcotics in a locked and permanently affixed compartment for 1 of 2 medication rooms reviewed for medication storage (West Hall Medication Storage Room). Findings included: Review of the Consultant Pharmacy report dated 11/26/2024 revealed Controls in refrigerator under double lock and key; in process of getting in secured lock box that is not removable from the fridge. An observation of the [NAME] Hall medication storage room was conducted on 12/17/2024 at 8:31 AM with the Assistant Director of Nursing (ADON). The narcotic lock box was inside a locked refrigerator. The narcotic lock box was not permanently affixed to the refrigerator and was removable. The narcotic lock box contained four unopened vials of Lorazepam (scheduled IV antianxiety medication). An interview was conducted with the ADON on 12/17/2024 at 8:40 AM. The ADON revealed she thought since the medication storage room was locked and the refrigerator was also locked and the medications were appropriately secured. An interview was conducted with the Consultant Pharmacist on 12/17/2024 at 9:19 AM. The Consultant Pharmacist stated the narcotic box should be permanently affixed to the refrigerator. The Consultant Pharmacist further stated that removeable narcotic box had been identified as an issue and was included in the November 2024 pharmacy report. An interview was conducted with the Director of Nursing (DON) on 12/18/2024 at 8:03 AM. The DON stated that the narcotic box in the [NAME] Hall Medication Storage Room refrigerator had not been permanently affixed to the refrigerator since she was hired in April of 2021. The DON further revealed that she was aware the narcotic box should be secured and affixed to the refrigerator. An interview was conducted with the Administrator on 12/18/2024 at 8:30 AM. The Administrator stated he was aware of the narcotic box not being permanently affixed to the refrigerator. He further stated that the facility had been discussing how to affix the narcotic box to the refrigerator but had not come up with a resolution.

Based on record review, and Medical Director, Nurse Practitioner, Consulting Pharmacist, resident and staff interviews, the facility failed to prevent a significant medication error when they failed to enter an admission order for an as needed (PRN) migraine nasal spray, that was to be continued from the hospital discharge summary when Resident #81 admitted to the facility. As a result, Resident #81 did not have the PRN migraine nasal spray during her entire stay at the facility. This affected 1 of 3 residents reviewed for medication errors. (Resident #81) The findings included: Review of Resident #81's discharge orders from the hospital dated 12/5/2024 revealed under the section: CONTINUE these medications which have NOT CHANGED, was an order that read butorphanol (Stadol) 10mg/ml nasal spray. Administer 1 spray into one nostril if migraine present. May repeat in one hour if pain relief is not adequate. Resident #81 was admitted to the facility on [DATE] and was discharged on [DATE]. Resident #81 was admitted to the facility with diagnoses that included aftercare following joint replacement surgery, unspecified fracture of right femur. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #81 was cognitively intact. Further record review revealed there was no physician order for Stadol in Resident #81's physicians orders. A Nurse Practitioner Progress note dated 12/5/2024 revealed in part that Resident #81 had a history of migraines and read She (Resident #81) has a Stadol nasal spray as needed. During an interview on 12/15/2024 at 4:28pm Resident #81 stated she had not had her migraine nasal spray since she had been admitted . Resident #81 stated when she has a migraine she becomes sick and nauseated and she would like to have her migraine medicine. Resident #81 stated she had told multiple Nursing Assistants (NA) and Nurses that she needed her medicine for migraines but no one had gotten it for her. Resident #81 also stated she talked to the doctor about having medication for migraine while at the facility. Review of Resident #81's progress notes revealed a note written by Nurse #3 dated 12/15/2024 written at 9:58pm that read in part Resident still upset about the Stadol not under her medication list. During an interview on 12/16/2024 at 12:43pm the Nurse Practitioner (NP) stated she was familiar with Resident #81. The NP stated when a resident was admitted she would go over the medications listed on the discharge summary, if the NP was not at the facility, a nurse would call her and read the medications from the discharge summary and the NP would tell the nurse what meds to continue and a verbal order would be written. The NP stated that she remembered the Assistant Director of Nursing (ADON) had called her for medication reconciliation for Resident #81, and the NP had not ordered to stop any of those medications. The NP was unsure why Stadol was not on Resident #81's MAR and said it was supposed to be continued when Resident #81 was admitted . The NP said maybe the med was not available at their pharmacy or had not been sent from pharmacy. The NP would expect the nurse to call the Pharmacy or the NP if medication was not received from the pharmacy or not available. The NP verified she had no communication from the Pharmacy regarding Stadol not being available. The NP stated oral pain medication had been increased for Resident #81 when NP had seen the resident, but later clarified it was for hip pain. During an interview on 12/16/2024 at 2:29pm the Assistant Director of Nursing (ADON) stated when a resident is admitted she will call the doctor or NP and go over the medications on the discharge summary verbally then the ADON enters the medications into the computer system and then another nurse checks them after the ADON, normally another administrative nurse. The ADON stated it had been brought to her attention that Resident #81 did not have Stadol on her MAR, and she was not sure how that happened. The ADON stated there were a lot of admissions on 12/5/2024 then the ADON stated I think I had trouble entering that order into the computer system and I forgot to go back, probably got interrupted. The ADON verified the order for Stadol had not been entered into the computer system as it should have been. The ADON was unsure which nurse had double checked the admission orders for Resident #81. During an interview on 12/16/2024 at 2:43pm Nurse #3 stated Resident #81 had complained about headaches. Nurse #3 stated last week the doctor was notified and took care of it by increasing the oral pain medication. During an interview on 12/17/2024 at 9:19am the Consulting Pharmacist verified the facility policy for new admissions is a double check system by the nurses to verify medications are entered into the computer system correctly, and that document would be scanned into the residents electronic medical record and saved as the verified discharge summary. Further review of Resident #81's electronic medical record revealed it did not contain a verified discharge summary for Resident #81. During an interview on 12/17/2024 at 2:27pm the Medical Director stated he was familiar with Resident #81 and had seen her on 12/10/2024 and there was no complaint of headaches or migraines at that time. The Medical Director was not aware Stadol was supposed to be continued for Resident #81. The Medical Director stated he had seen it on the discharge summary but thought there had been a concern about it interacting with other medications. The Medical Director was not aware the ADON had omitted entering the Stadol order into the computer system and that the NP had intended for it to be continued. The Medical Director stated that for medication reconciliation the admission orders were to be called to the NP or medical director if they were not in the building, the nurse calling would initial medications to be continued, enter them into the computer system, then the nurse who double checks would verify and initial as the second check, then that initialed discharge summary would be scanned into the resident's record as the verified discharge summary, then it could be reviewed by the NP or Medical Director. The Medical Director reviewed Resident #81's electronic medical record and verified there was not a verified discharge summary in Resident #81's electronic medical record. The Medical Director stated the medication reconciliation for Resident #81 did not appear to have been completed correctly and he would address it at the next quality meeting. During an interview on 12/18/2024 at 1:40pm the Director of Nursing (DON) stated she had not heard complaints of headaches from Resident #81, just general pain. The DON verified the ADON completed entering the admission orders and that they were checked by another administrative nurse, then the verified discharge summary was scanned into the electronic medical record. The DON was not aware Resident #81's electronic medical record did not contain a verified discharge summary or that Resident #81 had not had her PRN migraine medication while residing in the facility. The DON expected admission orders to be completed with a double check and the verified discharge summary to be scanned into the resident's record. During an interview on 12/18/2024 at 2:33pm the Administrator stated he was not well versed in the admission process but would expect if a resident has a discharge summary with a medication list and the provider orders to continue the medication, the Administrator expected the ordered medications to continue.

Based on observations, record review, and staff interviews the facility failed to store narcotics in a locked permanently affixed compartment for 1 of 2 medication rooms reviewed for medication storage (West Hall Medication Storage Room). Findings included: An observation of the [NAME] Hall medication storage room was conducted on 12/17/2024 at 8:31 AM with the Assistant Director of Nursing (ADON). The narcotic lock box was inside a locked refrigerator. The narcotic lock box was not permanently affixed to the refrigerator and was removable. The narcotic lock box contained four unopened vials of Lorazepam (scheduled IV antianxiety medication). An interview was conducted with the ADON on 12/17/2024 at 8:40 AM. The ADON revealed she thought since the medication storage room was locked and the refrigerator was also locked and the medications were appropriately secured. An interview was conducted with the Consultant Pharmacist on 12/17/2024 at 9:19 AM. The Consultant Pharmacist stated the narcotic box should be permanently affixed to the refrigerator. The Consultant Pharmacist further stated that removeable narcotic box had been identified as an issue and was included in the November 2024 pharmacy report. Review of the Consultant Pharmacy reported dated 11/26/2024 revealed Controls in refrigerator under double lock and key; in process of getting in secured lock box that is not removable from the fridge. An interview was conducted with the Director of Nursing (DON) on 12/18/2024 at 8:03 AM. The DON stated that the narcotic box in the [NAME] Hall Medication Storage Room refrigerator had not been permanently affixed to the refrigerator since she was hired in April of 2021. The DON further revealed that she was aware the narcotic box should be secured and affixed to the refrigerator. An interview was conducted with the Administrator on 12/18/2024 at 8:30 AM. The Administrator stated he was aware of the narcotic box not being permanently affixed to the refrigerator. He further stated that the facility had been discussing how to affix the narcotic box to the refrigerator but had not come up with a resolution.

Based on observations and staff interviews the facility failed to maintain doors in good repair (rooms 408, 405, 502, 506, 507, 609, 610, both doors of the main dining room, and both doors of the television room), maintain clean and sanitary floors (rooms 402, 405, 408), ensure a bathroom was free of lingering odors (bathroom in room [ROOM NUMBER]), maintain clean and sanitary hallway floors (400 hall and 600 hall), label and properly store personal care equipment in shared bathrooms (rooms 401, 402, 405, and 506), maintain clean and sanitary privacy curtains (rooms 407, 408, 501-A, and 610), maintain a bedside commode in good repair (bedside commode in the bathroom of room [ROOM NUMBER]), and maintain walls and baseboards in good repair (rooms [ROOM NUMBERS]) for 1 of 2 units (West Wing) on 3 of 3 halls (400 hall, 500 hall, 600 hall) reviewed for safe, clean, and homelike environment. Findings included: 1.a. An observation of the inside of the bathroom door of room [ROOM NUMBER] on 08/13/23 at 3:10 PM revealed a linear area roughly 2 inches long at approximately wheelchair armrest height of wood peeled away from the door exposing a rough, unfinished layer of wood. Additional observations of the inside of the bathroom door of room [ROOM NUMBER] on 08/14/23 at 4:54 PM, 08/15/23 at 8:47 AM, and 08/16/23 at 8:36 AM revealed a linear area roughly 2 inches long at approximately wheelchair height of wood peeled away from the door exposing a rough, unfinished layer of wood. An observation of the inside of the bathroom door of room [ROOM NUMBER] on 08/17/23 at 9:50 AM revealed an area approximately wheelchair height of wood peeled away from the door exposing a rough, unfinished layer of wood with an approximately one-inch splinter hanging off the door. b. An observation of the inside of the room entrance door of room [ROOM NUMBER] on 08/13/23 at 11:04 AM revealed a linear area at approximately wheelchair armrest height of wood peeled away from the door exposing a rough, unfinished layer of wood. Additional observations of the inside of the room entrance door of room [ROOM NUMBER] on 08/14/23 at 9:38 AM, 08/15/23 at 8:34 AM, 08/16/23 at 8:04 AM and 08/17/23 at 9:39 AM revealed a linear area at approximately wheelchair armrest height of wood peeled away from the door exposing a rough, unfinished layer of wood. c. An observation of the inside of the bathroom door of room [ROOM NUMBER] on 08/13/23 at 11:25 AM revealed multiple areas of wood peeled away from the door exposing a rough, unfinished layer of wood to the lower one third of the door. Additional observations of the inside of the bathroom door of room [ROOM NUMBER] on 08/14/23 at 9:39 AM, 08/15/23 at 8:33 AM, 08/16/23 at 8:02 AM and 08/17/23 at 9:42 AM revealed multiple areas of wood peeled away from the door exposing a rough, unfinished layer of wood to the lower one third of the door. In an interview with the Maintenance Director on 08/17/23 at 11:12 AM he stated a safety inspection performed in 2022 revealed all the doors in the facility needed to be replaced and a quote to replace the doors had been obtained in 2022, but the doors had not arrived. He stated the only thing he could do for the rough edges of the doors was sand them down. The Maintenance Director was unable to provide a schedule for sanding the doors down. 2.a. An observation of the floor of room [ROOM NUMBER] on 08/13/23 at 12:03 PM revealed food particles and dirt scattered across the floor and the floor was so sticky the surveyor's shoes stuck to the floor. Additional observations of the floor of room [ROOM NUMBER] on 08/14/23 at 9:29 AM, 08/15/23 at 8:26 AM, 08/16/23 at 7:54 AM, and 08/17/23 at 9:29 AM revealed food particles and dirt scattered across the floor and the floor was so sticky the surveyor's shoes stuck to the floor. b. An observation of the floor of room [ROOM NUMBER] on 08/13/23 at 11:04 AM revealed the floor was so sticky the surveyor's shoes stuck to the floor. Additional observations of the floor of room [ROOM NUMBER] on 08/14/23 at 9:17 AM, 08/15/23 at 8:34 AM, 08/16/23 at 8:04 AM, and 08/17/23 at 9:39 AM revealed the floor was so sticky the surveyor's shoes stuck to the floor. c. An observation of the floor of the shared bathroom of room [ROOM NUMBER] on 08/13/23 at 11:25 AM revealed dried yellow/brown stains to the floor in front of the toilet. d. An observation of the floor of room [ROOM NUMBER] on 08/14/23 at 9:12 AM revealed multiple dried tan stains scattered across the floor. Additional observations of the floor of room [ROOM NUMBER] on 08/15/23 at 8:42 AM and 08/17/23 at 9:49 AM revealed multiple dried tan stains scattered across the floor. An interview with the Housekeeping Supervisor on 08/17/23 at 11:12 AM revealed floors should be clean and free of debris and stains. She stated daily cleaning of rooms included sweeping and mopping, but there were days when rooms did not get cleaned due to not having enough housekeeping staff. The Housekeeping Supervisor also stated the floor tech had been out due to a family emergency and that also contributed to the floors not being clean. 3. A lingering odor of urine was noted to the shared bathroom of room [ROOM NUMBER] on 08/13/23 at 11:25 AM, 08/14/23 at 9:39 AM, 08/15/23 at 8:33 AM, 08/16/23 at 8:02 AM, and 08/17/23 at 9:42 AM. An interview with the Housekeeping Supervisor on 08/17/23 at 11:12 AM revealed bathrooms should be free of lingering odors. She stated daily cleaning of bathrooms included sweeping and mopping, but there were days when rooms did not get cleaned due to not having enough housekeeping staff. The Housekeeping Supervisor also stated the floor tech had been out due to a family emergency and that also contributed to the floors not being clean. 4. Observations of the hallway of the 400 hall on 08/13/23 at 10:52 AM revealed food debris and dirt scattered along the entire hallway. Additional observations of the hallway of 400 hall on 08/14/23 at 9:42 AM, 08/15/23 at 8:34 AM, 08/16/23 at 5:13 PM, and 08/17/23 at 9:34 AM revealed food debris and dirt scattered along the entire hallway. An interview with the Housekeeping Supervisor on 08/17/23 at 11:12 AM revealed the hallways should be vacuumed daily but there were days the hallways did not get vacuumed due to not having enough housekeeping staff. 5.a. An observation of the shared bathroom of room [ROOM NUMBER] on 08/13/23 at 2:41 PM revealed 3 unlabeled toothbrushes and 3 tubes of toothpaste were sitting on the sink. Additional observations of the shared bathroom of room [ROOM NUMBER] on 08/14/23 at 9:27 AM, 08/15/23 at 8:24 AM, 08/16/23 at 7:59 AM, and 08/17/23 at 9:26 AM revealed 3 unlabeled toothbrushes and 3 tubes of toothpaste were sitting on the sink. b. An observation of the shared bathroom of room [ROOM NUMBER] on 08/13/23 at 12:14 PM revealed an unlabeled comb and toothbrush were sitting on the sink and an unlabeled bottle of roll-on deodorant sitting on a handrail above the toilet. Additional observations of the shared bathroom of room [ROOM NUMBER] on 08/14/23 at 9:29 AM, 08/15/23 at 8:26 AM, 08/16/23 at 7:54 AM, and 08/17/23 at 9:29 AM revealed and unlabeled comb and toothbrush were sitting on the sink and an unlabeled bottle of roll-on deodorant sitting on a handrail above the toilet. c. An observation of the shared bathroom of room [ROOM NUMBER] on 08/13/23 at 11:25 AM revealed an unlabeled toothbrush and tube of toothpaste sitting on the sink. Additional observations of the shared bathroom of room [ROOM NUMBER] on 08/14/23 at 9:17 AM, 08/15/23 at 8:33 AM, 08/16/23 at 8:02 AM, and 08/17/23 at 9:42 AM revealed an unlabeled toothbrush and tube of toothpaste sitting on the sink. An interview with the Director of Nursing (DON) on 08/17/23 at 11:12 AM revealed all personal care equipment should be labeled and covered if needed by nurse aides (NAs). She explained there was no staff member assigned to round on rooms to check for labeled and properly stored personal care equipment. 6.a. An observation of the privacy curtain between a-bed and b-bed in room [ROOM NUMBER] on 08/13/23 at 3:21 PM revealed multiple orange/brown stains scattered across the curtain. An additional observation of the privacy curtain between a-bed and b-bed in room [ROOM NUMBER] on 08/17/23 at 9:54 AM revealed multiple orange/brown stains scattered across the curtain. b. An observation of the privacy curtain of room [ROOM NUMBER]-a and the privacy curtain between a-bed and b-bed in room [ROOM NUMBER] on 08/13/23 at 2:55 PM revealed multiple orange/brown stains scattered across both curtains. Additional observations of the privacy curtain of room [ROOM NUMBER]-a and the privacy curtain between a-bed and b-bed in room [ROOM NUMBER] on 08/14/23 at 9:12 AM, 08/15/23 at 8:42 AM, and 08/17/23 at 9:49 AM revealed multiple orange/brown stains scattered across both curtains. An interview with the Housekeeping Supervisor on 08/17/23 at 11:12 AM revealed she started replacing all privacy curtains approximately 2 months ago but had to stop due to a lack of housekeeping staff. She stated privacy curtains should be replaced when soiled and housekeeping staff also depended on the nursing staff to notify them when privacy curtains were soiled so they could be changed. 7. An observation of the bedside commode in the bathroom of room [ROOM NUMBER] on 08/13/23 at 3:10 PM revealed an approximately nickel-sized circular area of rust to both of the parallel metal bars on the top of the bedside commode. Additional observations of the bedside commode in the bathroom of room [ROOM NUMBER] on 08/14/23 at 4:54 PM, 08/15/23 at 8:47 AM, 8/16/23 at 8:36 AM, and 08/17/23 at 9:50 AM revealed an approximately nickel-sized circular area of rust to both of the parallel metal bars on the top of the bedside commode. An interview with the Director of Nursing (DON) on 0817/23 at 11:12 AM revealed nursing staff should have either replaced the rusty bedside commode with a new bedside commode or notified her so she could have replaced the bedside commode. 8. An observation of the corner of the wall to the right of the bathroom door in room [ROOM NUMBER] on 08/13/23 at 3:18 PM revealed missing sheetrock approximately half-way up the wall and the baseboard was missing. Additional observations of the corner of the wall to the right of the bathroom door in room [ROOM NUMBER] on 08/15/23 at 8:47 AM and 08/17/23 at 9:54 AM revealed missing sheetrock approximately half-way up the wall and the baseboard was missing. An interview with the Maintenance Director on 08/17/23 at 11:12 AM revealed he tried to repair damage sheetrock as quickly as possible, but he was unaware of the damaged sheetrock and missing baseboard in room [ROOM NUMBER]. He stated he relied on nursing or housekeeping staff to notify him of needed repairs, and he did not have a schedule for checking rooms for damage to walls in resident rooms. 37014 9. a. An observation of the room entrance door of room [ROOM NUMBER] on 08/14/23 at 8:05 AM revealed the wood door had several areas of rough, unfinished layers of wood along the edges of the door, approximately wheelchair height, from the doorknob and below. A subsequent observation of the room entrance door on 08/17/23 at 9:40 AM revealed the condition of the door remained the same. b. An observation of the room entrance door of room [ROOM NUMBER] on 08/14/23 at 8:06 AM revealed the wood door had several areas of rough, unfinished layers of wood along the edges of the door, approximately wheelchair height, from the doorknob and below. A subsequent observation of the room entrance door on 08/17/23 at 9:41 AM revealed the condition of the door remained the same. c. An observation of the entrance doors to the main dining room on 08/14/23 at 8:10 AM revealed the wood door had several areas of rough, splintered and unfinished layers of wood along the edges of the door from the middle edge of the door and below. A subsequent observation of the entrance doors to the main dining room on 08/17/23 at 9:50 AM revealed the condition of the doors remained the same. d. An observation of the entrance doors to the television room on 08/14/23 at 8:13 AM revealed the wood door had several areas of rough, unfinished layers of wood along the edges of the door from the middle edge of the door and below. A subsequent observation of the entrance doors to the television room on 08/17/23 at 9:54 AM revealed the condition of the doors remained the same. During an observation and interview with the Maintenance Director on 08/17/23 at 11:12 AM, he stated a safety inspection performed in 2022 revealed all the doors in the facility needed to be replaced and a quote to replace the doors had been obtained in 2022 but the doors had not arrived. The Maintenance Director stated the only thing he could do for the rough edges of the doors was to sand them down until they could be replaced. The Maintenance Director was unable to provide a schedule for sanding the doors down. 10. An observation was made of the privacy curtain in room [ROOM NUMBER] on 08/13/23 at 1:00 PM. Along the inside bottom portion of the curtain, were vertical and horizontal reddish-brown stains of various sizes, widths and lengths. There were also several round reddish-brown stains, approximately the size of a dime, scattered throughout the middle portion of the curtain. Subsequent observations on 08/14/23 at 4:48 PM and 08/17/23 at 9:38 AM revealed the condition of the privacy curtain remained the same. During an observation and interview on 08/17/23 at 11:12 AM, the Housekeeping Supervisor observed the stains on the privacy curtain and stated privacy curtains should be replaced when dirty. The Housekeeping Supervisor explained she had started changing privacy curtains about 2 months ago but got sidetracked and was not able to do room rounds to follow up to ensure housekeepers were doing their job due to not having enough staff. 37538 11. a) An observation made on 08/13/23 at 11:36 AM of room [ROOM NUMBER] revealed the sheetrock was missing or peeling away from the lower portion of the wall by the bathroom door. The wood door entering the room had several areas along the edges that were splintered and mostly affected the edge of door located by the doorknob and below. b) An observation made on 08/13/23 at 12:03 PM of room [ROOM NUMBER] revealed the wood door to enter the room had several areas of splintered wood along the edges and mostly affected the edge of door located from the doorknob and below. c) An observation made on 08/15/23 at 12:22 PM of room [ROOM NUMBER] revealed the wood door to enter the room had several areas of splintered wood along the edges and mostly affected the edges of door from the doorknob and below. An observation of the environment issues and interview were conducted on 08/17/23 at 11:12 AM with the Maintenance Director. The doors to rooms 502. 506, and 507 remained in the same condition and the sheetrock in room [ROOM NUMBER] continued to be in disrepair. The Maintenance Director revealed the facility had discussed replacing the doors after a previous inspection and provided documentation dated 08/2022. He stated he could sand the rough places on the doors smooth until they were replaced. The Maintenance Director revealed he was not aware of the damaged sheetrock in room [ROOM NUMBER] and explained a book was kept at each nurse station for staff guiding them on how to create a work order in TELS (maintenance tracking computer software) or if an emergency staff verbally told him. 12. Observations made on 08/13/23 at 11:10 AM and 08/14/23 at 8:37 AM of room [ROOM NUMBER]A revealed approximately half of the privacy curtain was unhooked and on the floor. There were multiple areas on the curtain with light brown stains mostly on the middle and lower portion of the curtain. An environment observation and interview were conducted on 08/17/23 at 11:12 AM with the HK Supervisor. The HK Supervisor observed the stains on the privacy curtain and stated the curtain should be replaced when dirty. The HK Supervisor revealed she had started changing privacy curtains about 2 months ago but got sidetracked and was not able to do room rounds and ensure the Housekeepers were doing their job due to not enough staff.

Based on observations, record review and interviews with residents and staff, the facility failed to provide sufficient nursing staff to ensure residents choices were honored for bathing preferences and eating meals in the main dining room, residents received assistance with incontinence care and personal and oral hygiene as needed, and cognitively impaired residents received constant supervision on a locked memory care unit for 7 of 8 sampled residents (Residents #181, #52, #29, #47, #35, #59, #66, and #68). This tag is cross-referenced to: F 561: Based on observations, record review, interviews with residents and staff, the facility failed to honor the residents' choice to eat their meals in the main dining room (Resident #181 and Resident #52) and provide their preferred number of showers each week (Resident #181) for 2 of 2 residents reviewed for choices. F 677: Based on observations and resident and staff interviews the facility failed to provide incontinence care (Resident #52 and Resident #29), a shave (Resident #47), and oral care (Resident #181) for 4 of 6 dependent residents reviewed for activities of daily living (ADL). F 689: Based on observations, record review and staff interviews, the facility failed to prevent four cognitively impaired residents from exiting the locked Memory Support Unit (MSU) unsupervised for 4 of 10 residents reviewed for accidents (Residents #35, #59, #66, and #68). Review of the facility's census dated 08/13/23 revealed there were a total 70 residents currently in the facility with 51 residents residing on the 400, 500 and 600 halls and 19 residents residing on the Memory Support Unit. During an interview on 08/13/23 at 2:47 PM, Nurse Aide (NA) #3 revealed she worked during the hours of 3:00 PM to 11:00 PM five days a week and most times, was asked to come in early due to there only being 2 NAs scheduled to cover the 400, 500 and 600 Halls. NA #3 stated when there were only 2 NAs, they each had to cover a hall and a half which made it difficult to get care provided. During an interview on 08/15/23 at 9:45 AM, NA #1 indicated the facility was often short-staffed. NA #1 stated when there were only 2 NAs scheduled to cover 400, 500 and 600 halls it was difficult to get care provided. In addition, there were times she has had approximately 31 residents on her assignment. NA #1 explained when there were only 2 NAs scheduled, they barely had enough time to wash the resident's face, assist residents with meals and provide incontinence care. She also indicated when there were only 2 NAs, they weren't able to provide residents with their scheduled shower, offer oral care, or assist residents with getting out of bed if they required a two-person assist with transfers. NA #1 revealed when working short-staffed, residents were not taken to the main dining room for meals and ate in their rooms instead. During an interview on 08/16/23 at 2:59 PM, NA #6 revealed she was not always able to get showers or other care needs provided when there was consistently only one NA and Nurse assigned to the MSU. NA #6 explained the residents on MSU needed a lot of constant supervision which was difficult if there was only one NA and Nurse for the 19 to 20 residents residing on MSU. She added on the rare occasion another NA was scheduled, they were pulled to another assist on another unit. During an interview on 08/16/23 at 3:45 PM, the Scheduler revealed staffing was based on the resident census. She explained for each 12-hour shift, there were usually 2 Nurses scheduled to cover the 400, 500 and 600 Halls and one nurse assigned to cover MSU. The Scheduler stated for NAs, she tried to schedule 2 NAs on MSU during the 7:00 am to 7:00 pm shift but most times there was only one and for the 400, 500, and 600 halls she tried to have 4 NAs but most times she only had 2 or 3 NAs scheduled. She stated they do not use staffing agencies to supplement the schedule and she had reached out to sister facilities for help but it had not worked out due to their own staffing challenges. The Scheduler stated when there were call-outs or shifts that weren't covered, she asked for volunteers to pick up extra shifts and reached out to their PRN (as needed) staff and/or asked staff to swap days. If they still couldn't get the shift scheduled, then administrative staff would fill in and the Director of Nursing, Infection Preventionist and Clinical Competency Coordinator worked a medication cart quite often. The Scheduler stated Administration has tried to fill the open positions by running ads on social media for current job openings, offered sign on bonuses, posted signage outside the building, and hosted an open house and job fair in order to recruit applicants. She revealed there were currently 7 open nurse positions, 5 for the 7:00 AM to 7:00 PM shift and 2 for the 7:00 PM to 7:00 AM shift and 13 open NA positions, 8 for the 7:00 AM to 7:00 PM shift and 5 for the 7:00 PM to 7:00 AM shift, which only added to the staffing challenges they currently faced. During interviews on 08/16/23 at 8:55 AM and 08/17/23 at 4:19 PM, the Director of Nursing revealed in the evenings and/or weekends, meals were not served in the main dining room and residents ate in their room due to staffing challenges. The DON explained the facility did not use agency staff to help supplement the schedule but they had administrative staff that could be pulled to cover shifts and help with resident care such as the Activities Director who was a NA, the Clinical Competency Coordinator who was a nurse, the Infection Preventionist, the Assistant Director of Nursing, and/or herself. The Administrator was out of the country and unable to be interviewed.

Based on observations, record review, and staff, Physician and Pharmacy interviews, the facility failed to remove expired medications and secure medications stored at the bedside for 7 of 9 storage rooms, medication carts, and residents (West Wing and Memory Support Unit medication rooms and 400 Hall and Memory Support Unit medication carts, and for Resident #29, Resident #52, and Resident #71) reviewed for medication storage. The findings include: 1. An observation of the locked west wing medication room on 08/17/23 at 2:08 PM with the Director of Nursing (DON) revealed in the cabinet was 1 unopened bottle of aspirin regular strength enteric coated tablets, 325 milligrams (MG) each, that had an expiration date of 6/2023. Also, on the shelf were 2 one-ounce tubes of triple antibiotic ointment that both had an expiration date of 06/2023. An interview with the DON on 08/17/23 at 2:08 PM revealed that her expectation was that expired medications be removed prior to its expiration date. She further revealed that night shift nursing was responsible for checking expiration dates and restocking the over-the-counter medications. She stated expired medications are placed in a box and sent back to pharmacy with a list of the medications being returned. 2. An observation of the locked Memory Support Unit (MSU) medication room on 08/17/23 at 2:36 PM with the DON revealed 20 containers of sterile water 110 milliliters (ML) that had an expiration date of 4/6/23. An interview with the DON on 08/17/23 at 2:36 PM indicated that her expectation was that expired medication be removed prior to its expiration date. She further revealed the saline containers belonged to a resident that no longer resided at the facility for their Continuous Positive Airway Pressure (CPAP) machine. She stated they should have discarded the saline. 3. a. An observation of the locked MSU medication cart on 08/17/23 at 2:40 PM with the DON and Nurse #1 revealed 24 white round pills, identified as lorazepam 0.5 MG tablets, that had an expiration date of 4/24/23 for Resident #68. An interview on 8/17/23 at 2:41 PM with Nurse #1 revealed this was a medication Resident #68 was admitted with and did not take it any longer. b. A continued observation of the locked MSU medication cart on 08/17/23 at 2:42 PM revealed an opened 30-fluid ounce bottle of active liquid protein concentrate nutrition supplement that had an expiration date of 7/19/23. An interview with the DON on 8/17/23 at 2:42 PM indicated that her expectation is that expired medication be removed prior to its expiration date. She further revealed the night shift nurse was responsible for checking expiration dates in the medication carts. 4. An observation of the locked 400 hall medication cart on 08/17/23 3:04 PM with the DON revealed 14 blue oval pills, identified as meclizine tab 12.5 MG tablet in individual pill packs, with an expiration date of 5/2023 for Resident #36. An interview with the DON on 8/17/23 at 3:05 PM indicated that her expectation is that expired medication be removed prior to its expiration date. She further revealed the night shift nurse is responsible for checking expiration dates in the medication carts. 39037 5. An observation of Resident #71's room on 08/15/23 at 8:47 AM revealed a 4-ounce tube of barrier cream containing menthol 44%, white petrolatum (petroleum jelly) 53%, and zinc oxide (a skin protectant) 20.6% was sitting on his overbed table. Additional observations of Resident #71's room on 08/15/23 at 2:44 PM, 08/16/23 at 8:16 AM, and 08/17/23 at 9:54 AM revealed a 4-ounce tube of barrier cream containing menthol 44%, white petrolatum 53%, and zinc oxide 20.6% was sitting on his overbed table. An observation of Resident #52's room on 08/13/23 at 11:06 AM revealed a 4-ounce tube of barrier cream containing menthol 44%, white petrolatum 53%, and zinc oxide 20.6% was sitting on his overbed table. An additional observation of Resident #52's room on 08/15/23 at 3:30 PM revealed a 4-ounce tube of barrier cream containing menthol 44%, white petrolatum 53%, and zinc oxide 20.6% was sitting on his overbed table. An observation of Resident #29's room on 08/15/23 at 8:29 AM revealed a 4-ounce tube of barrier cream containing white petrolatum 57% and zinc oxide 17% was sitting on top of her dresser. An additional observation of Resident #29's room on 08/16/23 at 8:10 AM revealed a 4-ounce tube of barrier cream containing white petrolatum 57% and zinc oxide 17% was sitting on top of her dresser. An interview with the Director of Nursing (DON) on 08/17/23 at 11:12 AM revealed there were several different types of barrier cream available at the facility but she did not consider creams containing zinc to be medicated creams. She stated she would need to educate herself more on the ingredients of the different creams available. The DON stated she felt that barrier cream should not be stored on the overbed table, but she felt it was ok for the cream to be stored inside the resident's dresser.

Based on observations, record review, and resident and staff interviews the facility failed to assess the ability of a resident to self-administer medications for 1 of 6 residents reviewed for medication administration (Resident #52). Findings included: Resident #52 was admitted to the facility 03/31/22 with diagnoses including heart failure, anemia, and diabetes. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was moderately cognitively impaired. Review of the medical record revealed no documentation Resident #52 had been assessed for self-administration of medication. An observation of Resident #52's overbed table on 08/13/23 at 11:06 AM revealed a cup containing 3 white pills and 1 blue pill sitting on the table. An interview with Resident #52 on 08/13/23 at 11:07 AM revealed he did not know what pills were in the medication cup on his overbed table or how long the cup had been sitting on the table. He stated sometimes nursing staff left cups of medication in his room without ensuring he took the medication. An interview with Nurse #3 on 08/13/23 at 11:13 AM revealed she was working the 7:00 AM to 7:00 PM shift and was assigned to care for Resident #52. She stated she gave Resident #52 his morning medications around 7:30 AM the morning of 08/13/23 and watched him swallow his medications. Nurse #3 stated Resident #52 liked to leave his light off, so it was not very bright in his room when she gave his medications, and she did not see the cup of medications sitting on his overbed table. She stated she did not know what medications were in the medication cup found on the overbed table and removed the medications from Resident #52's room. An interview with Nurse #4 on 08/15/23 at 12:14 PM revealed she worked the 7:00 PM to 7:00 AM shift on 08/12/23 and was assigned to care for Resident #52. She stated she gave Resident #52 his evening medications between 9:00 PM and 9:30 PM the evening of 08/12/23 and watched him swallow his medications. Nurse #4 stated she did not see a cup of pills on Resident #52's overbed table at any time she was in Resident #52's room throughout her shift on 08/12/23 and did not know what the medications were in the cup found on the overbed table. An interview with the Director of Nursing (DON) on 08/17/23 at 11:55 AM revealed she expected nursing staff to stay with residents when they took their medication unless they had an order to self-administer medication. She stated if the resident didn't want their medicine when it was brought to them, it should be removed from the room and discarded. The DON stated no cups of medication should be left in resident rooms. The DON confirmed Resident #52 did not have an order to self-administer his medication.

Based on observations, record review, interviews with residents and staff, the facility failed to honor the residents choice to eat their meals in the main dining room (Resident #181 and Resident #52) and provide their preferred number of showers each week (Resident #181) for 2 of 2 residents reviewed for choices. The findings included: 1. a) Resident #181 was admitted to the facility on [DATE] with diagnoses including debility, heart failure, and dementia. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #181 was assessed as cognitively intact. The care plan initiated on 07/31/23 revealed there was a potential for social isolation and low activity participation related to Resident #181 being new to the facility. Interventions included introduce to other residents with similar interest. During an interview on 08/16/23 at 2:42 PM Resident #181 stated he liked to eat lunch and dinner meals in the dining room so he could be around people and talk. An observation made on 08/16/23 at 5:33 PM revealed the tray cart had arrived on the hall and included Residents #181's dinner meal to be eaten in the room. There were no residents observed in the main dining room eating. During an interview on 08/17/23 at 8:36 AM Resident #181 revealed lunch was typically served in dining room but the dinner meals were served in his room, and he preferred to eat in the main dining room for socialization. During an interview on 08/17/23 at 4:19 PM the Director of Nursing (DON) revealed residents who preferred to eat their meals in the main dining room was a choice and should be honored. b) Resident #181 was admitted to the facility on [DATE] with diagnoses including debility, heart failure, and dementia. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #181's cognition was assessed as being intact. Review of the bathing schedule revealed during the day shift on Tuesday and Friday Resident #181 was to receive a type of bathing (a shower or bed bath). Review of the paper bathing records revealed NA staff were to document the type of bathing provided or if the resident refused. For Tuesday and Friday on 07/25/23, 07/28/23, 08/01/23, 08/08/23 and 08/11/23 the NA did not document a shower or bed bath were provided or refused by Resident #181. On 08/15/23 the NA documented Resident #181 received a shower. Review of the point of care documentation from 07/25/23 through 08/11/23 revealed the type of bathing and the amount of assistance provided to Resident #181 was included. The documentation showed bathing was either left blank or NA staff put 8/8 indicating bathing did not occur and no assistance was provided during the day or night. The NA documentation did show Resident #181 had received total assistance with one shower since admission on 08/15/23 and indicated no bed baths were provided. During an interview and observation on 08/13/23 at 3:29 PM Resident #181 was in bed wearing a pajama top. There were no obvious body odors and Resident #181's hair and fingernails did not appear unclean. Resident #181 stated he had not received a shower since his admission to the facility and indicated nursing staff wiped him off using the premoistened wipes located on the overbed table. An interview was conducted on 08/17/23 at 1:50 PM with NA #1 assigned to provide care on 08/01/23. NA #1 revealed Resident #181 needed total assistance with bathing and did receive a shower on 08/15/23. NA #1 revealed showers were documented when done and indicated she had assisted Resident #181 with a shower prior to 08/15/23 but she was unable to recall when. NA #1 revealed if there were only 2 NA staff assigned to work on the west wing it was hard to get everything the residents needed done including showers. An interview was conducted on 08/17/23 at 1:33 PM with NA #2 scheduled to provide care on 08/11/23. NA #2 stated she provided assistance with bathing and completed a bed bath for Resident #181 but had not provided assistance with a shower. An interview was conducted with DON on 08/17/23 at 4:33 PM. The DON revealed for bathing the NA staff were doing their best and there were times a resident might not get their shower on the exact day it was scheduled but NA staff did try to make it up on the following day. 39037 2. Resident #52 was admitted to the facility 03/31/22. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was moderately cognitively impaired and was able to make his needs known. The care plan last updated 07/13/23 revealed Resident #52 had the potential for social isolation and low activity participation and interventions included interviewing him about preferences, past roles, customary routines, and interests and introducing him to residents with similar interests. An observation made on 08/13/23 at 12:25 PM revealed the meal tray cart had arrived on the 400 hall and included Resident #52's lunch meal to be eaten in his room. There were no residents observed in the main dining room. An interview with Resident #52 on 08/17/23 at 9:35 AM revealed he would like to eat all his meals in the dining room if possible. He stated the dining room was usually only open for lunch during the week. Resident #52 stated the dining room was never open on the weekend, but he would choose to eat in the dining room if given the choice. An interview with the Director of Nursing (DON) on 08/17/23 at 4:19 PM revealed lunch was served in the main dining room Monday through Friday and all other meals were served in resident rooms due to not having enough staff to assist residents to the main dining room. She stated residents who preferred to eat their meals in the main dining room was a choice and should be honored.

Based on observations and staff interviews the facility failed to maintain a resident's dignity by not providing privacy when changing her shirt for 1 of 1 resident reviewed for dignity (Resident #29). The reasonable person concept was applied to this deficiency. A reasonable person would be upset if observed having their clothing changed without a privacy curtain in place or their room door being closed. Findings included: Resident #29 was admitted to the facility 04/12/22 with diagnoses including non-Alzheimer's dementia and cerebrovascular accident (stroke). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was moderately cognitively impaired and required extensive assistance with dressing. On 08/15/23 at 2:43 PM Resident #29 was observed lying in bed with food stains on the front of her shirt. An observation of Nurse Aide (NA) #3 on 08/15/23 at 2:59 PM revealed she entered Resident #29's room and removed Resident #29's shirt without closing the door to the room or pulling the privacy curtain between the resident's bed and the door to her room. From the hallway, Resident #29 could be seen without her shirt on. An interview with NA #3 on 08/15/23 at 3:10 PM revealed she should have pulled the privacy curtain or shut the door to Resident #29's room when she changed her shirt but did not because she was in a hurry and distracted. An interview with the Director of Nursing (DON) on 08/17/23 at 11:55 AM revealed she expected staff to either close the door to the room or pull the privacy curtain when changing a resident's clothes.

Based on observations, record review, and resident and staff interviews the facility to accurately code Minimum Data Set (MDS) assessments in the areas of transfers (Resident #52), eating (Resident #52), and oxygen use (Residents #29 and #39) for 3 of 24 sampled residents. Findings included: 1. Resident #52 was admitted to the facility on [DATE] with diagnoses including unsteadiness on feet and diabetes. The quarterly Minimum Data Set (MDS) dated [DATE] reflected Resident #52 was moderately cognitively impaired, received a therapeutic diet, and only transferred or ate once or twice during the look back period. The nutrition care plan last updated 08/15/23 revealed Resident #52 received a therapeutic diet and the intervention was to monitor the percent of his meal intakes. An interview with Resident #52 on 08/17/23 at 9:35 AM revealed he ate his meals in the dining room as often as possible. An interview with the MDS Coordinator on 08/17/23 at 1:32 PM revealed she received assistance with some parts of the MDS by a staff member who worked remotely. She explained the staff member who worked remotely coded the transfer and eating portions of Resident #52's quarterly MDS and would not have known Resident #52 usually ate in the dining room and required supervision assistance with transfers. She stated the quarterly MDS should have reflected Resident #52 transferred and ate with supervision assistance. An interview with the Director of Nursing (DON) on 08/17/23 at 4:19 PM revealed she expected the MDS to be coded accurately. 2. Resident #29 was admitted to the facility 04/12/22 with diagnoses including heart failure and chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe). Review of Resident #29's Physician orders revealed an order dated 04/12/22 for oxygen at 3 liters per minute continuously. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was not coded as receiving oxygen therapy. Observations of Resident #29 on 08/14/23 at 4:55 PM, on 08/15/23 at 8:37 AM, on 08/16/23 at 8:11 AM, and 08/17/23 at 9:47 AM revealed she had oxygen in place at 3 liters per minute. An interview with the MDS Coordinator on 08/17/23 at 1:32 PM revealed she received assistance with some parts of the MDS by a staff member who worked remotely. She explained the staff member who worked remotely coded the oxygen portion of Resident #29's quarterly MDS incorrectly and the MDS should have reflected the resident required the use of oxygen. An interview with the Director of Nursing (DON) on 08/17/23 at 4:19 PM revealed she expected the MDS to be coded accurately. 37538 3. Resident #39 was admitted to the facility on [DATE] with diagnoses including chronic obstruction pulmonary disease with dependence on supplemental oxygen. Review of Resident #39's physician orders included to apply oxygen via nasal cannula at 2 liters per minute (LPM) continuously every day and night shift with a start date of 10/07/22 and end date 07/24/23. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #39 did not use oxygen during the assessment lookback period. Review of the Medication Administration Record (MAR) for May 2023 revealed a physician order was transcribed to apply oxygen at 2 LPM continuously every shift with a start date of 10/07/2022 and end date of 07/24/2023. The MAR included nursing staff initials for the assessment lookback period from 05/24/23 through 05/30/23 to indicate Resident #39 received oxygen every day and night shift. During an interview on 08/17/23 at 3:12 PM the MDS Coordinator revealed an offsite nurse helped with the quarterly MDS dated [DATE] and signed oxygen was not in use. The MDS Coordinator stated the nurses' initials on the MAR showed Resident #39 used oxygen during the lookback period and the MDS assessment was incorrectly coded. During an interview on 08/17/23 at 4:28 PM the Director of Nursing stated she would expect MDS assessments were accurate and coded correctly to show oxygen was in use.

Based on record review, staff, Physician Assistant (PA) and Physician interviews, the facility failed to identify the urgent need for medical attention or notify the physician when an acute change was first identified for 1 of 3 residents reviewed for accidents (Resident #1). Resident #1 was admitted to the hospital on 05/27/21 and diagnosed with an impacted (occurs when the broken ends of the bone are jammed together by the force of the injury), angulated (where the normal axis of the bone has been altered causing the distal portion of the bone to point off in the opposite direction) and comminuted (the bone has broken into three or more pieces and in most cases, the number of bone fragments corresponds with the amount of force needed to break the bone) right femoral diaphyseal (bone break that occurs along the shaft of the long bone) periprosthetic (broken bone that occurs around the implants of a total hip replacement) fracture that required immediate surgical repair. Resident #1 was also diagnosed with bilateral [CONDITION(S)] (DVT; blood clots that form in veins deep inside the body) and subsequently passed away on 06/02/21. Findings included: Resident #1 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #1 with moderate impairment in cognition for daily decision making but could usually make herself understood and usually understood others. Resident #1 required extensive assistance of two staff members with bed mobility, transfers, toileting and bathing and supervision with locomotion on the unit using a wheelchair for mobility. The MDS further noted she had impaired range of motion on both lower extremities. Resident #1's medical record revealed none of her active care plans specified the level of assistance she required with transfers. The Physician Assistant (PA) progress note dated 05/19/21 noted Resident #1 was seen to evaluate increased lower extremity [CONDITION(S)] (swelling caused by excess fluid accumulation in the body tissues). Upon exam, she had 2 + lower extremity [CONDITION(S)] mid-thigh distally to ankles and a new order was written for [MEDICATION(S)] (medication used to reduce extra fluid in the body) 20 milligrams (mg) daily. Nurse's note written on 05/27/21 at 2:37 AM by Nurse #1 read in part, during nighttime rounds, Resident #1 indicated pain whenever her right leg was touched. Nurse Aide (NA) #1 called Nurse #1 to look at the leg which was at a 25-degree angle to the right, the curve inward at the knee. Did not float her heels as Resident #1 stated to move the leg hurt bad. Will check with the on-call provider in the AM and possibly request an x-ray. Will continue to observe throughout the night. During a telephone interview on 06/03/21 at 9:13 AM, Nurse Aide (NA) #1 confirmed she worked 7:00 PM to 7:00 AM on 05/26/21 to 05/27/21 and was assigned to provide care to Resident #1. NA #1 recalled when she started her shift, Resident #1 was in her wheelchair out in the common area and remained in her wheelchair until around 9:00 PM to 9:30 PM when she assisted Resident #1 to bed. She explained when assisting Resident #1 with transfers, sometimes she assisted independently and other times she had another staff member help assist. NA #1 confirmed she transferred Resident #1 to bed independently the evening of 05/27/21 and explained she lowered the bed, put her arms around Resident #1, underneath her armpits like I was giving her a hug, lifted her up and over to the side of the bed and then lifted her legs as she laid back on the bed. NA #1 verified that was how she normally transferred Resident #1. NA #1 added Resident #1 did not fall, hit her leg on the wheelchair or bed or complain of any discomfort during the transfer. NA #1 didn't recall noticing anything abnormal after she assisted Resident #1 to bed and stated she covered her up and left the room. Around 2:30 AM, NA #1 stated she checked on Resident #1, pulled the covers off to float her heels on a pillow and noticed her right leg was rotated outward and didn't look right. She informed Nurse #1 and they both went back to Resident #1's room. NA #1 recalled Nurse #1 lifted Resident #1's leg slightly and touched her thigh area. When Nurse #1 pushed on Resident #1's thigh, a lump came up and then disappeared. She added Nurse #1 assisted her with changing Resident #1, covered her back up and she fell back to sleep when they exited the room. NA #1 added when asked Resident #1 told Nurse #1 her leg hurt but never grimaced or cried out in pain when incontinence care was provided or when her leg was touched by Nurse #1. During a telephone interview on 06/02/21 at 2:10 PM, Nurse #1 confirmed she was the nurse assigned to provide care to Resident #1 during the hours of 7:00 PM to 7:00 AM on 05/26/21 to 05/27/21. Nurse #1 recalled at the start of the shift Resident #1 was up in her wheelchair tooling around like normal until sometime between 9:30 PM and 10:00 PM when NA #1 assisted her to bed. Nurse #1 stated at around 2:30 AM NA #1 was doing incontinence rounds and got her to look at Resident #1's leg. When she went to assess Resident #1, she noticed her leg looked odd and different than usual. She explained she did a cursory exam of Resident #1's leg but did not check for pedal pulse. She could not recall if Resident #1's foot was mottled at that time and stated her lower extremities were somewhat edematous but not as edematous as usual. Nurse #1 asked Resident #1 if she was hurting and Resident #1 replied yes but stated she didn't display any non-verbal indicators of pain or distress such as facial grimacing or moaning. She added Resident #1 fell back asleep and appeared to rest comfortably the remainder of the night. Around 6:30 AM, she and NA #1 went back into Resident #1's room, her legs were kind of straight but looked odd, they carefully changed her and then she had Nurse #2 come into the room to assess Resident 1's leg. Nurse #1 recalled Nurse #2 stating she would notify the PA when he came into the facility that morning. Nurse #1 confirmed typically she would call the on-call provider if something was [NAME] but did not on this date as she didn't feel it was emergent since Resident #1 only vocalized pain but displayed no other signs of distress or discomfort and fell back asleep. During a follow-up telephone interview on 06/03/21, Nurse #1 clarified she did touch Resident #1's right thigh but didn't really lift the leg. Nurse #1 stated there was a lump and described it as fleeting (lasting a very short time) and wasn't sure if it was just fatty tissue. She stated Resident #1 had her hand on her thigh and stated it hurt bad but her facial features and overall affect didn't indicate she was in any discomfort or distress. She added Resident #1 voiced no complaints of pain when Nurse #2 went into the room with her to assess Resident #1. Resident #1's March 2021 Medication Administration Record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was documented on the MAR the last dose administered to Resident #1 was on 05/26/21 at 5:00 PM. There were no orders for as needed pain medications. Further review revealed there was no documentation of nurse assessment completed on 05/27/21 by Nurse #1 related to the acute change to Resident #1's right leg. Nurse's notes written on 05/27/21 at 9:14 AM by Nurse #2 noted the Physician Assistant (PA) evaluated Resident #1 and gave orders for a right femur x-ray, 9:40 AM written by Nurse #2 noted a new order was received to send Resident #1 to the hospital for evaluation and 9:54 AM written by Nurse #2 read in part, Emergency Medical Services (EMS) arrived at the facility and transported Resident #1 to the hospital. During a telephone interview on 06/03/21 at 2:17 PM, Nurse #2 reported after being notified by Nurse #1 during shift report that something was wrong with Resident #1's leg, she and Nurse #1 went to Resident #1's room to assess and noticed her right leg was angled in the thigh area with a 25 degree curve to the outer part of the leg. Nurse #2 explained Nurse #1 reported she checked for pedal pulses during the night, so she didn't check for a pedal pulse at that time nor did she touch Resident #1's skin to see if it was cold. Nurse #2 added Resident #1's foot did not appear mottled and explained [CONDITION(S)] on Resident #1's lower extremities were normal for her. Nurse #2 stated Resident #1 did not appear to be in any pain and she knew the Physician Assistant (PA) would be at the facility within the hour so she did not call him at the time. Nurse #2 did not recall asking Resident #1 what had happened and stated she was not sure how Resident #1 could have sustained a leg fracture. She added although Resident #1 required a good bit of assistance during transfers, one staff member could assist her because she was a small lady and able to stand/pivot during a transfer. During an interview on 06/02/21 at 12:34 PM, NA #3 confirmed she was assigned to work on the Memory Support Unit (MSU) on 05/27/21 7:00 AM to 7:00 PM. NA #3 stated she and NA #2 were notified in shift report by NA #1 something was wrong with Resident #1's leg. NA #3 stated when she, NA #1 and NA #2 went to Resident #1's room, she was lying on her back in bed and her right leg was curved inward, appeared shorter than the other leg and when asked if she was in pain, Resident #1 replied yes. NA #2 explained Nurse #2 was already aware and going to talk to the PA when he arrived at the facility, so she went to get the Physical Therapist (PT) to look at Resident #1's leg since he had been working with her. NA #2 stated although Resident #1 could stand and pivot with guidance she always got another staff member to assist her when transferring Resident #1. During a telephone interview on 06/04/21 at 3:20 PM, NA #2 confirmed she was assigned to work on the MSU on 05/27/21 7:00 AM to 3:00 PM and she and NA #3 were both notified during shift report that NA #1 and Nurse #1 had discovered something wrong with Resident #1's leg during the middle of the night. NA #2 added she and NA #3 went with NA #1 to Resident #1's room and when NA #1 uncovered Resident #1 legs and pulled her gown up, she noticed her right leg was angulated at the knee and rotated outward. NA #2 recalled Resident #1 was alert and didn't appear to be in any distress. NA #2 stated Resident #1 denied any pain or discomfort when she asked her; however, when NA #3 asked if she was in pain, Resident #1 replied yes. NA #2 stated neither she nor NA #3 attempted to move or touch Resident #1's leg at that time and could not recall what her foot looked like but explained her legs usually looked mottled from the knee down due to [CONDITION(S)]. NA #2 added when they all observed Resident #1 around 7:00 AM on 05/27/21, everything about her seemed normal other than her leg being angulated. NA #2 stated Resident #1 required one to two staff assistance with transfers and when she transferred her independently, she used a mechanical lift. NA #2 recalled when she provided care to Resident #1 the day before, on 05/26/21 until the end of her shift at 3:00 PM, Resident #1 was at baseline, her right leg was intact with no angulation and she had remained in bed until PT got her up that afternoon for therapy. The Physician Assistant (PA) progress note dated 05/27/21 at 9:10 AM read, notified by nursing that Resident #1 was noted to have an abnormal angulation of her right femur overnight. Resident #1 noted to have pain upon movement of lower extremity. Right femur with 30-degree angulation with positive pedal pulses. X-ray ordered. During an interview on 06/02/21 at 1:50 PM, the PA confirmed he was asked to evaluate Resident #1's right leg on 05/27/21 at approximately 8:10 AM to 8:20 AM. The PA recalled Resident #1 was lying on her back in bed and when he looked at her right leg, her femur was misaligned at a 30-degree angle. He gave orders to obtain an x-ray but a few minutes later he decided she needed to go to the hospital for an evaluation due to obvious fracture. He stated when he touched Resident #1's leg, she voiced no discomfort, the skin of her leg did not feel cold and he felt a very faint pulse. He was not sure how Resident #1 could have obtained a fracture as she did not attempt to self-transfer or self-ambulate, she was not found on the floor and there was no report of a fall or other incident. He stated given her advanced age and poor nutritional status, it was very likely she was osteopenic in which case, just rolling her over for care could cause something to snap. The PA reported he was the after hours on-call provider 05/26/21 PM to 05/27/21 AM and stated Nurse #1 should have called him at 2:37 AM when Resident #1's leg was first noticed to be misaligned and he would have instructed her to be sent to the hospital for evaluation. The Emergency Medical Services (EMS) report dated 05/27/21 noted a call was received at 9:32 AM and they were with Resident #1 at the facility at 9:43 AM. The EMS report indicated Resident #1 was lying supine (laying face upward) in bed in minimal distress and upon assessment, Resident #1's right femur, midshaft was severely angulated laterally, pedal pulses (arterial pulse which can be felt on top of the foot in front of the ankle) were absent, the foot was mottled (marked with spots or smears of color) and cold to the touch. With assistance of staff, Resident #1 was transferred to the stretcher and transported to the hospital at 9:56 AM. The hospital radiology report dated 05/27/21 at 11:04 AM confirmed Resident #1 had a lateral and anteriorly angulated, impacted and comminuted right femoral diaphyseal periprosthetic fracture and chronic appearing right superior and inferior pubic rami (arm or branch of a bone) fractures. There was no mention of osteopenia (reduced bone mass) or [CONDITION(S)] (condition when bone strength weakens and is susceptible to fracture). The hospital discharge summary dated 06/02/21 read in part, Resident #1 was also found to have bilateral DVTs ([CONDITION(S)]) and was started on [MEDICATION(S)] (blood thinner). On 06/02/21, she was unexpectedly found pulseless and apneic (stopped breathing) and considering the circumstances, it was thought that a pulmonary embolism (condition in which one of the pulmonary arteries in the lung gets blocked by a blood clot) was the most likely cause of death. During an interview on 06/02/21 at 12:20 PM and follow-up telephone interview on 06/04/21 at 8:32 AM, the Physical Therapist (PT) explained prior to Resident #1 being admitted to the hospital on 05/27/21, she was on therapy caseload for transfers, bed mobility, positioning and range of motion. The PT explained she was dependent with all mobility and needed extensive staff assistance with transfers. He added Resident #1 had limited range of motion on her left leg due to contractures but could stand and pivot during transfers with one or two staff assistance, depending on the comfort level of the person completing the transfer. The PT recalled on the afternoon of 05/26/21, he worked with Resident #1 on lower extremity range of motion exercises and her right leg was intact during their session. On 05/27/21 around 9:00 AM, he was asked by NA #2 to look at Resident #1's leg and when he observed Resident #1, she was lying on her back in bed and her right leg was deviated quite a bit from its normal position and curved inward. He recalled her skin was intact but stated he felt it appeared to be fractured and she needed to be sent to the hospital. The PT spoke to Nurse #2 who stated to him she was aware and would have the PA assess Resident #1 when he arrived at the facility. After speaking to Nurse #2, the PT stated he reported his observation to the Administrator. During a joint interview on 06/02/21 at 3:31 PM, the Director of Health Services (DHS) recalled when she arrived at the facility the morning of 05/27/21, Nurse #2 reported to her that Resident #1's right leg was misaligned, the PA had already seen Resident #1 and ordered an x-ray. The DHS added when she visualized Resident #1's leg, it was misaligned, the skin was intact with no bruising or swelling and Resident #1 voiced no complaints of pain. She stated she spoke with the PA and they decided to send her out to the hospital for evaluation. The DHS stated she had no idea how Resident #1 sustained an injury to her leg and explained she wasn't mobile, had poor intake, if she had fallen she wouldn't have been able to get up on her own and other than her leg being angled, her skin was intact with no swelling or bruising. The DHS confirmed the change to Resident #1's leg was first identified at 2:37 PM by NA #1 and Nurse #1 and indicated Nurse #1 should have contacted the on-call provider when Resident #1's leg was first noticed to be misaligned and at the very least, Nurse #2 should have contacted the on-call provider when informed during shift report at 6:30 AM instead of waiting until the PA arrived at the facility. She added nursing staff, including Nurse #1 and Nurse #2, were instructed to immediately call her and/or the PA, Physician or on-call provider whenever there was a change in condition which included injury of unknown origin. During a joint interview on 06/02/21 at 3:31 PM, the Administrator stated on 05/27/21 at 8:45 AM, the PT informed her Resident #1's leg was misaligned at a 25 to 30-degree angle. She added the PT worked with Resident #1 the afternoon of 05/26/21 and her leg was intact at that time. When she spoke with Nurse #1, she stated after assessing Resident #1's leg around 2:30 AM, she did not notify the on-call provider because Resident #1 appeared comfortable and slept the remainder of the shift and felt it would be ok to wait until later in the morning. During a telephone interview on 06/08/21 at 4:53 PM, the Medical Director (MD) stated Resident #1 was a very frail, elderly lady with advanced dementia and poor nutritional status. The MD could not state what could have caused her to sustain a femur fracture and explained any clinical condition could potentially cause mottling and lack of pedal pulse. During a telephone interview on 06/11/21 at 2:11 PM, the hospital Radiologist (physician specializing in Radiology) stated the x-ray results for Resident #1 confirmed she had an angulated, impacted and comminuted right femoral diaphyseal periprosthetic fracture. The Radiologist explained there would had to have been a good amount of impact to cause this type of fracture and typically, this type of fracture was caused by a traumatic event such as a fall out of bed or knocking the leg into a wall forcefully. The Radiologist added although Resident #1 was osteopenic at baseline, she did not have an insufficiency fracture (type of stress fracture which is the result of normal stresses on abnormal bone); therefore, it was highly unlikely the fracture occurred due to turning or repositioning Resident #1 in bed during care. The facility provided the following the following Corrective Action Plan with the correction date of 06/01/21: Resident #1's leg was first noticed to be misaligned (incorrect position) 5/27/21 at 237 am indicative of a possible fracture which resulted in a delay of treatment. In addition, licensed professionals also failed to assess/establish the plan of care for transfers for Resident #1. On 05/27/21 at approximately 2:30AM, Nurse Aide (NA) #1 noticed Resident #1's leg was angulated and notified Nurse #1. Nurse #1 assessed Resident #1's leg and noted it to be misaligned 25 degrees but did not notify the facility provider at that time. Nurse #2 was notified by Nurse #1 at approximately 6:30 AM that something was wrong with Resident #1's leg and visually assessed Resident #1 with Nurse #2. Nurse #1 informed Nurse #2 she would notify the Physician Assistant (PA) when he arrived at the facility later that morning. The PA was notified around 8:15 AM to 8:20 AM, assessed Resident #1 and gave initial orders to obtain an x-ray but later decided to send her to the hospital for evaluation and treatment due to possible femur fracture. Emergency Medical Services (EMS) was notified, arrived at the facility, and transported Resident #1 to the hospital at 9:56 AM. What Corrective action will be accomplished for the residents found to have been affected by the deficient practice? · Resident #1 was assessed on 05/27/21 at 2:37 AM by Nurse #1. · Nurse #1 and Nurse #2 completed shift change between 6:00 AM-6:30 AM and assessed Resident #1. · Physician Assistant assessed Resident #1 between 8:10 AM and 8:20 AM and ordered a mobile x-ray. · Director of Nursing saw Resident #1 and requested the Nurse Practitioner to send her to the emergency room around 9:00 AM upon her arrival. · Resident #1 was sent to the hospital on 05/27/21 at approximately 9:56 AM. · Responsible Party was notified of Resident #1's transfer to the hospital on 05/27/21. · Primary MD was notified of transfer on 05/27/21. · Nurse #2 was reeducated by the Director of Nursing (DHS) on notification of change of condition on 5/27/2021. · 24-hour report for injury of unknown was made to the state on 05/27/21. · The 5 day investigation was completed on 06/01/21. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? · All residents have the potential to be affected · Evaluation of all long-term residents of transfer status from bed to chair and chair to bed and care plan will be updated to reflect current transfer status. Therapy and nursing coordinated and evaluated resident transfer from chair to bed transfer status to determine the most appropriate of resident transfer status. This began on 5/27/2021 after the adhoc QAPI (Quality Assurance Performance Improvement) meeting and was completed on 05/28/21. The current record and care plans were reviewed and updated by the MDS Coordinator and Director of Therapy. The current records and care plans will be reviewed and updated for new admissions, quarterly and significant changes on an on-going basis by the MDS Coordinator and Director of Therapy. What measures will be put in place or what systemic changes will be made to ensure that the deficient practice will not reoccur? 1. Education began on 5/27/21 conducted by the Director of Health Services (DHS) for all staff/all departments to include but not limited to licensed nurses and nursing assistants on Change of condition to include but not limited to: a. Facility uses Interact program to provide guidance to nurses on when to communicate acute changes in resident condition provider. The change in condition file cards are decision support tools for the nursing staff to help with determining whether to report specific symptoms, signs, and lab results immediately, vs. non immediately (e.g. the next day). This was reviewed with all staff at an in-service that was provided on 05/27/21 and completed on 06/01/21. b. Notification - immediately to the physician when the resident has a medical change in condition. c. What a change in condition is: i. An incident to include but not limited to skin tear, fall, bruise, etc. depending on type, location and severity of injury ii. Injury known or unknown origin iii. Transfer to the hospital iv. Allegation of abuse or neglect d. Notification of the Director of Nursing of the change of condition. e. Assessment/observation of the change in condition should be documented in nurse's notes or via SBAR (Situation, Background, Appearance, Review and Notify) at time of note of change which includes but not limited to: i. Vital Signs ii. Head to toe assessment/observation iii. Pedal pulses iv. Lung sounds v. Bowel sounds vi. Nurses notes Any staff not receiving education due to scheduled time off or FMLA will be educated before their next scheduled shift. Education will also be added to new partner orientation on a go forward basis. The DHS is tracking education to ensure education has been completed. 2. Education began on 05/27/21 conducted by the DHS for all staff/all departments on the following policies: · Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property: · Definition of abuse and neglect · Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property policy to include but not limited to: · Reporting within 2 hours after an allegation is made if an event upon which the allegation is based involve abuse or results in serious bodily injury · Reporting within 24 of a suspicious crime however if the suspicious crime involves serious bodily injury to the patient, the incident should be reported to local law enforcement within 2 hours after forming the suspicious. · Investigating of Patient Abuse, Neglect, Exploitation, Mistreatment and Mistreatment, and Misappropriation of Property: · If and injury has occurred including an injury of unknown origin, or abuse, neglect and occurrence report with supervisory investigation should be completed · Completed witness statements form all staff · Any staff not receiving education due to scheduled time off or FMLA will be educated before their next scheduled shift. Education will also be added to new partner orientation on a go forward basis. The DHS is tracking education to ensure education has been completed. 3. Nurse management will review the Facility Activity Report (24-hr report) daily and DHS will review the report on Fridays beginning on 05/27/21 of resident's incidents and accidents report for change of condition documentation and notifications of providers and responsible party time 4 weeks then monthly. Nurse Manager will review weekend reports remotely. The report will capture any significant changes of condition, ongoing audits will be determined based on the results. Audit tools will be reviewed by the Administrator and the DHS weekly and during the monthly QAPI committee meeting until substantial compliance is achieved. 4. ADHOC Quality Assurance Performance Improvement meeting was held on 5/27/2021 conducted by the Administrator and DHS to discuss the plans other interventions were identified as below a. The DHS and Nurse management staff will conduct weekly observation of 10 residents for transfer status beginning 05/28/21 to ensure resident is being transferred appropriately as determined by care plan times 4 weeks then monthly. Ongoing audits will be determined based on the results. Audit tools will be reviewed by the Administrator and the DHS weekly and during the monthly QAPI committee meeting until substantial compliance is achieved. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained 1. The DHS will review the results from the audits conducted from the incidents and accidents report to ensure that the change in condition documentation and notification of the physicians and DHS were completed. This information will be reviewed at the monthly QAPI committee meeting times 3 months or until substantial compliance is achieved. 2. The DHS will review the audit tools related to the transfer from bed to chair and will be reviewed during the monthly QAPI committee meeting times 3 months or until substantial compliance is achieved. Date of Completion: June 1, 2021 The Corrective Action plan was validated on 06/16/21 and concluded the facility implemented an acceptable corrective action plan on 06/01/21 as evidenced by facility documentation and staff interviews. Review of the in-service attendance sheets 05/27/21 to 06/01/21 revealed all staff received education on the facility's abuse policy, timely reporting of suspected abuse, injuries of unknown origin and procedure for acute change in condition to include assessment, observation and timely notification. Review of the document utilizing the 05/27/21 resident census revealed all residents were assessed for transfer status and care plans updated accordingly. Review of the facility's audit tools completed 05/27/21 to 06/13/21 revealed no identified concerns. Interviews conducted with staff confirmed they received in-service education and were able to describe what to do when an acute change was identified, which included completing and documenting a thorough assessment, when to report and who to notify of the acute change.

Based on observations, record review and physician and staff interviews, the facility failed to prevent a cognitively impaired resident with known wandering and exiting seeking behaviors from exiting the facility unsupervised on three separate occasions. This affected 1 of 3 residents reviewed for accidents (Resident #2). While Resident #2 was outside unattended, there was a high likelihood for serious injury. The findings included: Resident #2 admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and history of falls. A care plan initiated on 01/09/21 noted Resident #2 was at risk for falls related to generalized weakness, poor safety awareness, history of falls and an actual fall on 01/09/21 with the goal he would not sustain an injury. Interventions included: assist with toileting and transfers as needed, cue for safety awareness and place call light within reach. A care plan initiated on 01/11/21 noted Resident #2 was an elopement risk based on the high-risk score from his admission elopement assessment with the goal he would not elope from the facility through the next review. Interventions included: consider placing a wanderguard on the resident for exit seeking behaviors, monitor his location closely, and redirect as needed. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #2 with severe impairment in cognition for daily decision making. He required supervision with walking and locomotion, used no mobility devices and displayed wandering episodes daily during the MDS assessment period that placed him at significant risk of getting to a potentially dangerous place. a. Nurse's progress note written on 02/25/21 at 1:25 PM by Nurse #1 read in part, frequent attempts to get out. Resident #2 opened his room window earlier this morning and said he was trying to leave. Staff able to redirect only for short periods of time. Telephone attempt to speak with Nurse #1 on 06/15/21 at 11:38 AM was unsuccessful. Nurse's progress note dated 02/28/21 at 11:24 AM written by Nurse #2 read in part, while doing rounds, Resident #2 was not found anywhere on unit. In another resident's room, the window was found unlocked with the screen pushed out. Resident #2 was found in the woods behind the building and returned inside with staff calmly. No injuries were identified and vitals stable upon assessment. During a telephone interview on 06/04/21 at 3:20 PM, Nurse Aide (NA) #2 stated on 02/28/21, she could not recall the exact time but sometime after breakfast she had started doing her rounds on the Memory Support Unit (MSU) when she noticed Resident #2 standing by the window in another resident's room. When she asked him what he was doing, he replied nothing, just looking out the window. NA #2 stated she really didn't think much about it and went into the resident room next door to provide care. Approximately 5 to 7 minutes later as she was exiting the resident's room, Dietary Aide (DA) #1 came to the unit to let them know he was outside the building. NA #2 stated she immediately went outside to get him; he was near the wooded trees behind the building and came back inside without incident. She added he had no visible injures or appeared to be in any distress. During a telephone interview on 06/09/21 at 2:52 PM, DA #1 recalled sometime before lunch on 02/28/21 she had stepped out the back of the building from the kitchen to take a break and noticed someone walking down the road toward her from the left side of the building. DA #1 added she realized it was Resident #2, went back into the kitchen and told other dietary staff who then went out to get Resident #2 while she went to alert staff on the MSU. When she got back outside, the dietary staff and another NA were already walking the resident back toward the facility. She did not recall Resident #2 displaying any signs of distress as he was led back into the facility. During a telephone interview on 06/04/21 at 9:49 AM, Nurse #2 stated Resident #2's normal behavior was to wander around the MSU and exit-seek and staff all try to keep an eye on him. On 02/28/21, Nurse #2 recalled she and NA #2 started looking for him and realized he wasn't on the unit. They both started doing room checks and discovered a screen pushed out of an opened window in another resident's room. Nurse #1 stated she immediately called the facility's missing person code; an all staff search was started of the premises and Resident #2 was found out behind the building near the wooded area and brought back into the building. She added he was found within a few minutes of calling the code. Nurse #2 reported upon assessment, Resident #2 had no injuries, vitals were stable, and he voiced no complaints of pain or distress. Nurse #2 could not recall the last time Resident #2 was on the unit prior to finding him outside around 11:00 AM to 11:30 AM. Nurse #2 added they tried hard to keep an eye on all the residents on MSU but it could be challenging when there was only one Nurse and one NA. An observation of the room where Resident #2 opened the window and exited the building on 02/28/21 was conducted with the Administrator on 06/09/21 at 11:05 AM. The window slid open to the left and drilled into the window frame was a screw that prevented the window from opening more than 6 inches. The room was located at the end of the hall facing the backside of the building and property. The distance from the window on the side of the building to the opposite edge of the road was approximately 20 to 25 feet. When turning from the main road onto the driveway of the facility, the distance from the driveway entrance to the facility was .2 miles or 1,056 feet. Each side of the driveway headed toward the facility, the driveway around the perimeter of the building and parking lots were surrounded by trees that separated the facility from other residential homes and wooded areas. Resident #2 was noticed walking along the road toward the middle, back area of the building where the dumpsters, kitchen, parking spaces and maintenance building were located. An online website named Custom Weather was used to obtain the outside weather in the [NAME] area on 02/28/21 and noted at 10:54 AM and 11:54 AM the temperature was 66 degrees Fahrenheit with wind speeds of 16 miles per hour (mph). The facility's investigation timeline provided by the Administrator revealed the following details upon Resident #2's return to the facility on [DATE]: Resident #2 was assessed by the nurse, a head count was completed of all residents on the memory care unit and additional staff were assigned during waking hours to assist with observation of Resident #2's location. It was discovered the memory care unit had a window alarm system that was disarmed, leadership staff were unaware the system existed, and the alarm company was notified to have it reactivated. Each shift, staff ensured all windows were closed and locked. b. Nurse's progress note written on 03/03/21 at 2:56 PM by Nurse #3 read in part, Resident #2 was last seen on the unit at approximately 2:10 PM. At 2:20 PM, staff were notified he was located on the road outside of the facility. Resident #2 was returned to the facility and upon nurse assessment, had no apparent injury, vitals were stable and mental status at baseline. Upon inspection, window screen was observed pushed out of another resident's room window and laying on the ground. Telephone attempts on 06/04/21 at 3:15 PM and 06/10/21 at 4:10 PM to speak with NA #3 were unsuccessful. During a telephone interview on 06/07/21 at 9:46 AM, Nurse #3 confirmed he was assigned to work on the MSU 03/03/21 7:00 AM to 7:00 PM when Resident #2 eloped from the building. Nurse #3 recalled Resident #2 had been wandering around the unit that day as normal and at approximately 2:00 PM, he was sitting out in the common area with Nurse #3, NA #3 and other residents on the unit but would frequently get up and make loops around the unit. About 5 to 10 minutes later, Nurse #3 stated he and NA #3 noticed Resident #2 was no longer in the common area with them and when they began looking for him, they discovered a screen was pushed out of one of the resident's unlocked window. Around that same time, Nurse #3 stated he was notified by staff (could not recall who) that Resident #2 was outside on the main driveway entrance and he was immediately brought back into the facility without incident. He could not recall the exact location where Resident #2 was found but stated he had stepped off the driveway and was headed toward the wooded area. Nurse #3 stated once Resident #2 was back in the building, he was assessed with no injuries identified, his vitals were within normal limits and he was placed on one-to-one supervision for the remainder of the shift. He added later that same afternoon, the windows in the resident rooms on MSU were fixed so they would only open a few inches. Nurse #2 explained there was usually one Nurse and one NA assigned on the MSU and residents were usually kept out in the common area of the unit with staff for supervision. He added with residents that that frequently wandered, staff checked on their whereabouts frequently. He didn't recall receiving any specific education after the first elopement incident on 02/28/21 other than making sure the windows were locked and Resident #2's whereabouts monitored. An observation of the room where Resident #2 opened the window and exited the building on 03/03/21 was conducted with the Administrator on 06/09/21 at 11:05 AM. It was the same room and window he exited from on 02/28/21. Facility staff were unable to state the exact location on the driveway or how close to the entrance where Resident #2 was found. An online website named Custom Weather was used to obtain the outside weather in the [NAME] area on 03/03/21 and noted at 1:54 PM the temperature was 58 degrees Fahrenheit with wind speeds of 13 mph. At 2:54 PM the temperature was 60 degrees Fahrenheit with wind speeds of 13 miles mph. The facility's investigation timeline provided by the Administrator revealed the following details upon Resident #2's return to the facility on [DATE]: Resident #2 was assessed by the nurse, a head count was completed of all residents on the memory care unit and floor tech assigned for the day to provide one-to-one supervision to Resident #2. Alarm company had still not arrived on-site to evaluate the window alarm system. On 03/04/21, window stops were placed on all windows allowing them to only open 6 inches to eliminate risk of elopement. Resident #2's elopement care plan was revised on 03/04/21 with an intervention added for staff to ensure windows were secured and safety checks were completed throughout each shift. A physician's progress noted dated 03/09/21 noted Resident #2 was seen for follow-up of dementia with behavioral disturbances and read in part, his dementia has progressed to the point he needs constant supervision and care. He has an awareness that something isn't right but does not understand what. His medications were reviewed with no changes and instructions were for staff to continue to try and redirect as possible. c. Nurse's progress note written on 03/12/21 at 6:10 PM by Nurse #2 read in part, Resident #2 wandering unit this shift and was seen trying to unlock the front door but was unable and came back to common area. When passing out dinner trays, he was not in his room. All staff were alerted, Resident #2 was found outside on premises and brought back into the facility. Assessment completed and no injury noted. During a telephone interview on 06/04/21 at 3:20 PM, NA #2 recalled on 03/12/21 she was working on the MSU with Nurse #2 when Resident #2 eloped from the building. NA #1 stated she remembered seeing Resident #2 around 4:00 PM to 4:15 PM when she started doing incontinence rounds before dinner. She did not remember how long it took her to complete her rounds but stated the dinner trays were usually delivered to the unit around 5:00 PM. As she started to help Nurse #2 pass out the meal trays, she noticed Resident #2 was not on the unit and an all staff search was started. NA #2 was not sure of the exact location but stated he was found outside near the wooded area beside the building. NA #2 explained since the window screen alarms had already been repaired by this time, the only thing they could determine was he followed the dietary staff off the unit when they delivered the meal trays due to a delay on the front entrance door locking system. She added, after this incident the facility had the entrance door fixed and a new keypad installed which fixed the delay. NA #2 stated there were usually one Nurse and one or two NAs assigned to the MSU. She explained when there was only a Nurse and NA assigned to MSU, it was more difficult to provide constant supervision of the residents; however, they worked together to make sure one of them was supervising the residents if the other staff member was providing care. During an interview on 06/09/21 at 11:26 AM, Nurse #2 confirmed she was assigned to the MSU on 03/12/21 7:00 AM to 7:00 PM when Resident #2 eloped from the building. Nurse #2 stated it was around dinner time as the meal trays had been delivered to the unit when she and NA #2 discovered he was not in his room. Nurse #2 stated she immediately called the missing person code, an all-staff search was started, Resident #2 was found outside the building by the Former Assistant Director of Nursing (FADON) and immediately brought back inside the building. Nurse #2 stated once Resident #2 was back in the building, he was assessed with no injuries identified. She explained they had been keeping a close eye on him due to his exit-seeking and the only thing they could determine was he must have gotten out the front door when dietary staff delivered the meal trays. During a telephone interview on 06/11/21 at 3:33 PM, the FADON explained staff were aware of Resident #2's exit-seeking behaviors and tried their best to keep their eyes on him. On 3/12/21, the FADON recalled she was working on the opposite side of the facility when she heard the missing person code and an all staff search was immediately conducted. She explained since he was found along the driveway toward the front entrance the last time he eloped, she decided to get into her vehicle to go and search for him while staff searched the other areas of the premises. The FADON stated as she was driving down the driveway toward the entrance, she looked off to the left side and noticed Resident #2 standing in a clear spot of field that led straight into a wooded area. She stopped her car, ran over to where he was standing, and when asked what he was doing he replied, I was looking for you. He was agreeable to get into the car with her and they both returned to the facility without further incident. She explained when you stood on the porch in front of the MSU front entrance, to the right of the building was the driveway that led out to the main road and she found him approximately two-thirds down the driveway from the building to the stop sign. The FADON added upon assessment, Resident #2 had no injuries from his elopement. The FADON stated after talking to staff, she couldn't get a clear story as to how he was able to get off the unit and explained the NA assigned to the unit was in the shower room with another resident while the floor technician and Nurse were monitoring the other residents and in the blink of an eye, he was gone. She added they identified a delay in the front entrance locking system and assumed that was how he was able to get out of the building. The FADON stated at the time, dietary staff used the front entrance to deliver meal trays as well as other facility staff when coming in and out of the building but no one was going to admit that they did not check to make sure the door locked back when it was opened. After that incident on 03/12/21, she reported all staff were educated to stand and wait for the door to close and lock back securely before leaving the area. The FADON voiced the staff on the MSU really looked out for the residents but it was hard providing constant supervision when there was only one Nurse and one NA on the unit. An observation of the front entrance door to the Memory Support Unit (MSU) was conducted on 06/09/21 at 11:05 AM. The entrance doors opened to a covered porch leading out to the driveway and parking lot. To the right of the door as you exited the porch was an area of grass leading to the side road that circled the perimeter of the building to the main driveway that led in and out of the facility. The side road to the right of the building was approximately 60 feet from the edge of the porch. When turning from the main road onto the driveway of the facility, the distance from the driveway entrance to the facility was .2 miles or 1,056 feet. Each side of the driveway headed toward the facility, the driveway around the perimeter of the building and parking lots were surrounded by trees that separated the facility from other residential homes and wooded areas. An online website named Custom Weather was used to obtain the outside weather in the [NAME] area on 03/12/21 and noted at 4:54 PM the temperature was 69 degrees Fahrenheit with wind speeds of 13 mph. The facility investigation timeline provided by the Administrator revealed the following details upon Resident #2's return to the facility on [DATE]: Resident #2 was assessed by the nurse, a head count was completed of all residents on the memory care unit and no point of elopement was identified; however, a 45 second delay was identified on the front entrance door of the unit before the door locked back after opening. Alarm company notified. Education provided to all staff to remain at the door until a red light appeared and then manually ensure door was locked before leaving the door. During an interview on 06/09/21 at 10:45 AM, the Administrator stated she started employment at the facility on 03/04/21 but was provided a timeline by the former DHS of Resident #2's elopements from the facility. The Administrator stated after Resident #2 eloped on 02/28/21, they discovered there was a non-functioning window screen alarm system on the MSU. She explained on 03/01/21 when they contacted the alarm company for them to come onsite to assess the alarm system, they were told there would be a two-week waiting period. She added they had also contacted other alarm companies in the area but were unable to locate one that could come onsite any sooner. After Resident #2's second elopement on 03/03/21, the Administrator explained window stoppers where placed on all the windows in the MSU to prevent them opening more than 6 inches and the alarm company they originally contacted arrived onsite 03/09/21 and repaired the window screen alarm system. On 03/12/21, the Administrator explained the floor technician had been sitting with Resident #2 all afternoon and around dinner time, he started assisting staff pass out dinner trays, turned around to look for Resident #2 and noticed he was gone. She added they discovered there was a delay with the entrance door lock and the only thing they could determine was when dietary staff brought trays to the unit, he must have exited through the front door after the dietary staff left the unit. The Administrator since the window screen alarm system and delay in the entrance door lock were both repaired, there have been no further incidents of elopements. During a telephone interview on 06/16/21 at 1:55 PM, the Medical Director (MD) confirmed it would not be safe for Resident #2 to be outside unsupervised due to the severe impairment in his cognition. The facility provided the following Corrective Action Plan with the correction date of 03/23/21: The facility failed to supervise a cognitively impaired resident with wandering behaviors from exiting the facility unsupervised on three separate occasions. What Corrective action will be accomplished for the residents found to have been affected by the deficient practice? 2/28/21 * Resident #2 was admitted on [DATE]. Resident #2 exited the facility unsupervised from the Memory Support Unit (MSU) on 02/28/2021 and was observed by dietary staff at approximately 11:26 am standing at edge of woods behind the facility. Resident was last observed ambulating in unit around 11:15am. Resident #2 was assisted back to the facility. Assessment was completed upon return to facility. No injuries were found. Upon admission his BIMS score was 2 (severe cognitive impairment). Elopement Risk Assessment was performed on admission. Resident was identified as high risk; therefore, he was admitted on the Memory Support Unit (MSU). He was care planned for elopement risk upon admission. * Resident rooms were inspected in the unit on 02/28/21 following the incident and window in Room 12 was found open and screen pushed out. It was determined that resident had climbed out of another resident's window. * Nonclinical staff scheduled on unit during waking hours on 02/28/21 for additional support and visual observation of Resident #2. * During the unit inspection on 02/28/21 after the incident, it was determined that the facility has an existing window alarm in the MSU but has not been activated for more than a year. 3/3/21 * Resident #2 exited the facility unsupervised on 03/03/2021 and found at end of the facility driveway at approximately 2:20 pm by the Sheriff's Department. The distance from the point of exit to the facility driveway is 2/10 of a mile. Resident was transported back to facility via vehicle by Sheriff's Dept. Resident was last observed walking in the halls of the MSU at 2:10 pm. Assessment was completed on 03/03/2021. No injuries were found. * Upon return to unit, resident was placed on one on one observation during waking hours for closer monitoring. This continued for 24 hours. * Resident rooms and unit inspection completed on 03/03/21. During the inspection the window in Room 12 was found open and screen pushed out. It was determined that resident had climbed out again of the same window, same as the previous incident on 02/28/21. 3/12/21 *Resident #2 exited the facility unsupervised on 03/12/2021. Resident #2 was observed on right side of the building by staff at 5:08pm. Resident was last observed in dining room at approximately 4:10pm. Staff assisted resident back to facility. Assessment was completed 03/12/21. No injuries were found. * Upon return to facility, Resident #2 was placed on hourly visual checks through 03/16/2021. * Resident rooms were inspected on 03/12/21. All windows are locked and screen intact. * Window alarm tested on [DATE] and was found to be functioning. All window screens will need to be intact and attached for the window alarm not to be activated. * The Assistant Director of Health Service inspected the exit doors on unit on 03/12/21 after the incident. Upon inspection, a 30 second delay in the locking mechanism system of the front door of Memory Care Unit (MSU) was identified. * It was determined that resident may have exited the front door of the MSU when the dinner meal trays were delivered. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? *Elopement Book was reviewed by Director of Health Service (DHS) on 03/04/21 to ensure all high-risk elopement residents have appropriate intervention and identified on facility elopement book. Elopement Book is kept at each nurse's station and at front desk. Each resident at MSU and residents with Wanderguard has a face sheet and a picture in the book for ease of identification. This is to identify residents at high risk for elopement. Facility will continue to complete elopement risk assessments upon admission, every quarterly and significant change to identify high risk wanderers per policy. What measures will be put in place or what systemic changes will be made to ensure that the deficient practice will not reoccur? 2/28/21 * The DHS provided education to all MSU staff on 02/28/21 to ensure all windows are closed and locked every shift. The remaining facility staff including nursing, activities, therapy, laundry, housekeeping, central supply, maintenance, dietary and business office were educated on checking all windows are closed and locked when rounding in MSU. All other staff who are on FMLA or otherwise out will receive in-service prior to returning to work. * Alarm Company was contacted on 03/01/2021 to evaluate status of existing window alarm and request was made to reactivate the alarm. * Maintenance Director made several follow-up calls and facility placed on two-week waiting list due to volume of calls and referrals at the alarm company. 3/3/21 * Window stops were placed on all windows allowing windows to open approximately 6 inches on 03/04/21. * Social Worker sent referrals on 03/04/2021 to other facilities specific to behavior management. * On 03/03/21 request also sent for psychiatry consult for increased behavior and exit seeking. Chart review showed resident was just recently seen by Psychiatry on 03/02/2021 and no changes were made on medication at that time. Follow up referral was made to request for alternative intervention or possible alternative placement. * A Town Hall Meeting was held on 03/06/2021 at various times. This meeting was for all staff members/all departments. Agenda items included but were not limited to significance of resident elopement, completing Elopement Risk Assessment Form upon admission, every quarterly significant change and/or annually per policy, elopement book location at nurse's station and front desk. Facility had a memory support resident who was able to elope from facility so systems where put into place so this incident will not happen again, and staff was explained as to what their roles are to prevent this from happening again. Roles to include but not limited to the doors locked, door alarms functioning, windows are locked and functioning. Staff was also educated on resident behavior indicators, resident verbalizing to go home, packing their belongings or history of exit seeking. Previous Director of Health Services followed with up employees that did not attend the Town Hall Meeting and ensure that they were educated on materials presented on the meeting. *Alarm company onsite on 03/08/21 and repair was made on window alarm. Window alarm in MSU activated. 3/12/21. * The DHS held in-services on 03/12/21 and completed on 03/16/21 with all staff to review the delay on the locking mechanism on the front door in MSU. All staff exiting the MSU through front door will remain at door until red light appears and manually ensure door is locked before leaving front door. The DHS tracked the employee education. * All staff were educated by DHS on 03/12/21 to 03/16/21 on residents at risk for elopement and elopement prevention program. Inservice included but not limited to delay in locking system of MSU door, staff needing to wait until panel light turn red, the completion of resident elopement risk assessment and the intervention put in place. The DHS tracked the employee education. The Elopement Program includes management of patients/residents residing in the facility and procedure for elopement risk assessment. Also discussed resident behaviors that put them at high risk such as verbalizing desire to go home, packing belongings or history of exit seeking. * All other staff who are on FMLA or otherwise out will receive in-service prior to returning to work. All Department Managers are responsible of keeping track of in-services in each department. * Alarm company was contacted to evaluate the delay on the locking mechanism on the keypad on 03/12/21. Alarm company was onsite on 03/14/2021 and replaced keypad on MSU door. This fixed the delay on the keypad. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: * During the monthly Quality Assurance and Performance Improvement (QAPI) meeting on March 23, 2021, elopement incidents and controls were discussed. This includes the checking of Wanderguard door to ensure functioning. This is done by using the Wanderguard checker, the light on the Wanderguard checker turns green to confirm the Wanderguard system on door is functional. The Maintenance Director checks Wanderguard system door which include front door and MSU door daily during the week, Manager on duty on weekends, to ensure function of keypad. Residents residing in the locked MSU do not require a Wanderguard. * The elopement program was also reviewed during the QAPI meeting on March 23, 2021. MDS Coordinator reviewed the process utilizing the Elopement Risk Assessment Form and reviewed Wanderguard orders. * The Elopement Book was reviewed 03/13/21. The Elopement Book is in each nurse's station and at the front desk. Each resident at high risk for elopement has a face sheet and a picture printed and placed in the Elopement Book. This is determined by completing an Elopement Risk Assessment Form upon admission, quarterly, significant change and/or quarterly. A resident with a score of 11 or higher will be considered a high risk and interventions put in place. Face Sheets of residents on MSU are in the Elopement Book and residents with Wanderguard are also in the elopement book. * The DHS and/or designee will audit the Elopement Book every week times 4 weeks, then every other week times 2 weeks, every month times 2 months to ensure the book is up to date and current. These audits began on 03/16/21. * The MDS Coordinator will audit Elopement Risk Assessment Form completion every week times 4 weeks then monthly times 4 months. These audits began on 03/16/21. ** Note: After review of audits, unable to locate previous documentation from elopement or elopement assessments but was able to validate and findings reviewed on monthly QAPI in March, April and May 2021. *The Maintenance Director will audit function of keypad of the MSU front door daily times 4 weeks, Manager on duty on weekends, then monthly times 2 months. These audits began on 03/16/21. * The Maintenance Director will audit function of window alarm daily, Manager on duty on weekends times 4 weeks, then monthly times 2 months. These audits began on 03/16/21. * Ongoing audits will be determined based on the results of prior audits. Audit tools will be reviewed by Administrator and/or DHS weekly and results will be presented during the monthly QAPI Committee Meetings until substantial compliance is achieved. Date of Completion: 3/23/2021 The Corrective Action Plan was validated on 06/16/21 and concluded the facility implemented an acceptable corrective action plan on 03/23/21 once the window screen alarm system was reactivated on the MSU, the locking mechanism for the front entrance door to the MSU was replaced and the elopement plan was reviewed during QAPI meetings held on 03/23/21, 04/28/21 and 05/31/21. The daily monitoring report of the facility exit doors and window screen alarms for March 2021 to June 2021 were reviewed with no concerns identified. Observations conducted with the Administrator and Maintenance Director on 06/09/21 revealed when a screen was removed from a window of the MSU, the panel next to the nurses' station identified the room number and alarm sounded. When the Administrator entered the code into the keypad panel, the alarm turned off for a few seconds and then started to alarm again until the Maintenance Director placed the screen back into the window. The alarm turned off once the window screen was secure and the code was reentered into the panel. The front entrance door to the MSU had a key panel, when the door was opened, the light turned green and once the door was shut, it automatically locked within a few seconds and the light on the keypad panel turned red. Elopement books were observed at each nurses' station t [TRUNCATED]