Every finding on record at Warren Hills Nursing Center

Based on observation, record review and staff interviews the facility failed to implement their infection prevention program policies and procedures and follow their Hand Hygiene policy when Nurse #3 failed to perform hand hygiene and change gloves when flushing a peripherally inserted central catheter (PICC) line (a long thin flexible tube inserted through an arm vein near the heart for long term intravenous access) and connecting the intravenous (IV) antibiotic tubing to the PICC line tubing. In addition, the Wound Treatment Nurse failed to change the disposable gloves and perform hand hygiene during wound care observation for Resident #2 and Resident #22. The deficient practice occurred for 2 of 4 staff observed for infection control practices (Nurse #3 and Wound Nurse).The findings included: The facility's Infection Prevention and Control Standards policy, last approved September 2025, revealed the purpose of the policy was to implement the Infection Prevention and Control Program (IPCP) to minimize the risk of infection to the residents and staff. The policy further read that staff were to support resident safety by adhering to all policies and procedures related to infection prevention including standard and transmission-based precautions. The facility's Hand Hygiene policy, last approved June 2025, stated that hand hygiene was regarded as the single most important means of preventing the spread of infections. The policy further noted that hand hygiene was to be performed after contact with non-intact skin, before performing dressing care or touching wound of any kind, after handling used dressings, and after touching equipment or furniture that is near a resident. The IV Therapy policy last approved on October 2025 read in part that the PICC line flushing procedure stated the nurse was to wash hands thoroughly prior to flushing the PICC line. 1. A continuous observation of medication administration for Resident #28 was conducted with Nurse #3 on 2/24/26 at 9:13 am through 9:19 am. Nurse #3 was observed to don gloves, remove and prepare prescribed medications from the medication cart outside Resident #28's room. Nurse #3 was then observed to depress and lock the medication cart, gather the medications, which included IV antibiotics and enter Resident #28's room without removing her gloves or performing hand hygiene. Nurse #3 then administered the oral medications to Resident #28 and proceeded to prepare the IV antibiotics for administration through the PICC line in the right upper arm of Resident #28. Without removing her gloves and performing hand hygiene, Nurse #3 then hung the bag of IV antibiotics on the IV pole, inserted the end of the new IV tubing into the antibiotic bag, and primed the IV tubing (filled the tubing with the solution from the IV medication to remove air). Nurse #3 then opened the IV pump chamber and placed the IV tubing in the chamber and closed the chamber latch with the gloved hand. Nurse #3, without removing the gloves and performing hand hygiene, then removed the disinfecting cap from the PICC line, wiped the hub with an alcohol wipe, flushed the PICC line with normal saline, connected the IV tubing from the antibiotic to the PICC line and started Resident #28's IV antibiotics. Nurse #3 was observed to remove her gloves and perform hand hygiene with hand sanitizer and exited Resident #28's room at 9:19 am. An immediate interview was conducted with Nurse #3 on 2/24/26 at 9:20 am who revealed she should have removed the gloves after pulling the medications from the medication cart, performed hand hygiene, and put on clean gloves before working with Resident #28's IV antibiotic and PICC line. Nurse #3 was unable to state why she did not remove the gloves and perform hand hygiene before working with Resident #28's PICC line, she stated she just didn't do it. The Infection Preventionist (IP) was interviewed on 2/26/26 at 8:57 am and revealed Nurse #3 should have removed the gloves and performed hand hygiene before she entered Resident #28's room to administer medications. The IP stated Nurse #3 was to perform hand hygiene and don clean gloves before she flushed the PICC line and administered the IV antibiotics to Resident #28. The Director of Nursing (DON) was interviewed on 2/25/26 at 4:22 pm. The DON stated that Nurse #3 should have removed the gloves worn and performed hand hygiene after preparing the medication, touching the medication cart, IV pole, and IV pump. The DON stated Nurse #3 was required to perform hand hygiene prior to flushing the PICC line and starting Resident #28's IV antibiotic. During an interview with the Administrator on 2/26/26 at 12:19 pm she revealed Nurse #3 should have performed hand hygiene prior to starting the process of administering Resident #28's IV antibiotic. 2. A continuous observation of Resident #2's pressure ulcer treatment was conducted on 2/24/26 at 11:48 am through 12:00 pm with the Wound Treatment Nurse. The Wound Treatment Nurse was observed to perform hand hygiene, don clean gloves and prepared to cleanse Resident #2's sacral and left buttock pressure ulcers. The Wound Treatment Nurse was observed to spray the wound bed of the stage 4 sacral pressure ulcer with wound cleanser and wipe the wound bed with gauze. The stage 4 sacral pressure ulcer presented with slough (yellow/white, dead tissue that accumulates in the wound which harbors bacteria) present on the wound bed. The Wound Treatment Nurse then sprayed the stage 3 left buttock pressure ulcer with wound cleanser and wiped the wound bed with gauze. The Wound Treatment Nurse did not change gloves or perform hand hygiene after cleansing the stage 4 pressure ulcer and before cleansing the stage 3 pressure ulcer. The Wound Treatment Nurse was then observed to prepare and place the new wound treatment dressings on Resident #2's sacral and left buttock wounds. The Wound Treatment Nurse did not remove the soiled gloves or perform hand hygiene after cleansing Resident #2's pressure ulcers or before preparing and placing the wound treatments. The Wound Treatment Nurse was observed to remove soiled gloves and perform hand hygiene and exited Resident #2's room at 12:00 pm. An immediate interview was conducted with the Wound Treatment Nurse on 2/24/26 at 12:01 pm. The Wound Treatment Nurse stated she should have removed the soiled gloves and performed hand hygiene between cleaning the wounds and putting on new dressings. The Wound Treatment Nurse stated she was nervous and just forgot to change her gloves. An interview was conducted on 2/26/26 at 8:56 am with the Infection Preventionist (IP) who stated the Wound Treatment Nurse should have removed the soiled gloves and performed hand hygiene after cleansing Resident #2's pressure ulcers. The IP stated the new treatment dressings should not have been placed on the wound bed with the soiled gloves. During an interview with the Director of Nursing (DON) on 2/25/26 at 4:22 pm she revealed the Wound Treatment Nurse should have removed the gloves and performed hand hygiene after cleansing the wound beds and putting the new dressings on to prevent contamination of the new dressings. The Administrator was interviewed on 2/26/26 at 12:19 pm. The Administrator stated the Wound Treatment Nurse had been educated on the hand hygiene policy and should have followed the policy when the pressure ulcer treatment was completed. 3. An observation was conducted of wound care with the Wound Nurse for Resident #22 on 2/24/26 at 2:17 PM. The Wound Nurse was already in the resident's room when the surveyor entered the room. The Wound Nurse performed hand hygiene, donned a gown and clean gloves. The Wound Nurse removed the old dressing and without removing her gloves and performing hand hygiene the Wound Nurse proceeded to clean the pressure ulcer to Resident #22's left buttock with gauze soaked in wound cleanser. Without changing her gloves or performing hand hygiene the Wound Nurse opened the new dressings. The Wound Nurse then removed her gloves and completed hand hygiene. The Wound Nurse donned a new pair of gloves and placed calcium alginate (wound dressing) to the wound bed. The Wound Nurse then applied Zinc Oxide ointment to the wound edges and outer wound area. She then applied a dry dressing to left buttock wound, gathered trash, removed her gloves and completed hand hygiene. The Wound Nurse assisted Resident #22 on his back with the head of bed elevated. During an interview with the Wound Nurse on 2/24/26 at 2:33 PM, the Wound Nurse stated she should have removed her gloves and performed hand hygiene after removing the old dressing and prior to cleaning the wound. The Wound Nurse stated she became nervous and forgot this step. During an interview with the Infection Preventionist on 2/24/26 at 3:10 PM it was revealed that all staff received infection control training which included hand hygiene annually. The IP stated the Wound Nurse should have removed the old dressing, performed hand hygiene and donned a new pair of gloves prior to cleaning the wound. An interview was conducted with the Director of Nursing on 2/24/26 at 3:35 PM. The DON stated the Wound Nurse should have performed hand hygiene and changed her gloves to prevent cross contamination of Resident #22's wound. The DON stated the Wound Nurse should have performed hand hygiene and changed her gloves after removing the old dressing and prior to cleaning the wound.

Based on observation, record review, and interviews with staff, the Consultant Pharmacist, and the Physician Assistant, the facility failed to evaluate the continued need for a medication prescribed for wheezing. This deficient practice had the potential to result in residents receiving medications without clinical indication, ongoing monitoring, or justification of continued use for 1 of 6 residents reviewed unnecessary medications (Resident #75).The findings included:Resident #75 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbances, pleural effusion (abnormal accumulation of excess fluid in the space between the lungs and chest wall), and congestive heart failure (CHF). The nursing progress note dated 11/20/25 at 8:03 pm revealed the Physician Assistant (PA) was notified by Nurse #2 that Resident #75 had a wheeze (a high-pitched, whistling sound produced during breathing caused by narrowed or obstructed airways). Nurse #2 noted that the PA ordered a chest x-ray and ipratropium bromide 0.5 milligram (mg)/albuterol sulfate 2.5 mg, 3 mg/3 milliliters, inhalation solution (combination bronchodilator medication used via a nebulizer to open airways and reduce mucus) every 4 hours.Resident #75 had an active physician order dated 11/20/25 for ipratropium bromide 0.5 milligram (mg)/albuterol sulfate 2.5 mg, 3 mg/3 milliliters, inhalation solution. Administer one (1) inhalation orally via nebulizer (medical device used to deliver medication directly to the respiratory system) every 4 hours for wheezing. The health status note dated 11/23/25 revealed Resident #75's radiology results for the chest x-ray revealed no acute findings. The PA was notified and no new orders were received.The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #75 had moderate cognitive impairment with unclear-slurred or mumbled words.The Medical Director visit note dated 12/02/25 revealed Resident #75 denied chest pain and shortness of breath. Resident #75 was noted to have even and unlabored respirations which were clear to auscultation (listening by stethoscope).The Medical Director visit note dated 1/20/26 revealed Resident #75 denied chest pain and shortness of breath. Resident #75 was noted to have even unlabored respirations which were clear to auscultation.The PA visit note dated 1/30/26 revealed Resident #75 had no complaints, denied any chest pain, shortness of breath, or other discomforts. The PA further noted the resident did not exhibit any signs of respiratory distress and was found to have clear lungs without wheeze. The Medical Director visit note dated 2/17/26 revealed Resident #75 denied any shortness of breath and was noted to have even and unlabored respirations which were clear to auscultation.The Medication Administration Record (MAR) for November 2025 through February 2026 revealed Resident #75 was administered the medication as ordered with the exception of refusals. The medication was last administered on 2/25/26 at 12:00 pm. An observation was conducted on 2/23/26 at 1:10 pm of Resident #75. Resident #75 was in bed with no wheeze or shortness of breath noted. A nebulizer machine was noted to be placed at the foot of the bed. Support Nurse #2 was interviewed on 2/25/26 at 3:21 pm who confirmed she was responsible for the oversight of Resident #75. Support Nurse #2 stated that she was not sure why Resident #75 was still receiving the bronchodilator medication because she had not observed any wheezing from the resident. She stated she had discussed Resident #75 with nursing staff on 2/25/26 and no staff member had reported continued wheezing to support the need for the medication. Support Nurse #2 stated she would discuss discontinuation of the medication with the PA.A telephone interview was conducted on 2/25/26 at 2:42 pm with the Consultant Pharmacist who revealed she reviewed Resident #75's medications monthly during the medication regimen review to evaluate the need of the medications prescribed. The Consultant Pharmacist stated she would not address the bronchodilator medication order with the provider because based on the PA visit notes the provider reviewed medications and noted to continue with current treatment plan for Resident #75. A telephone interview was conducted with the Physician Assistant on 2/26/26 at 11:21 am. The PA reported that Resident #75 had CHF with occasional wheeze so the medication order would be warranted to be an as needed (PRN) order. The PA stated she had not observed Resident #75 to have wheezing and it had not been reported by any staff so she would not have expected the medication to continued being used. The PA stated she did review the medications and assess Resident #75 at each visit, but she was not aware the medication continued to be administered, and she did not notice the order was not written for an as needed medication. An attempt to conduct a telephone interview with the Medical Director on 2/26/26 at 12:55 pm was unsuccessful. During an interview with the Director of Nursing (DON) on 2/26/26 at 10:32 am she revealed that when the order was initially received for Resident #75 it should have been written as a PRN order instead of scheduled. The DON stated that the nursing staff should have identified no symptoms were being exhibited by Resident #75 and contacted the provider to discuss changing the order to PRN or discontinuing the order. The DON stated that while physician orders were reviewed in the clinical meeting, they normally reviewed new orders during the meeting and did not have a process in place for older standing orders. The Administrator was interviewed on 2/26/26 at 12:24 pm and she stated the PA wrote the order for Resident #75's medication and should have identified it was ordered and remained in place as routine for the extended period.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) Assessments for 3 of 29 residents whose MDS assessments were reviewed for accuracy (Resident #2, Resident #28 and Resident #38).The findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses which included dementia with behaviors. The wound provider visit note dated 1/16/26 revealed Resident #2 was treated for a stage 4 pressure ulcer to the sacrum, a stage 3 pressure ulcer to the left buttock, and an unstageable deep tissue injury (DTI) to the right heel. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #2 was coded for one stage 3 pressure ulcer and one unstageable deep tissue injury (DTI). An interview was conducted with the MDS Nurse on 2/25/26 at 3:38 pm who confirmed Resident #2 had a stage 3 pressure ulcer, a stage 4 pressure ulcer, and a DTI at the time of the MDS quarterly assessment based on the documentation from the wound provider. The MDS Nurse stated she just overlooked the stage 4 pressure ulcer when she completed Resident #2's quarterly assessment. During an interview conducted on 2/26/26 at 12:18 p.m., the Administrator stated that the MDS Nurse was responsible for accurately completing Resident #2's MDS assessment for pressure ulcers. The Administrator stated the MDS Nurse had the information for Resident #2's pressure ulcers and the assessment should have been accurately coded. 2. Resident #28 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis (infection of the bone) of the right ankle and foot. Resident #28 had a physician order dated 2/07/26 for vancomycin intravenous (IV) solution; use 1.25 gram intravenously every 24 hours for infection related to osteomyelitis right ankle and foot until 3/04/26. The care plan dated 2/09/26 revealed Resident #28 had a care plan in place for IV medication via PICC (peripherally inserted central catheter used for long-term intravenous access) with risk for complications such as infection and infiltration. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #28 was cognitively intact. The MDS assessment further noted that Resident #28 was coded for intravenous medication use but was not coded for IV access. During an interview conducted on 2/25/26 at 3:38 p.m., the MDS Nurse stated that Resident #28's PICC IV access should have been coded as IV access on the assessment. She acknowledged that she inadvertently overlooked the IV access when completing Resident #28's assessment. During an interview conducted on 2/26/26 at 12:18 p.m., the Administrator stated that the MDS Nurse was responsible for accurately completing Resident #28's MDS assessment. She further explained that Resident #28's assessment should have been coded accurately for the IV access. 3. Resident #38 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease and cerebral infarction.Review of Resident #38's electronic health record revealed a physician's order dated 3/11/19 for Clopidogrel (an antiplatelet medication) 75 milligram (mg) one tablet by mouth daily. A review of Resident #38's December 2025 Medication Administration Record (MAR) revealed documentation of Clopidogrel 75mg one tablet by mouth daily. A review of Resident #38's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was coded as receiving an anticoagulant. An interview was conducted with Support Nurse #2 on 2/26/26 at 1:11 PM. Support Nurse #2 confirmed she had completed Resident #38's quarterly MDS dated [DATE]. Support Nurse #2 indicated she was being trained to complete the MDS. She stated that coding Resident #38 as receiving an anticoagulant was an error. During an interview with the Administrator on 2/2626 at 2:30 PM she stated Resident #38's MDS assessment should have been coded accurately.

Based on observations, record review and staff interviews, the facility failed to place a resting hand orthosis ([NAME], a device designed to support the hand, wrist, and fingers in a functional position) to the right hand for contracture management for 1 of 3 resident reviewed for position, mobility and range of motion (Resident #6).The findings included:Resident #6 was admitted to the facility on [DATE] with diagnoses which included stroke with hemiparesis (weakness caused by stroke) affecting the right dominant side. The care plan initiated on 11/19/25 and under review on 2/23/26 revealed Resident #6 had right hemiplegia/hemiparesis related to stroke with interventions which included perform range and motion exercises with am and pm care daily, apply [NAME] daily, complete hand hygiene and skin checks. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #6 had severe cognitive impairment and was coded for functional limitation in range of motion on the upper and lower extremity on one side. The Occupational Therapy (OT) Discharge summary dated [DATE] revealed Resident #6 was discharged from OT services due to reaching her maximum potential and an order for the [NAME] was in place. The OT discharge summary further noted that Resident #6's family and the nursing staff were provided education on splinting. Resident #6 had a physician order dated 2/06/26 for splint; apply right upper extremity [NAME] daily, complete hand hygiene and skin checks every day shift to prevent contracture and skin breakdown.Observations were conducted on 2/23/26 at 10:56 am, 12:57 pm, and 2:45 pm of Resident #6. Resident #6 was observed in bed without a splint in place. Resident #6's right arm rested along the abdomen and leg with slight bend noted at the wrist that did not appear to be lying flat. The splint was observed to be on the table in the room. Observations of Resident #6 were conducted on 2/24/26 at 8:28 am, 12:06 pm, and 2:44 pm. Resident #6 was observed in bed without the splint in place. The splint was observed to be on the table in the room. The Treatment Administration Record (TAR) revealed Resident #6 was documented to have the right upper extremity splint in place on 2/23/26 and 2/24/26 by Nurse #3.An interview was conducted with Nurse #3 who revealed the therapy staff placed Resident #6's right upper extremity splint and would then notify her that it was in place and she documented the splint as in place on the TAR. Nurse #3 stated she believed the splint was to stay in place for 8 hours but she did not manage the splint placement or removal for Resident #6. The Rehabilitation Manager was interviewed on 2/25/26 at 3:15 pm who revealed the therapy staff were responsible for Resident #6's right upper extremity [NAME] splint when she was on the therapy caseload but once the resident was discharged from therapy services the nursing department was responsible for the splint. The Rehabilitation Manager stated once Resident #6 discharged from therapy on 2/06/26 a physician order was placed for nursing to manage the splinting for the right upper extremity. She stated the therapy department met with nursing staff and provided education regarding the use and management of the right upper extremity [NAME] and signed off the care to nursing. The Rehabilitation Manager stated Resident #6's splint was recommended to be worn for up to 4 hours during the day shift. During an interview on 2/25/26 at 4:26 pm the Director of Nursing (DON) stated once the resident was no longer on therapy the Nurse was responsible for putting the splint in place for Resident #6. The DON stated that Nurse #3 would have seen the order for Resident #6's splint to place the splint on during the day shift so the order should have been followed by Nurse #3. The Administrator was interviewed on 2/26/26 at 12:22 pm and revealed that Nurse #3 would have been the staff member responsible to manage Resident #6's splint on 2/23/26 and 2/24/26 and Nurse #3 should have ensured the splint was in place as ordered.

Based on observation, record review and resident and staff interviews, the facility failed to secure the indwelling urinary catheter tubing to prevent tugging or pulling for 1 of 1 resident reviewed for indwelling urinary catheter (Resident #22).Resident #22 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of bladder and urinary retention. A physician's order dated 9/5/2025 indicated Resident #11 had an indwelling urinary catheter for urinary retention.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. He was coded as having an indwelling urinary catheter.An observation was conducted of wound care on 02/24/2026 at 2:17 PM with the Wound Nurse. During the observation Resident #22 did not have a leg band in place to secure the tubing for his indwelling urinary catheter. There was no tension on the catheter tubing during the observation. An interview was conducted with Resident #22 on 2/24/26 at 2:22 PM. Resident #22 stated that staff sometimes forgot to place a securement device on his indwelling urinary catheter tubing. Resident #22 was unable to say how long it had been since he's had a leg band on. Resident #22 denied any discomfort or tension on the catheter tubing. An observation was conducted of Resident #22's urinary catheter on 02/25/2026 at 9:54 AM with the Infection Preventionist. During the observation Resident #22 was observed to be lying in bed with urinary catheter tubing not secured. There was no tension on the catheter tubing during the observation.An interview was conducted with the Infection Preventionist (IP) on 2/25/2026 at 10:00 AM. The IP stated the resident was supposed to have a leg band in place because it prevented the indwelling catheter from becoming dislodged and causing trauma to the bladder. She stated the nurse on the hall was responsible for making sure the leg band was in place. The IP nurse further stated the nurse aide caring for the resident should let the nurse know when the leg band was not in place. An interview was conducted with Nurse # 4 on 2/25/26 at 10:07 AM. Nurse #4 stated the nurse was responsible for checking to see if the resident had a leg band in place. Nurse # 4 stated he had not been made aware that Resident #22 did not have a leg band in place. During an interview with Nurse Aide (NA) #1 on 02/25/2026 at 2:14 PM, she stated the IP nurse had made her aware that Resident #22 did not have a leg band in place. NA #1 stated the resident usually had a leg band and she just had not gotten to him during her care rounds so that she could notify the nurse that the leg band was missing. NA #1 stated Resident #22 received his bath on the night shift. Multiple attempts to contact NA #2 who cared for Resident #22 the night of 2/24/26 (7:00 PM on 2/24/26 through 7:00 AM on 2/25/26) were unsuccessful. An interview was conducted with the Director of Nursing (DON) on 2/25/26 at 2:33 PM. The DON stated that the nurse or nurse aide should have made sure Resident #22's indwelling urinary catheter tubing had a securement device in place.

Based on observation, record review and staff and resident interviews, the facility failed to obtain a physician order for supplemental oxygen for 1 of 2 residents reviewed for respiratory care (Resident #28). The findings included:Resident # 28 was admitted to the facility on [DATE] with diagnoses which included cellulitis of the right lower leg and pneumonia. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #28 was cognitively intact and was not coded for supplemental oxygen therapy. The nursing progress note dated 2/14/26 at 11:27 am by Nurse #3 revealed Resident #28 complained of shortness of breath. Resident #28 was noted to have an oxygen saturation in the 80's (normal range of oxygen saturation is 95-100%) on room air. Nurse #3 placed 2 liters of supplemental oxygen via nasal cannula on Resident #28 and the oxygen saturation increased to 94 to 96%. Nurse #3 further noted that the provider was notified via electronic communication. An interview was conducted with Nurse #3 on 2/24/26 at 2:50 pm who revealed she did notify the provider on 02/14/26 that Resident #28 required oxygen and did get the order, but she stated she had trouble entering the order. Nurse #3 stated she could usually fumble her way through putting in an order, but she must have not realized the order for the oxygen was never put in when she had the trouble. She stated the Support Nurse normally entered physician orders, so it was not something she had to do often. Nurse #3 stated she did not notify any Support Nurse or reach out for assistance to enter Resident #28's oxygen order when she had difficulty entering the order on 02/14/26. A review of the physician orders revealed no physician order for supplemental oxygen use for Resident #28.An observation and interview were conducted with Resident #28 on 2/23/26 at 11:16 am. Resident #28 was observed with supplemental oxygen in place at 2 liters via nasal cannula. Resident #28 stated she had recently been diagnosed with pneumonia and had been on oxygen since having trouble breathing a while ago. Resident #28 stated the oxygen was not something she had required prior to coming to the facility. Support Nurse #2 was interviewed on 2/25/26 at 3:27 pm who confirmed she was the Support Nurse assigned to Resident #28. Support Nurse #2 stated that when additional orders were received by a provider the nurse that obtained the order was responsible to enter the order. Support Nurse #2 stated she just did not think to review Resident #28's order to make sure the oxygen order was in place. An attempt to conduct a telephone interview with the medical provider on 2/26/26 at 12:55 pm was unsuccessful. An interview was conducted with the Director of Nursing (DON) on 2/25/26 at 4:22 pm who revealed that Nurse #3 was responsible to notify the provider and enter any orders obtained for Resident #28's supplemental oxygen. The DON further noted that Nurse #3 should have reached out to her or asked another nurse that was working for assistance if she was having difficulty entering the oxygen order. The DON stated the physician orders were normally reviewed in the clinical meetings but she was unable to recall if Resident #28's orders were reviewed.

Based on record review, observations, and staff interviews the facility failed to date open medications for 1 of 3 medication carts reviewed for medication storage (Hall 100 medication cart). The findings included:During an observation of Hall 100 medication cart with Nurse #1 on 2/24/26 at 3:15 pm the following was observed: - one plastic squeeze bottle of brimonidine/timolol solution 0.2/0.5% eye drops (a medication used to treat eye conditions like glaucoma) was observed open with no open date noted. The manufacturer's recommendation for the brimonidine/timolol solution 0.2/0.5% was to be used or discarded within 4 weeks of opening.- one plastic squeeze bottle of olopatadine solution 0.2% eye drops (an antihistamine eye drop used for relief of allergic conjunctivitis) open with no open date noted. The manufacturer's recommendation for the olopatadine solution 0.2% eye drops was to be used or discarded within 4 weeks of opening, even if the bottle was not empty.Nurse #1 was interviewed on 2/24/26 at 3:19 pm who revealed the medications were to be dated when initially opened. Nurse #1 stated she was not present when the medications were opened and was unable to state why they were not dated. An interview was conducted with the Director of Nursing (DON) on 2/25/26 at 3:03 pm who revealed the medications were to be dated when opened by the nurse. The DON further stated that nurses should check any medication that was open to ensure an open date was noted before use on the resident.

Based on record review, resident, and staff interviews, the facility failed to provide written documentation for advance directive information and the opportunity to formulate an advance directive for 13 of 22 residents reviewed for advanced directives. Residents #57, #71, #58, #55, #70, #68, #29, #72, #38, #52, #65, #61, #45. The findings included: a. Resident #57 was admitted to the facility on [DATE]. Resident #57 had severe cognitive impairment. Review of a physician ' s order dated 7/24/24 revealed Resident #57 was a full code. There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. b. Resident #71 was admitted to the facility on [DATE]. Resident #57 was cognitively intact. Resident #71 held a physician order for full code. There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. c. Review of Resident #58 was admitted to the facility on [DATE]. Resident #58 was cognitively intact. Review of a physician ' s order dated 9/25/24 revealed Resident #58 was a full code. There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. d. Resident #55 was admitted to the facility on [DATE].Resident #55 had moderate cognitive impairment. Resident #55 held a physician order for full code. There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. e. Resident #70 was admitted to the facility on [DATE]. Resident #70 was cognitively intact. Review of a physician ' s order dated 10/23/23 revealed Resident #70 was a full code. There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. f. Resident #68 ' s was admitted to the facility on [DATE]. Resident #68 was cognitively intact. Resident #68 held a physician order for full code. There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. g. Resident #29 was admitted to the facility on [DATE]. Resident #29 had severe cognitive impairment. Resident #29 held a physician order for Do Not Resuscitate (DNR). There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. h. Resident #72 was admitted to the facility on [DATE]. Resident #72 was cognitively intact. Resident #72 held a physician order for full code. There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. i. Resident #38 was admitted to the facility on [DATE]. Resident #38 was cognitively intact. Resident #38 held a physician order for Do Not Resuscitate (DNR). There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. j. Resident #52 was admitted to the facility on [DATE]. Resident #52 was cognitively intact. Resident #52 held a physician order for full code. There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. k. Resident #65 was admitted to the facility on [DATE]. Resident #65 had severe cognitive impairment. Resident #65 held a physician order for full code. There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. l. Resident #61 was admitted to the facility on [DATE]. Resident #61 was cognitively intact. Resident #61 held a physician order for full code. There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. m. Resident #45 was admitted to the facility on [DATE]. Resident #45 was cognitively intact. Resident #45 held a physician order for full code. There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. An interview was conducted with the Social Worker on 11/21/24 at 1:06 PM. The Social Worker stated advance directives were reviewed during the care plan meeting. She stated the review of advance directives was documented on the Care Plan assessment or in the Social Services assessment upon admission and readmission. The Social Worker stated she filled out an advance directive form to show that advance directive was discussed with the residents or family during care planning. The Social Worker stated the Advance Directive form was uploaded into the electronic medical record. There was no documentation of education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party on the advance directive form. An interview was conducted with the Administrator on 11/21/24 at 1:30 PM. The Administrator stated the education and discussion of Advanced Directives should have been documented for each resident in the facility. The Administrator stated he expected that residents would be reassessed for advance directives when readmitted and during the care plan meeting.

Based on observation, staff interviews, the facility failed to dispose/discard expired medications in 1 of 3 medication carts (600 Hall medication cart) observed for medication storage. The findings included: An observation was conducted of the 600 Hall medication cart on 11/21/24 at 10:48 AM. One opened bottle of Senna -Plus with an expiration date of October 2024 was found on the cart. An interview was conducted with Medication Aide #2 on 11/21/24 at 10:50 AM. Mediation Aide #2 stated the medication should have been discarded. Medication Aide #2 stated the medication aide/ nurse assigned to the cart was responsible for checking for expired medications each shift. An interview was conducted with the Director of Nursing (DON)on 11/21/24 at 11:28 AM. The DON stated the medication aides and nurses assigned to the medication cart were responsible for checking carts for expired medication. The DON stated expired medications were to be removed from the cart immediately. An interview was conducted with the Administrator on 11/21/24 at 1:28 PM. The Administrator stated the medication aides and nurses assigned to the medication cart were responsible for checking carts for expired medication. The Administrator stated expired medications were to be removed from the cart immediately.

Based on record review, staff and resident interviews, the facility failed to provide written notification of a roommate change for 1 of 1 resident reviewed for notification of a change (Resident #37). The findings included: Resident # 37 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact. An interview was completed on 11/18/24 at 10:00 a.m. with Resident #37. Resident #37 stated approximately 2 to 3 weeks ago she received a new roommate. Resident #37 stated prior to that day she was in a room alone. The Resident stated she went out to an appointment and when she returned, she had a new roommate. Resident #37 stated she had not received written or verbal notification she would be getting a new roommate. Review of facility records revealed Resident #37 received a new roommate on 10/29/24. There was no documentation in the medical record for Resident #37 indicating a discussion or notification of a new roommate in October 2024. An interview was completed on 11/20/24 at 2:10 p.m. with the facility's Social Worker (SW). The SW stated it was her process to contact residents and their responsible party prior to the resident receiving a new roommate. The SW revealed she only notified a resident and their Responsible Party (RP) verbally and not in writing when there was a change in roommates. The SW stated she did not notify Resident #37 or their RP verbally or in writing that Resident #37 would be getting a roommate. The SW was unable to say why she did not provide notification. An interview was completed on 11/21/24 at 11:30 a.m. with the Director of Nursing and the facility Administrator. The Administrator stated it was his expectation a resident and their RP would be notified of a roommate change verbally and in writing prior to the roommate change.

Based on record review and staff interviews, the facility failed to refer a resident with a serious mental illness for a Level II Preadmission Screening and Resident Review (PASRR) for 1 of 2 residents reviewed for PASRR (Resident #34). Findings included: Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE]. On 8/7/2023 Resident #34 was diagnosed with delusional disorder. A Level I PASRR determination notification letter dated 3/3/2020 indicated No further PASRR screening is required unless a significant change occurs with the individual's status which suggest a diagnosis of mental illness or mental retardation or, if present, suggests a change in treatment needs for those conditions. No facility documentation was discovered indicating a Level II PASRR referral had been completed for Resident #34 after the diagnosis of a serious mental illness had been made. An interview with the Social Worker (SW) on 11/20/2024 at 2:50 p.m. revealed she was not aware Resident #34's Level II PASRR screening had not been completed. She stated the Admissions Director would let her know if a resident required screening. During an interview with the Admissions Director on 11/21/2024 at 9:35 a.m. she revealed she checked residents' PASRR screening upon admission. She explained she had failed to check Resident #34's PASRR upon readmission. After reviewing his diagnosis, she indicated Resident #34 met the criteria for serious mental illness and she should have submitted a referral for a Level II PASRR screening. During an interview with the Administrator on 11/21/2024 at 10:35 a.m. he revealed he was not aware Resident#34's PASRR screening had not been completed upon readmission and explained this was a problem.

Based on record review and staff interviews, the facility failed to provide written notification for reason of discharge to the Ombudsman for 4 of 6 residents reviewed for hospitalization (Resident #38, Resident #51, Resident #61, Resident #71). The findings included: a. Resident #71 was admitted to the facility on [DATE]. Resident #71 transferred to the hospital on 7/15/2024 and returned to the facility on [DATE]. A record review revealed there was no documentation the Ombudsman received written notification for transfer to the hospital. b. Resident #51 was admitted to the facility on [DATE]. Resident #51 transferred to the hospital on 10/18/2024 and returned to the facility on [DATE]. A record review revealed there was no documentation the Ombudsman received written notification for transfer to the hospital. c. Resident #38 was admitted to the facility on [DATE]. Resident #38 transferred to the hospital on 6/15/2024 and returned to the facility on [DATE]. A record review revealed there was no documentation the Ombudsman received written notification for transfer to the hospital. d. Resident #61 was admitted to the facility on [DATE]. Resident #61 transferred to the hospital on 12/21/2023 and returned to the facility on [DATE]. Additionally, Resident #61 transferred to the hospital on 9/10/2024 and returned to the facility on [DATE]. A record review revealed there was no documentation the Ombudsman received written notification for transfer to the hospital. During an interview with the Social Worker (SW) on 11/19/2024 at 12:58 p.m. she revealed she had not sent discharge information to the Ombudsman's office for those residents who were sent to the hospital. The SW reported she was not aware she had to send written notification to the Ombudsman when a resident transferred to the hospital. During an interview with the Administrator on 11/21/2024 at 10:30 a.m. he revealed he was not aware the SW had not submitted monthly discharge reports to the Ombudsman. He stated it was the responsibility of the SW to send discharge notifications to the Ombudsman.

Based on observations, record review and staff interview the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following a recertification and complaint survey of 4/8/2022. This was for one recited deficiency on the current recertification and complaint survey in the area of Food and Nutrition Services (F812). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F812: Based on observations, record review, and staff interviews the facility failed to maintain food service equipment without a buildup of debris on 3 of 4 pieces of cookline equipment (top/bottom convection oven, gas range oven) observed for cleanliness, and failed to remove excessive ice buildup and clean 2 of 2 nourishment refrigerators observed for cleanliness. These practices had the potential to affect all residents. During the recertification and complaint survey of 4/8/2022 the facility was cited for failing to maintain kitchen equipment in a clean and sanitary condition to prevent cross contamination. An interview was completed on 9/14/2023 at 10:56am with the Administrator. The Administrator indicated the QAA committee met monthly to discuss the facility's ongoing performance improvement plans. The Administrator stated there was a current monitoring plan in place related to the identified F812 deficient practice. The Administrator explained the monitoring plan included the use of a cleaning schedule and cleaning list that must be followed. The Administrator indicated it was her expectation the facility continued to follow the QAA process and monitor identified issues within the facility to sustain complaince.

Based on observations, record review and staff interviews the facility failed to maintain food service equipment without a build up of debris on 3 of 4 pieces of cookline equipment (top/bottom convection oven, gas range oven) observed for cleanliness, and failed to remove excessive ice buildup and clean 2 of 2 nourishment refrigerators observed for cleanliness. These practices had the potential to affect facility residents. The findings included: During the initial tour of the kitchen on 9/11/23 at 9:52AM observation of the double stacked convection oven revealed a buildup of dark charred food debris on the bottom of both the top and bottom stacked convection ovens. The bottom convection oven door had a buildup of grease on the inside of the doors and lower inside rim of the oven. The gas range oven had a buildup of dark black food debris on the bottom of the oven. A second observation of the convection ovens and gas range oven on 9/14/23 at 8:55 AM revealed the ovens to be in the same condition. Observation of the 600-hall nourishment refrigerator on 9/11/23 at 11:25 AM revealed a 2-inch buildup of ice on the top, bottom, and left sides of the freezer. Inside the front ice debris was a 2-inch by 3-inch pink stain. During observation on 9/14/23 at 8:29 AM the 300-hall nourishment refrigerator was observed. The freezer top shelf had frozen paper debris stuck and the shelf was sticky to touch. On 9/14/23 at 8:32 AM observation of the 600-hall nourishment refrigerator revealed a 2-inch buildup of ice on the top, bottom and left sides of the freezer. Inside the front ice debris was a 2-inch by 3-inch pink stain. During an interview on 9/14/23 at 9:03 AM the Dietary Manager revealed the convection ovens were scheduled to be cleaned and on the scheduled day staff called out and had not been cleaned. He indicated environmental services were responsible for cleaning the nourishment refrigerators. During an interview on 9/14/23 at 10:12 AM the Director of Nursing stated the Environmental Service should have a cleaning list and follow it.

Based on observation, record review, and staff interviews the facility failed to develop a written individualized person-centered care plan in the area of pressure ulcer for 1 of 4 residents reviewed for pressure ulcers (Resident #58). The findings included: Resident #58 was admitted to the facility on [DATE]. The nursing admission skin check dated 8/24/23 revealed Resident #58 had an open area to the right heel. Review of Resident #58's care plan developed on 8/24/23 revealed no care plan for the right heel pressure ulcer. The Weekly Skin Check dated 8/25/23 revealed Resident #58 had a stage 3 pressure ulcer to her right heel which was present upon admission. A physician order dated 8/25/23 to clean wound with wound cleanser, apply [non-adhering wound treatment], and wrap with gauze daily. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #58 was coded for a stage 3 pressure ulcer which was present upon admission. An interview was conducted on 9/14/23 at 8:45 am with the MDS Nurse who revealed she was responsible to develop a written care plan for Resident #58's pressure ulcer but she stated she was not aware of Resident #58's pressure ulcer until this week. The MDS Nurse was unable to state how she coded Resident #58 for a pressure ulcer on her assessment on 8/31/23 but did not develop a written care plan. During an interview on 9/14/23 at 10:11 am the Wound Treatment Nurse revealed she documented Resident #58's right heel pressure ulcer information in her medical record with treatment orders upon admission to the facility. She stated the MDS Nurse was able to review the information from the medical record to develop a written care plan for Resident #58's right heel pressure ulcer. An interview with the Director of Nursing (DON) on 9/14/23 at 10:24 am revealed the MDS Nurse was responsible for implementing resident care plans. The DON stated the MDS Nurse was able to review the information in the medical record and develop a written care plan for Resident #58's right heel pressure ulcer. During an interview on 9/14/23 at 10:46 am the Administrator revealed the MDS Nurse was responsible to develop the written care plans. The Administrator stated pressure ulcers were typically communicated to the MDS Nurse by the weekly wound report and review of admissions when pressure ulcers were present.

Based on observations, record review, resident interviews, staff interviews, and Medical Director interview, the facility failed to obtain a physician order for supplemental oxygen for 2 of 3 residents reviewed for oxygen (Resident #26 and Resident #45). Findings included: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and dependence on supplemental oxygen. Review of the Nursing Admission assessment dated [DATE] by Nurse #1 revealed Resident #26 had oxygen in place at 2 liters (L) via nasal canula (NC) upon admission to the facility. Record review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #26 was cognitively intact and was coded for supplemental oxygen use. Observations on 9/11/23 at 9:59 am an 9/12/23 at 12:20 pm Resident #26 was observed with oxygen at 2 liters via NC in use. During an interview on 9/11/23 at 10:05 am Resident #26 stated he used oxygen at home prior to admission and had used the oxygen since he arrived at the facility. Record review of Resident #26's physician orders revealed no order for supplemental oxygen. An interview was conducted with Nurse #1 on 9/12/23 at 1:22 pm who revealed a physician order was required for Resident #26's oxygen. Nurse #1 was unable to state why Resident #26's oxygen order was missed. An interview was completed on 9/14/23 at 10:31 am with the Director of Nursing (DON) who revealed when Resident #26 admitted to the facility with oxygen in place the admitting nurse should have obtained and entered an order for supplemental oxygen. The DON was unable to state how the supplemental oxygen order for Resident #26 was missed. A telephone interview was conducted on 9/14/23 at 9:35 am with the Medical Director who revealed a physician order was required for supplemental oxygen. He stated when Resident #26 admitted to the facility with oxygen in place the order should have been obtained. 2. Resident #45 was admitted to the facility on [DATE] with diagnoses which included pneumonia, respiratory failure with hypoxia, and anxiety. Resident #45 was discharged to the hospital on 8/03/23 and returned to the facility on [DATE]. Review of the hospital discharge record dated 8/21/23 revealed no order for supplemental oxygen for Resident #45. The Nursing Admission assessment dated [DATE] by Nurse #1 revealed Resident #45 had oxygen at 2 liters per nasal canula in place upon admission to the facility. The Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #45 was coded for oxygen use during the lookback period. Observations on 9/11/23 at 11:05 am and 9/12/23 at 8:37 am Resident #45 was observed with oxygen at 2 liters via nasal canula in use. Record review of Resident #45's physician orders revealed no order for supplemental oxygen. An interview was conducted with Nurse #1 on 9/12/23 at 1:22 pm who revealed a physician order was required for Resident #45's oxygen but he was unable to state how the oxygen order was missed. An interview was completed on 9/14/23 at 10:31 am with the Director of Nursing (DON) who revealed when Resident #45 readmitted with oxygen in place the admitting nurse should have obtained and entered an order for supplemental oxygen. The DON stated Resident #45 had an oxygen order in place before her discharge to the hospital and it was missed when she returned. A telephone interview was conducted on 9/14/23 at 9:35 am with the Medical Director who revealed a physician order was required for supplemental oxygen. He stated when Resident #45 was admitted to the facility with oxygen in place the order should have been obtained.

Based on record review, staff interviews, Physician interviews, Hospice Administrator interview, and Pharmacy Consultant interview, the facility failed to ensure Physician orders for as needed (PRN) psychotropic medications were time limited in duration for 1 of 5 residents reviewed for unnecessary medication (Resident #45). The findings included: Resident #45 was admitted to the facility on [DATE] with diagnoses which included anxiety and major depressive disorder. Resident #45 was discharged to the hospital on 8/03/23 and returned to the facility on [DATE] under hospice services. A physician order dated 8/21/23 for lorazepam (an anxiety medication) 0.5 milligram (mg) every 4 hours as needed (PRN) for anxiety without a stop date. The Note to Attending Physician/Prescriber dated 8/21/23 revealed the facility was notified by the Pharmacy Consultant that Resident #45's PRN lorazepam medication did not have a stop date. The Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #45 was not coded for behaviors and had not received medication for anxiety during the lookback period. Review of the Medication Administration Record for August 2023 and September 2023 revealed Resident #45 had not been administered the PRN lorazepam. During an interview on 9/13/23 at 2:30 pm the Director of Nursing (DON) revealed when a resident was on hospice services and a pharmacy recommendation was received, she would forward the information to hospice for review and wait to hear from them. She stated she was not sure if she had received a response for Resident #45's PRN lorazepam order. The DON stated she was ultimately responsible for the pharmacy recommendations and was to ensure they were addressed and completed when received. A telephone interview was conducted on 9/13/23 at 3:04 pm with the Pharmacy Consultant who revealed when a PRN psychotropic medication was noted to not have a stop date the facility would be notified, and a response was requested from the prescriber to add a stop date. The Pharmacy Consultant stated if the facility had not responded to the pharmacy recommendation before the next monthly review a second notification would be sent to the facility. The Pharmacy Consultant stated the expectation was that the facility would follow-up and complete the recommendation for Resident #45's PRN lorazepam prior to the next monthly visit. A telephone interview was conducted on 9/13/23 at 6:15 pm with the Hospice Administrator who revealed she did not recall receiving any recommendations from the facility pharmacy to add a stop date to the PRN lorazepam, but stated the orders were written by the facility physician so the facility was responsible to adjust Resident #45's PRN lorazepam order if required. A telephone interview was conducted on 9/14/23 at 9:01 am with the Nurse Practitioner who revealed she was aware of the 14-day stop date requirement for PRN psychotropic medication, and she stated she normally would order for 14 days and re-evaluate if the medication was still needed. The Nurse Practitioner stated she must have missed the stop date for Resident #45's PRN lorazepam order. A telephone interview on 9/14/23 at 9:40 am with the Medical Director revealed the facility was responsible to notify him when a response was not received from another provider regarding the pharmacy recommendation for a 14-day stop date for Resident #45's PRN lorazepam and he would address the pharmacy recommendation. An interview was conducted with the Administrator on 9/14/23 at 10:49 am who revealed the DON should have reached out to the Medical Director to obtain a stop date for Resident #45's PRN lorazepam.

Based on observation and staff interview the facility failed to maintain the kitchen equipment clean and in a sanitary condition to prevent cross contamination by failing to clean 2 of 2 plate warmers. The findings included: During the meal observation on 4/06/22 at 11:35 AM the tray line area was observed. The first 3 cylinder well plate warmer was observed with dark black dried food particles inside each well and the middle well had crumpled up foil in the bottom. The second 3 cylinder well plate/pellet warmer was observed to have dark black dried food particles in each well and the middle well had ketchup packets in the bottom of the well. During a second observation of the kitchen on 4/07/22 at 9:46 AM the first 3-cylinder plate warmer was observed with dark black dried food particles inside each well and the middle well had crumpled up foil in the bottom. The second 3 cylinder well plate/pellet dispenser was observed to have dark black dried particles in each well and the middle well had ketchup packets in the bottom. In an interview on 4/07/22 the Dietary Manager indicated they were transitioning from one contract dining service to another service and the cleaning schedules needed to be updated. He stated he would add the plate warmers to the weekly cleaning schedule and have staff clean the plate dispensers. In an interview on 4/07/22 the Administrator indicated she would want staff to clean all the kitchen equipment, including the plate dispensers.

Based on observation and staff interviews the facility failed to discard expired medications for 2 of 2 medication carts reviewed for medication storage. (Middle Hall Med Cart, 300 Hall Med Cart) Findings included: 1. During an observation of the Middle Hall medication cart for medication storage on 4/6/22 at 12:13 PM, an opened and accessed [MEDICATION(S)] Discuss with an opened date of 2/19/22 was in the drawer. The manufacturer's label revealed that medication was to be discarded 30 days after opening. An interview was conducted with Medication Aide #2 on 4/6/22 at 12:27 PM. Medication Aide #2 stated that she was unaware that the medication had expired. Medication Aide #2 stated she reordered medication when the medications ran out. An interview was conducted with Nurse #4 on 4/6/22 at 12:32 PM. Nurse #4 stated that medication carts were to be checked by night shift for expired medications. An interview was conducted with the Director of Nursing (DON) on 4/6/22 at 4:12 PM. The DON stated night shift nurses were responsible for checking the medication carts for expired medication. The DON stated cart checks were part of the night shift nursing duties. 2. During an observation of the 300 Hall Medication Cart on 4/7/22 at 9:04 AM, a bottle of opened and accessed [MEDICATION(S)] eye drops had an open date of 12/23/21. The manufacturer's instruction stated to discard opened medication 4 weeks after opening. An opened and accessed bottle of [MEDICATION(S)] was in the drawer with an open date of 1/27/22. The manufacturer's label stated to store opened medication at room temperature for 6 weeks. An opened and accessed bottle of Olapatidine Solution .02% (an eye medication) had an opened date of 2/14/22. The medication label read 2 drops to both eyes twice daily for 14 days. An interview was conducted with Support Nurse #1 on 4/7/22 at 9:20 AM. Support Nurse #1 stated that night shift was responsible for checking the medication carts nightly for expired medication. An interview was conducted with the Director of Nursing on 4/7/22 4:12 PM. The DON stated that she expected that expired medications would be removed from the medication cart and discarded. 3. An observation of the 300 Hall Medication Cart on 4/7/22 at 9:04 AM, 17 pills (different sizes, shapes, color) and 3 half pills (white in color) were loose in the medication cart. An interview was conducted with Support Nurse #1 on 4/7/22 at 9:20 AM stated that she was not aware that the loose pills were in the cart. Support Nurse #1 stated that night shift was responsible for checking the medication carts nightly for expired medication. An interview was conducted with the Director of Nursing (DON)on 4/7/22 at 4:12 PM. The DON stated night shift nurses were responsible for checking the medication carts for expired medication. 4. An observation of the 300 Hall Medication Cart on 4/7/22 at 9:04 AM. A bottle of one daily multivitamin with minerals had an expiration date of 3/22. An interview was conducted with Support Nurse #1 on 4/7/22 at 9:20 AM. Support Nurse #1 stated that she was unaware that the medication was expired. She immediately discarded the medication. An interview was conducted with the night shift nurse (Nurse #6) on 4/7/22 at 4:00 PM. Nurse #6 stated that night shift had a checklist that they followed each night, and the checklist did include checking the medication cart for expired medication. Nurse #6 stated she could not recall the exact days for checking the medication cart but knew that it was assigned at least two days a week to check medication cart for expired medications. Nurse #6 stated it was the responsibility of the nurse administering the medication to check the expiration date prior to giving the medication. An interview was conducted with the Director of Nursing on 4/7/22 4:12 PM. The DON stated that she expected that expired medications would be removed from the medication cart and discarded.

Based on record review, staff interviews, and physician interview, the facility failed to hold blood pressure medication when blood pressure was below parameters as ordered by physician for 1 of 1 resident reviewed for medication administration. (Resident #66). Findings included: (1) Resident #66 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #66 ' s MAR for March and April 2022 revealed the order parameters for the [MEDICATION(S)] HCI were listed on the MAR and required the blood pressure to be entered before documentation of the medication administration. The MAR record report revealed the [MEDICATION(S)] HCI was administered 20 times with DBP below order parameters on following dates and times: 3/1/22 at 12:00 am DBP was 61 mmHg. 3/3/22 at 12:00 am DBP was 69 mmHg. 3/12/22 at 12:00 am DBP was 54 mmHg. 3/13/22 at 12:00 am DBP was 56 mmHg. 3/14/22 at 12:00 am DBP was 63 mmHg. 3/15/22 at 8:00 am DBP was 61 mmHg. 3/16/22 at 4:00 pm DBP was 60 mmHg. 3/17/22 at 12:00 am DBP was 60 mmHg. 3/18/22 at 12:00 am DBP was 57 mmHg. 3/19/22 at 4:00 pm DBP was 64 mmHg. 3/22/22 at 12:00 am DBP was 58 mmHg. 3/23/22 at 12:00 am DBP was 52 mmHg. 3/28/22 at 12:00 am DBP was 66 mmHg. 3/31/22 at 12:00 am DBP was 62 mmHg. 4/01/22 at 12:00 am DBP was 58 mmHg. 4/02/22 at 8:00 am DBP was 62 mmHg. 4/02/22 at 4:00 pm DBP was 65 mmHg. 4/03/22 at 8:00 am DBP was 65 mmHg. 4/03/22 at 4:00 pm DBP was 64 mmHg. 4/06/22 at 12:00 am DBP was 52 mmHg. Record review of Resident #66 ' s medical record from 3/1/22 through 4/6/22 revealed no negative outcome related to [MEDICATION(S)] being administered outside of parameters. During an interview on 4/7/22 at 2:06 pm Medication Aide #1 revealed she was aware of Resident #66 ' s blood pressure medication parameters and was unable to state why she administered the medication on 3/19/22. Medication Aide #1 stated she took the blood pressure before the medication was administered, but she may have been rushed when she gave the medication to Resident #66. During an interview on 4/7/22 at 2:16 PM Nurse #3 revealed she was aware of the blood pressure parameters for Resident #66 ' s blood pressure medications. Nurse #3 stated she may have given the medication because Resident #66 ' s SBP was usually high when she checked it before giving the medications, but she was unable to state for sure why she administered the medications on 3/3/22, 3/12/22, 3/13/22, 3/14/22, 3/16/22, 3/17/22, 3/18/22, 3/22/22, 3/23/22, 3/28/22, 4/1/22 and 4/6/22. She stated the facility had provided education on blood pressure medication and monitoring for parameters which included taking the blood pressure before giving the medication. Attempts to contact Nurse #1 and Nurse #2, who administered medication to Resident #66 on 3/1/22, 3/15/22, 3/31/22, 4/2/22, and 4/3/22 were not successful. During an interview on 4/7/22 at 12:05 pm the Director of Nursing (DON) revealed the Nurses were expected to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/7/22 at 12:22 pm the Physician revealed the blood pressure parameters were ordered for Resident #66 for his severe diastolic heart failure. The Physician stated the parameters were expected to be followed by the Nurses and he stated if the Nurse had a question about administering the medication, they were able to call him at any time. During an interview on 4/7/22 at 4:35 pm the Administrator stated the staff were expected to follow Resident #66 ' s physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, a review of the facility video footage, record reviews, interviews with the emergency medical staff, fire department staff, facility staff, family member and the physician the facility failed to prevent a supervised smoker from having cigarettes and lighters in her possession and attempt to smoke while unsupervised for 1 of 9 residents (Resident #1) reviewed for smoking. Resident #1 exited the facility while unsupervised onto a breezeway outside the building in a wheelchair which was a non-designated smoking area. While unsupervised Resident #1 attempted to ignite a lighter that she had in her possession to light a cigarette but sparks from the lighter caused the resident to catch fire. The resident was taken to the hospital for evaluation and treatment and found to have second-and-third degree [MEDICAL CONDITION] her head, neck, anterior trunk, bilateral upper extremities, and bilateral thighs. The resident died the following morning. The findings included: The Smoking Policy read in part. It is the policy of this facility that smoking is not allowed in the facility by residents or staff. Residents are allowed to smoke outside in designated areas if the criteria outlined in the policy are followed .The following interventions may be considered by the care plan team. C. Supervised smoking may be advisable if resident is not able to comprehend or follow the rules or if the resident disregards safety interventions. Supervised smoking should be scheduled by the care plan team and the resident. Efforts will be made to adhere to resident preferences but also allow for staff availability. The facility Smoking Policy did not address advising family members or visitors not to bring in any smoking materials and did not mention if residents could be searched for any hidden smoking materials. Observations on [DATE] at 11:30 AM revealed the facility ' s smoking times were posted at the ,[DATE] hall nurses station and on the 600 hall nurses station at 12:15 PM. The posted smoking times were listed as 9am, 11am, 1pm, 3pm, 5pm, 7pm, 9pm. Resident # 1 was admitted to the facility on [DATE] and with [DIAGNOSES REDACTED]. Resident #1 ' s most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed she was cognitively intact. She had clear speech, was understood and could understand. The resident ' s MDS did not reveal any behaviors including wandering. Resident #1 was coded as requiring extensive one person physical assistance with bed mobility and transfers. She was assessed as having upper and lower extremity impairment on one side and used a wheelchair for mobility. The MDS revealed she had skin damage with one burn and did not require the use of oxygen. The Smoking Assessment completed on [DATE] revealed, Resident #1 had no cognitive loss, was able to light, hold, smoke, dispose a cigarette safely. Resident #1 did not require supervision for safe smoking. The Smoking Injury written by Nurse #1 completed on [DATE] revealed, in part, Resident #1 had a 2 centimeter by 2 centimeter round burned area to upper left thigh with slough in the middle and redness around edges. Resident stated that she dropped her cigarette and burned herself while smoking outside last Monday. She stated that her daughter knew about it but she did not want staff to find out about it. The report revealed the resident was alert and oriented to person, place, time and situation. An interview with nursing assistant (NA) #1 was conducted on [DATE] at 3:40 PM. NA #1 reported on [DATE] when she first saw Resident #1 ' s [MEDICAL CONDITION] on her upper inner thigh, she informed the resident she would need to immediately report the area to the Nurse. She stated Resident #1 was upset that she would be reported to the nurse and indicated that her family member was aware of the [MEDICAL CONDITION]. NA #1 reported Resident #1 was alert and oriented, aware of the facility smoking policy and should have reported her burn to staff immediately. An interview was conducted with Nurse #1 on [DATE] at 2:37 PM. Nurse #1 reported she was notified of Resident #1 ' s burn on [DATE] by NA #1 who worked with Resident #1 that day. Nurse #1 reported Resident #1 had confirmed that she burned herself while out smoking and she had told her family member but did not report the burn to staff. Nurse #1 stated she completed a new smoking assessment that day and Resident #1 changed from an independent smoker to a supervised smoker. Nurse #1 reported she verbally informed Resident #1 she would be a supervised smoker and her cigarettes and lighter would now be stored on the nursing cart. Nurse #1 reported the resident had verbalized understanding of the change in her smoking from independent to a supervised smoker. The nurse ' s note written by Nurse #1 at 12:59 PM on [DATE] revealed, in part, Resident #1 was informed that she would be placed on supervised smoking, received education and would have a staff member present when she went out to smoke. She was also educated that all of her smoking materials lighters and cigarettes would have to be at the nurses ' station and dispensed by the nurse. Resident #1 verbalized understanding. The Responsible Party (RP) was informed of resident being placed on supervised smoking and to give cigarettes and smoking materials to nurse and the RP verbalized she understood the smoking policy. The Smoking Assessment completed on [DATE] revealed, in part, Resident #1 required supervision for safe smoking and smoking supplies should be stored at the nursing station. The report revealed the resident had a recent burn on her left thigh and failed to report it to staff for treatment. The interventions included having the resident on supervised smoking, Director of Nursing and Administrator meet with the residents ' responsible party on [DATE] and discussed the supervised smoking policy and Resident #1 was not to have smoking paraphernalia in her possession. An interview was conducted with the Director of Nursing (DON) on [DATE] at 10:45 AM. The Director of Nursing stated the day NA #1 reported the burn to the nurse, Resident #1 had been giving herself her bed bath. The Director of Nursing reported Resident #1 was independent in her activities of daily living after staff set up her bath, she only required staff to wash her back and one arm. She stated Resident #1 tried to do as much for herself as possible and was able to turn and reposition herself in the bed. The DON specified Resident #1 had hid her burn from staff and only told her family member of the burn. Resident #1 ' s care plan updated on [DATE] revealed a plan of care was in place for the risk of further injuries related to her preference to smoke and had a recent burn to thigh from dropping cigarette ashes and not reporting the incident to staff. The care plan ' s goal was to minimize further smoking injuries. The interventions included staff supervision when smoking in the smoking area, the restrictions on smoking would be discussed with resident and to store smoking items (cigarettes, pipes, lighter, etc.) in a secure location such as the nursing cart. A nurse ' s note written on [DATE] by Nurse #5 revealed a family member of Resident #1 approached and gave Nurse #5 a pack of new, unopened, green pack of cigarettes for Resident #1. A telephone interview was conducted with Resident #1 ' s RP on [DATE] at 2:22 PM. The RP revealed she was aware of the burn to Resident #1 ' s thigh. The RP stated facility staff called her on [DATE] to notify her of the burn to Resident #1 ' s leg, reviewed the smoking policy and informed her, Resident #1 was now supervised when smoking. The RP stated when Resident #1 became a supervised smoker she would give a pack of cigarettes to the nurse and if she took Resident #1 out herself, she would give the resident 2 cigarettes to hold and smoke. She stated when she knew Resident #1 was going out to smoke with staff, she would hand the resident 2 cigarettes to smoke while with the staff. An interview with NA #4 was conducted on [DATE] at 9:50 AM. NA #4 stated that staff would routinely check Resident #1 for cigarettes and if they found any in her fanny pack they would take them from her and tell the nurse. NA #4 stated on one occasion she found Resident #1 had a cigarette in her possession and she gave it to the nurse. NA #4 revealed it had been over two weeks since she had worked with Resident #1 and she did not remember when she had last seen Resident #1 smoking. An interview with NA #3, who cared for Resident #1 on [DATE], was conducted on [DATE] at 3:26 PM. NA #3 stated she was the NA assigned to Resident #1 during the time of the incident on [DATE]. NA #3 stated Resident #1 was in her wheelchair in her room when she came to work on second shift on [DATE]. NA #3 stated Resident #1 had been on the hall talking with staff before returning to her room for the evening meal. NA #3 stated the resident was in her room at 5:15 PM when she delivered her dinner tray. NA #3 stated the last time she saw Resident #1 was around 6:00 PM when she picked up her dinner tray, then went to assist other residents. NA #3 revealed usually Resident #1 would request to be taken out to smoke but that day she did not request to go out. NA #3 stated Resident #1 would sometimes try to sneak cigarettes and staff would remind her she was supervised smoker, take any smoking items the resident was trying to keep in her possession and report it to the nurse. NA #3 stated she had not seen Resident #1 with any smoking materials and NA #3 stated she was aware Resident #1 was a supervised smoker as she had a fall 30 days ago and the nurse told me that day, she was now a supervised smoker. An interview with Nurse # 2 was conducted on [DATE] at 11:50 AM. Nurse #2 stated on [DATE] she was on the 200 hall when just after 7:00 PM she heard the code red for fire called. Nurse #2 stated she got the fire extinguisher and followed protocol by going to the 300 hall to check on residents there. She reported the fire was located off the ,[DATE] hall and smoke was noticeably thick on the 100 hall. Nurse #2 reported Resident #1 was in the room with her dinner meal when she provided her evening medications around 5:15 PM. Nurse #2 stated Resident #1 asked her to close the door on her way out, which was her usual request. Nurse #2 stated another nurse informed her Resident #1 was a supervised smoker after she received treatment for [REDACTED]. Nurse #2 revealed a list of the supervised smokers was posted at each nurses ' station and staff were aware of which residents were supervised. Nurse #2 stated Resident #1 always came to her to ask for her cigarettes and her lighter. A recording of the facility surveillance footage of the incident on [DATE] was reviewed on [DATE]. In the video footage between 6:40 PM to 6:44 PM staff were observed on the 200 hall entering residents ' rooms with care items and closing a residents ' door. At 6:46 PM Resident #1 was observed to open her 200 hall room door and exit her room, no staff were seen on the 200 hall during this time. Resident #1 is seen to propel her wheelchair backwards past the ,[DATE] hall nursing station headed towards the 100 hall. In the 100 hall video footage staff are observed to enter residents ' rooms with care items and closing residents ' door. As Resident #1 is seen entering the 100 hall no staff were visible on the hall. Resident #1 exited the facility using the 100 hall exit door at approximately 7:06 PM and 100 hall staff are seen to exit residents ' rooms shortly thereafter carrying small bags of care items. Resident #1 is seen sitting alone outside the 100 hall door breezeway located between the 100 and 600 hall doors. In the video it appears Resident #1 attempts 5 times to light something close to her mouth. On the sixth attempt to light the object Resident #1 bursts into flames. In the video Resident #1 is seen outside on fire, then multiple staff are seen coming out in response to the fire. A review of the nurse note written by the DON at 1:06 AM on [DATE] revealed, in part, resident noted outside courtyard sitting in wheelchair with [MEDICAL CONDITION] head, face, upper torso, arms, hands, thighs. Staff had extinguished fire, 911 called. Residents clothing was removed immediately by numerous staff members and normal saline was applied to the resident ' s skin to moisten the burned areas. Once the resident was stable enough to be moved she was wheeled into the therapy gym. While in the therapy gym, the resident ' s skin was continued to be moistened with normal saline compresses, oxygen was applied and vital signs were taken. Blood pressure ,[DATE], pulse 94, oxygen saturation 95 %. Staff remained by resident until EMS (emergency medical service) and Fire Department arrived and exited the building. Director of Nursing notified Resident #1 ' s Doctor at 7:18 PM. Administrator notified the residents ' RP at 7:26 PM. An Incident Audit Report for Resident #1 written by the Director of Nursing on [DATE] revealed the Director of Nursing, Nurse Supervisor and other staff were alerted that there was a fire on the 600 hall. Director of Nursing and staff responded by running down 100 hall to exit through the corridor outside to 600 hall. DON and staff were unable to get to the door due to excessive smoke coming from outside into the 100 hall area. Director of Nursing ran to pull fire alarm and obtain fire extinguisher. Other staff members were coming down the hall with fire extinguisher. Director of Nursing exited the door at the end of 100 hall to see staff from 600 hall exhausting the fire. Resident ' s clothing was removed immediately by numerous staff members and normal saline was applied to the resident ' s skin to moisten the burned areas. Once the resident was stable enough to be moved she was wheeled into the rehabilitation gym. While in the gym, the resident skin was continued to be moistened with normal saline, oxygen was applied and vital signs were taken. Staff remained by the resident until EMS and Fire Department arrived and exited the building. Administrator notified the residents ' RP at 7:26PM. The Investigation Guide written by the Administrator and DON on [DATE] revealed Resident #1 was found upright in a wheelchair noted [MEDICAL CONDITION] unresponsive. First aide was immediately provided by licensed nurses. The scene described Resident #1 was found in the breezeway outside between the 100 and 600 hall. Resident #1 was noted in a non-smoking area with flames noted to her clothing, both upper and lower extremities were noted with flames. Also noted on the scene were what appeared to be a pack of cigarettes, several lighters, a fanny pack and a soda can. The Root cause of the incident listed the resident was non-compliant with supervised smoking and was found to have hidden lighters in her possession/ on her body/ fanny pack. Her room was immediately searched for any unsecured smoking materials no cigarettes or lighters were found. All lighters were located on the resident. An interview was conducted with the Director of Nursing on [DATE] at 10:45 AM. She stated she was working in the conference room when the supply clerk ran in to tell her there was a fire on the 600 hall. The Director of Nursing and Nurse #5 ran towards the 100 hall and due to the amount of smoke filling the hall they could not reach the door. The DON stated she ran back to pull the fire alarm and ran back towards the 100 hall door. The Director of Nursing reported Nurse #5 had to kick to the door open and when she got outside, she saw 600 hall staff were outside responding to the code and had extinguished the fire. The Director of Nursing stated she called the Administrator to notify her of the fire. The Director of Nursing reported NA #2 was cutting off Resident #1 ' s clothing and fanny pack and pieces of clothing continued to smolder which staff extinguished. Resident #1 was burned from her fanny pack to her bottom. The DON reported staff continued to douse Resident #1 with saline to cool her skin. The Director of Nursing reported the resident never lost consciousness and when she was stable staff moved her to the therapy gym. She stated EMS arrived, assessed the resident, got her onto the stretcher and loaded her into the ambulance. The Director of Nursing stated she went out to the ambulance and EMS staff told her they were taking Resident #1 to the local hospital to be picked up by Life flight helicopter and flown to a Burn Center. The Director of Nursing indicated Resident #1 was aware of where the designated smoking area was located and to her knowledge never been on the 100 hall. The DON revealed Resident #1 had recently lost two family members, failed to report the burn to her thigh and was aware that she would lose her independent smoking privilege, when staff became aware of the cigarette burn. The Director of Nursing stated it looked like Resident #1 was wearing some type of puffy goose down [NAME]et a sweat shirt, sweat pants and a bra. She reported it had been a typical day for the resident, she had not noticed any change or indication of depression after learning of the deaths of her two family members ' . An interview was conducted with the Social Worker (SW) on [DATE] at 3:10 PM. The Social Worker stated that she had clocked out and was walking to her car, when she heard someone yell. The Social Worker stated she saw someone with flames sitting upright in a wheel chair in the breezeway located between the 100 and 600 hall. The SW stated she ran back into building, saw flames out the 600 hall door and alerted staff to the fire. The SW stated she grabbed a fire extinguisher and ran out the 600 hall door to extinguish the fire. The Social Worker stated other 600 hall nurses ran out with fire extinguishers to extinguish the blaze. She stated more staff (not sure which staff) arrived, took her fire extinguisher and extinguished the resident. The Social Worker indicated she was not sure who had yelled, as the incident happened fast and all the staff responded quickly. An interview was conducted with Nurse #3 via phone on [DATE] at 3:36 PM. Nurse #3 stated she was working on the assisted living hall when a visitor came on the hall and yelled something was on fire outside. Nurse #3 revealed as she headed towards the 600 hall nurse station she could see flames out the therapy gym window and she alerted Nurse # 4 who was at the nurses ' station. Nurse #3 stated that Nurse #4 ran to the 600 hall door opened it, saw the flames told her to grab a fire extinguisher and Nurse #4 ran back inside to call 911. Nurse #3 stated she grabbed the fire extinguisher and ran outside. Nurse #3 stated she first thought a trash can was on fire then she saw an arm move and pointed the fire extinguisher towards the middle of a body. She indicated she stood 4 feet from the fire as she did not know if there was an oxygen tank involved and directed the fire extinguisher towards the middle of the body. Nurse #3 stated the blaze was so large she thinks she emptied two fire extinguishers putting out the fire. She stated she could see the person gasping for air, others around her were hollering but the incident happened so quickly she did know who they were. She stated the smoke and fumes were so thick she had difficulty breathing. Nurse #3 reported Resident #1 ' s face was scarred, her eyebrows were gone and she had about 3 inches of hair left on her scalp. An interview was conducted with Nurse # 4 via phone on [DATE] at 11:06 AM. Nurse #4 stated she was sitting at the 600 hall nurses ' station close to 7:04 PM when a visitor came on the hall and yelled something was burning outside. Nurse #4 stated she ran to the 600 hall door, looked out and saw someone was on fire in the breezeway. Nurse #4 ran inside, told Nurse #3 to grab a fire extinguisher and ran in the hall, grabbed another fire extinguisher, yelled at staff to call code red and ran outside to extinguish the fire. When she came back outside other staff (NA #2, Nurse #3) were extinguishing the fire, when the DON and Nurse #5 burst out the 100 hall door. Nurse #4 stated she continued to run back and forth bringing saline, handing to the Director of Nursing, Nurse #5 and NA #2 who cut the bags open and doused Resident #1 with saline and doused the blanket that was used to cover the resident. Nurse #4 stated someone said to move the resident into the therapy gym so she held up Residents #1 ' s feet while NA #2 pushed her wheelchair into the therapy gym. An interview was conducted with NA #2 on [DATE] at 3:14 PM. NA #2 revealed he was in the break room when he heard code red called and ran towards the 600 hall location. NA #2 reported when he arrived Nurse #3 was in the process of extinguishing the fire. NA #2 stated he took over her fire extinguisher and helped put out the flames. NA #2 reported he ran to the 100 hall nurses station to retrieve his scissors and returned to cut off Resident #1 ' s [NAME]et and clothing. NA #2 stated Resident #1 was wearing a silky type [NAME]et with a hoodie and sweat clothes. NA #2 stated he instructed staff (did not know who) to bring a blanket as other staff were dousing the resident with saline. He reported someone then said to move the resident into the therapy gym so he pushed her wheelchair while Nurse # 4 held her feet up and they moved her into the therapy gym. An interview was conducted with the supply clerk on [DATE] at 11:11 AM. The supply clerk stated she was at the 600 hall nurse station when a visitor came down the hall and said there something on fire outside. The supply clerk stated when she ran out the 600 hall door she realized that someone was on fire. The supply clerk stated she ran through smoke to the conference room to notify the Director of Nursing of fire at the 100 hall door. She stated then ran to check on the 200 hall residents and discovered that Resident #1 was not in her room. The supply clerk stated she heard someone page to bring gauze and saline to the therapy gym, so she ran to the central supply room for the supplies and brought them to the therapy gym. The supply clerk stated she helped out for 10 minutes then returned to the hall to check on and instruct residents to stay in their rooms. An interview was conducted with Nurse #5 on [DATE] at 3:20 PM. Nurse #5 stated that she and the Director of Nursing were working in the conference room when the supply clerk ran into announce a code red on the 600 hall. The Nurse #5 stated she and the Director of Nursing ran towards the 100 hall door and could not reach the door due to the amount of smoke filling the hall. Nurse #5 stated the Director of Nursing ran back to pull the fire alarm, she called 911 to report the fire and then proceeded to kick the 100 hall door open. Nurse #5 stated it was difficult to hear the 911 operator, as multiple staff members were outside yelling and calling for supplies. Nurse #5 stated she went back inside the 100 hall so she could hear the 911 operator and answer their questions. Nurse #5 stated the 911 operator informed her help was on the way and to wait outside to direct the emergency personnel to the resident. Nurse #5 stated she ran out the front door and over to the gate leading to the ,[DATE] hall breezeway. Nurse #5 stated a first responder arrived and she took him to the therapy room where Resident #1 had been moved. Nurse #5 stated by that time the fire truck and ambulance had arrived and facility staff moved aside to let the emergency personnel take over the situation. An interview with the Administrator was conducted on [DATE] at 1:39 PM via phone. The Administrator reported that according to the facility ' s video surveillance footage around 6:45 PM on [DATE] Resident #1 was noted to leave her room in her wheelchair and wheel herself backwards to the end of the 100 hall. The video footage showed Resident #1 exited out the door to the 100 hall breezeway. Next Resident #1 began to smoke, her clothing caught fire and shortly thereafter staff came out to assist her. The Administrator stated she received a phone call about 7:15 PM from the Director of Nursing making her aware of what had happened. The Administrator revealed that she used to be a burn nurse so she instructed the Director of Nursing to apply saline, call 911 and notify the fire department. The Administrator stated she instructed the Director of Nursing, after they extinguished the fire to move the resident to the therapy gym where they could lay her down in case she went into [MEDICAL CONDITION]. The Administrator stated staff provided simple first aid by keeping the resident moist and applied oxygen. The Administrator stated she called the residents ' RP at 7:26 PM and made her aware there had been an accident that involved Resident #1. The Administrator stated when she arrived to the facility she instructed staff to check all the residents ' rooms for any smoking materials like cigarettes and lighters and collected any smoking materials that were found. The Administrator stated between 10:45 PM and 11:00 PM she called the family member of Resident #1 for an update and left a message for them to return her call. At 11:23 PM she received a call back from a family member who stated they were at the Burn Center and Resident #1 had a ,[DATE] % change of survival, had [MEDICAL CONDITION] an inhalation injury. The Administrator stated that evening 100% of the staff working were in-serviced on the smoking policy, the smoking list was updated and posted at each nurses ' station. No smoking signs were posted outside the designated smoking area and new smoking signage was posted on all entrance/exit doors and halls informing visitors not to provide smoking materials to any resident. An observation was conducted with the Administrator of Resident #1 ' s wheelchair and charred fanny pack on [DATE] at 11:20 AM. A bath basin held the melted remains of a fanny pack, a charred pack of cigarettes which was green in color, multiple bent cigarettes, 2 green lighters and a vertically split can were observed among the blackened charred remnants. The Fire Department First Responder report dated [DATE] revealed, in part, Patient clothes caught fire. Was extinguished by staff. Firefighters assisted EMS with burn patient, removed and taken from the facility. An interview with the County Fire Chief was conducted on [DATE] at 10:19 AM, via phone. The Fire Chief reported he was working on [DATE] when they received a call to the Nursing Center. The Fire Chief stated when he arrived on the scene, staff had extinguished the fire. He stated the emergency medical service arrived at the same time and took control of the situation and the resident. The Fire Chief stated the fire departments role was to assist EMS with getting the patient prepared for the ambulance to transport to the hospital. An interview was conducted with County EMS paramedic #1 on [DATE] at 11:00 AM. Paramedic #1 reported when they arrived the patient was sitting upright in her wheelchair. Paramedic #1 reported they put a non-rebreather (oxygen mask that delivers oxygen at a half flow rate) applied burn sheets and got the resident onto the stretcher. Paramedic #1 reported the patient had full [MEDICAL CONDITION] was burned from her head down to the top part of her upper legs. Paramedic #1 reported the patient was covered and taken to the ambulance where she was able to answer questions appropriately. Paramedic #1 reported the patient was taken to a local hospital to wait for Life Flight. However in route they received a call the Life flight was delayed and to go ahead into the hospital emergency department where the patient would be intubated. The paramedic reported she remembered it was unusually warm and windy that night. An interview was conducted with County EMS paramedic #2 on [DATE] at 11:05 AM. Paramedic #2 reported when they arrived the patient was seated-upright in a wheelchair and [MEDICAL CONDITION] her kneecap to her head. Paramedic #2 reported there were several cut open and empty bags of saline on the ground and it looked like staff had tried to cool the patient down with saline. Paramedic #2 reported they wrapped the patient in burn sheets and moved her to the ambulance, where they started her on an IV solution and assessed her breathing. Paramedic #2 reported they were on the scene a total of 14 minutes before they headed to the local hospital where the patient was to be picked up by Life Flight. Paramedic #2 reported when they arrived at the local hospital, Life Flight advised them to take the patient into the ER for rapid intubation as her airway was compromised and their arrival was delayed. Paramedic #2 reported the patient was intubated in the ER and transferred to the Life Flight where she was to be taken to another area hospital burn center. The Sheriff report revealed the report was dated [DATE]. The investigation report revealed a patient of the nursing center had been badly burned. Fire and EMS were on the scene while the Sheriff interviewed the staff, who reported a female resident had been outside smoking a cigarette and caught on fire. The local hospital ER report dated [DATE] at 8:16 PM revealed, in part, the patient was brought to the ER department by the local County EMS. For emergency load to Life flight transport to burn center. Patient began to decompensate with oxygen saturation dropping in route. Patient brought into emergency department for intubation and stabilization prior to flight. Patient intubated on arrival and Life Flight arrived just prior to intubation and patient was put on their monitor. The local hospital burn center admission note on [DATE] revealed, in part, patient with mixed 2nd and 3rd degree [MEDICAL CONDITION] the head, neck, anterior trunk, bilateral upper extremities, bilateral thighs. After evaluation it was determined that surgery was not indicated. Patients ' wounds were extensive and the majority are third degree. A discussion with the family about goals of care due to extensive burn and the patient was made comfort care. The discharge disposition revealed, the patient expired on [DATE] at 6:46 AM. The events prior to the death were [MEDICAL CONDITION] followed by [MEDICAL CONDITION]. A corrective action plan for noncompliance developed by the facility and dated [DATE] specified the following: On 02.14.2020, 100% of identified smokers, 11 skilled resident smokers, were assessed by licensed nurses for any alterations in skin integrity that would indicate a potential burn, any residents found with skin integrity concerns resembling a burn. The weekly skin assessments will continue with no stop date. Results: None noted. Monitoring: Weekly skin assessments will continue for 100% of active residents and documentation will continue in the E-mar, assessments and documentation will be completed by the licensed nurse. Any [MEDICAL CONDITION] noted will be immediately reported to the licensed nurse for assessment, incident report, notifications of the physician, responsible party, and root cause analysis with updates the care plan, interventions to prevent recurrence. Any [MEDICAL CONDITION] determined to remotely resemble a burn will result in staff immediately initiating 1:1 staff supervision of the resident until no longer deemed necessary as evidenced by care plan updates and medical record documentation. On 02.14.2020 the Administrator posted notices to notify visitors not to give residents smoking materials to include lighters/cigarettes/vaping materials, but to give to staff for security. Signage posted on entrance doors, nursing stations, and other areas visible to visitors and family members. Results: Administrator and/or Director of Nursing daily rounds reveal signage posted on entrance doors, nursing stations, and throughout the facility. Monitoring: Daily monitoring to ensure signage continues to be posted on all entrance doors, nursing stations, and various other areas throughout the facility effective 02.14.2020. The monitori

Based on observations, record review, and staff interviews, the facility failed to ensure 1 of 1 residents with a wander guard device did not exit the facility unsupervised (Resident # 1). Findings include: 1. Resident # 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident had limited mobility in her lower extremities but was able to self-propel about the facility in a wheelchair. A review of Resident # 1's care plan dated [DATE] revealed the resident was identified as being an elopement risk / wanderer as evidenced by being disoriented to place and wanting to go home. Interventions included use of a wander alert device (wander guard) and offering diversional and structured activities if presenting exit seeking behaviors. (A wander guard device is a tracking device designed to prevent persons at risk from leaving a facility unless they are accompanied. The system tracks the person using a wrist or ankle band and automatically locks doors or alarms if the person moves within a defined area without being accompanied by an authorized person). A review of the facility Incident Log on [DATE] revealed Resident # 1 exited the facility unsupervised on [DATE]. During an interview on [DATE], the Staff Development Coordinator (SDC) stated she was notified a resident had exited the facility when a couple on their way to church noticed Resident # 1 in the parking lot of the Dialysis Center next to the facility, and returned her to the facility. The SDC stated the resident was immediately assessed for injury. The wander guard attached to the wheelchair was checked and found to be functioning properly as well as the door alarm and locking mechanism when the resident was in close proximity to the exit. The SDC stated the alarm did sound when the resident was wheeled through the main entrance door through which she had exited. The SDC stated she notified the Maintenance Director, the Director of Nurses, and the resident's physician and family. During an interview on [DATE] at 2:10 PM, the Maintenance Director (MD) stated he was near the facility on [DATE] when he was notified of the resident's going outside the facility and went to the facility immediately. The Maintenance Director stated he immediately checked all wander guards and the locking mechanisms and alarms for all the facility exits and all were functioning properly. The Maintenance Director stated the number three on the keypad for the main entrance did not always work when he pressed it and he installed a different keypad even though it would not have affected the alarm or locking mechanism of the system. The company representative was contacted and came to the facility two days later, and together they checked all wander guard devices again as well as the locking mechanisms and alarms for the doors. All were working properly. The Maintenance Director stated they viewed the facility's new video security system for the main entrance and it showed the resident approaching the main entrance door around 7:00 AM and again about twenty minutes later. The alarm sounded and the lock mechanism functioned properly and staff arrived to remove the resident from the area within one minute. On Resident # 1's third approach about 20 minutes later, the resident lifted her leg to push against the door as well as pushing on the handle. The alarm did not sound, and it appeared she pressed the handle until the door opened and she went through the door. When the resident was returned, the alarm sounded. The Maintenance Director stated they had not been able to figure out why the alarm had not sounded at the time. The Maintenence Director stated the video showed Resident # 1 propelled the wheelchair down the sidewalk to the Dialysis Center next to the facility. No one proceeded her or followed her. The video showed the resident exited the facility at 7:28 AM, and was returned by a couple on their way to church who observed the resident alone in a wheelchair outside of the facility. The resident was returned to the facility seven minutes later. An attempt was made to view the facility video security system on [DATE], but the recordings were found to be inaccessible after thirty days. During an interview on [DATE] 2:35 PM, the Regional Consultant stated, During the investigation we studied the security videos to determine any possible cause for the alarm not sounding. She is a large lady and she had refused to have the wander guard applied to her arm or leg. She had also managed to remove it before because she didn't want it on her arm or leg, so it was put on the arm of the wheelchair. We noticed that when she raised her leg as she got close to the door, it shifted her body causing her to lean to the side, the same side the wander guard was on, and her body was in front of the wander guard. We came to the conclusion her body blocked the signal between the device and the alarm system as the device was attached to the metal wheelchair and not in direct contact with her skin. After realizing what happened, every resident was checked for placement of the wander guard to ensure it was on the arm or the leg and not the wheelchair. During an interview on [DATE] at 2:45 PM, the Director of Nursing (DON) stated she was notified on [DATE] around 8:00 AM by (Nurse # 1) Resident # 1 had exited the facility and the alarm had not sounded and the door had not locked. She stated she notified the Administrator. She stated the wander guard device was checked as soon as the resident was brought back to the facility and was working. The DON stated all wander guard devices were immediately checked as well as all of the exit door locks and alarms and all were functioning properly. The DON stated when the determination was made the wander guard signal could be blocked if not in direct contact with the body, Resident # 1's wander guard was placed on her arm. The DON stated an investigation was initiated with statements taken from staff and the appropriate reports to the State Agency was initiated. The DON stated interventions were implemented to review and update the Elopement Books as needed. The Elopement Books were located at each nurses station and at the front of the facility. The Elopement Policy was reviewed and revised on [DATE]. Inservices on elopement prevention were given beginning [DATE] until all staff had been inserviced by [DATE]. The DON stated after consulting with Resident # 1's family, the family expressed the desire to have Resident # 1 transferred to a facility closer to home with a secured unit. On [DATE], audits initiated [DATE] of residents identified as being at risk for elopement ensured each identified resident had a wander guard bracelet on, physicians orders were in place, electronic documentation was in place for nurses and nursing assistants to check placement every shift and nurses for checking function every day, and were completed [DATE]. A review on [DATE] of the security company technician's report dated [DATE] revealed the facility's front door and all other doors alarms and locking mechanisms were checked and found to be operating properly. The facility Elopement Books were reviewed and revised by [DATE] to ensure each resident identified as an elopement risk had a copy of their face sheet and picture placed in the Elopement Book along with the location of the placement of the wanderguard device. The Elopement Books were located at each (two) nurses stations and in an office at the front of the building near the entrance. Careplans for residents at risk for elopement, and having wandering and exit seeking behaviors were reviewed and revised by [DATE] by the MDS Coordinator. Audits of the testing of all wanderguards, and all exit doors for functioning lock mechanisms and alarms were conducted on [DATE], with continued daily testing by the Maintainence Director. Documentation of the evaluation of the wanderguard system by the Maintainence Director and the (name of) company representative was completed [DATE] by the company representative. Inservices on the education of elopement prevention were conducted [DATE] - [DATE] of all staff with attestation statements of staff attending inservices. Inservices were provided to all staff (and to be included in orientation of new employees) were given by the Director of Nursing (DON) and the Staff Development Coordinator (SDC) completed [DATE]. Education included the elopement policy, checking placement and function of wanderguards, documentation on the Medication Administration Records and Treatment Admiistration Records, reporting of any elopement incident or exit seeking behavior to the Physician, Responsible Party, and Administrator immediately and initiating one on one if unable to apply the wander guard device, completing incident reports with notifications of the Physician, Responsible Party and Administrator, importance of supervision along with alarms. Also included were observing, reporting, documenting exit seeking behavior, what to do when cannot be redirected such as notifying Physician, Administrator / DON, initiating one on one. No staff were allowed to work until inservice training completed. Audits to ensure all residents were assessed for risk of elopement on admission, quarterly and as needed by completing the Risk Assessment in the computer system by nurses and MDS nurses were completed by [DATE]. The Quality Assurance (QA) review conducted on [DATE] included the review of audits and inservices for effectiveness. The QA Tool Elopement Risk assessment being applied to all new admissions was reviewed by the clinical team. A moderate to high score ensured a wanderguard device was placed and the resident was careplanned. Daily QA reviews Monday through Friday of the ongoing audits and the QA Tool Elopement Risk assessment was to continue for three months. Any issues were to be reported to the Administrator immediately for appropriate action. The ongoing auditing programs were to be reviewed weekly, attended by the QA team: DON, nurse managers, MDS coordinators, therapy, dietary manager, social worker, and others as needed. Interviews on [DATE] with direct care staff and nursing staff revealed they attended inservices on elopement prevention. Observations of residents with wanderguard devices [DATE] - [DATE] revealed the devices were in place and in direct contact with the residents' bodies. Observations of a resident with a wanderguard approaching an exit on [DATE] revealed the security system functioned properly and that staff responded to the alarm in less than one minute.