Every finding on record at White Oak Manor - Charlotte

Based on observations, record review, and interviews with the Nurse Practitioner (NP) and staff, the facility failed to prevent a resident with severe cognitive impairment, wandering and exit seeking behavior and at high risk for falls, from exiting the facility unsupervised without staff's knowledge. On two consecutive nights Resident #89 exited the facility through an unlocked emergency exit door near the back of the facility that was in working order, but the door had been manually unlocked, and the door alarm had been turned off with a key and therefore did not alarm. On 6/28/25 at an undetermined time early in the morning (it was still dark outside) Nurse #1 noticed Resident #89 was not walking in the hallway and was not in his room. Nurse #1 approached Nurse Aide #1 who was on the end of the hallway near the emergency exit door and reported she had not seen Resident #89 but had heard a door slam near the emergency exit. Nurse Aide #1 indicated another resident that resided in a room near the emergency exit door was known to slam her door and since the emergency door alarm did not go off, she assumed that was what she had heard. Nurse #1 exited through the emergency exit door and walked for 5 to 7 minutes from the back of the facility around to the front where he located Resident #89 standing at the main entrance. Nurse #1 estimated the resident was outside unsupervised for approximately 10 minutes. Nurse #1 thought the emergency exit door locked automatically and was not aware the emergency door alarm had been turned off with a key and did not check the door after the incident or before the end of his shift to ensure it was locked. On 6/29/25 at approximately 1:30 AM Resident #89 was observed in bed and at approximately 2:00 AM Nurse #1 noticed the resident was not in bed and walked immediately to the emergency exit door. He observed the resident through the glass window on the door outside walking away from the building and redirected him back inside. The emergency exit door was again unlocked and did not alarm when Nurse #1 exited through the door to retrieve the resident. When exiting the emergency door if you walked straight ahead and did not follow the sidewalk path, approximately 8 feet in front of the door was a concrete drain box (a concrete structure around a water drain underground). The concrete box opening was approximately 3 feet by 3 feet had no safety covering and was 3 to 4 feet deep into the ground. The sidewalk path outside of the emergency exit door curved immediately to the left up an inclined hill and the sidewalk then turned left and ran directly parallel to a two-lane road that had a posted speed limit of 30 miles per hour. The sidewalk ran along the road for approximately 142 feet and then turned left running along the main driveway used to enter the facility's parking lot and continued in front of the building approximately 180 feet to the main entrance door. Resident #89 was not injured; however, there was a high likelihood of serious harm, injury, or death. This deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #89). Immediate jeopardy began on 6/28/25 when Resident #89 exited the facility unsupervised and without staff knowledge. Immediate jeopardy was removed on 4/11/26 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure all staff and providers are aware of the elopement, education is completed and monitoring systems put into place are effective.The findings included:Resident #89 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance, intracranial injury without loss of consciousness (mild traumatic brain injury), abnormalities of mobility and gait, muscle weakness, insomnia, and orthostatic hypotension (sudden drop in blood pressure when standing).The care plans initiated on 1/28/25 indicated Resident #89 had problem areas including cognitive decline, wandering and exit seeking behaviors, was at risk for falls, and had a diagnosis of insomnia with sleep pattern disturbance. The interventions included administering medications as ordered, monitoring for medication side effects (mood/behavior changes, excessive daytime sleepiness, dizziness and ineffectiveness of medication), wearing a wander guard bracelet, redirecting attempts to exit the facility, encouraging adequate rest periods, discouraging long naps during the day, ensuring proper foot wear was worn, frequent checks by staff, monitoring environment for safety and making adjustments as needed, assessing possible contributing factors of falls including blood pressure (standing and sitting), and notifying the physician of any medication side effects and/or changes in behaviors.Resident #89 had a physician's order dated 1/29/25 for a wander alarm bracelet due to wandering/exit seeking behaviors. A nurse's note dated 4/29/25 at 6:25 AM written by Nurse #1 revealed Resident #89 was confused roaming the building looking for an exit sign to attempt to leave and was very difficult to redirect.A nurse's note dated 4/29/25 at 6:39 AM written by Nurse #1 indicated Resident #89 was confused and kept roaming the building. Resident #89 continuously attempted to exit the building aggressively telling staff, I have to go and was very difficult to redirect. An elopement risk assessment dated [DATE] revealed Resident #89 had a history of wandering and exit seeking behaviors and exhibited these behaviors within the last 90 days. Resident #89 had risk factors related to elopement which included walking independently, cognitive impairment, poor decision-making skills and verbalizing a desire to leave the facility and/or go home. The assessment score was 3 (lowest risk 0 - highest risk 5) indicating Resident #89 was at a moderately high risk for elopement and to continue current safety interventions that were in place. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #89 was severely cognitively impaired, exhibited wandering behaviors one to three days during the assessment period and wore a wander/elopement alarm daily. The MDS assessment further revealed Resident #89 required supervision to touching assistance walking 10 feet, partial to moderate assistance walking 50 feet with two turns, and supervision to touching assistance walking 150 feet and was not coded for any falls in the past 30 days. Resident #89's active physician orders as of 6/28/25 included the following: Trazodone (anti-depressant medication used for insomnia) 50 milligrams (mg) once a day at bedtime.Melatonin (a supplement used for insomnia and to regulate the sleep-wake cycle) 3 mg once a day at bedtime.Midodrine (medication for low blood pressure) 5 mg three times a day.A nurse's note dated 6/28/25 at 7:06 AM written by Nurse #1 revealed Resident #89 was wandering throughout the night and redirected back to his room several times. Resident #89 was successful in exiting the facility through the emergency exit door on the west hallway and was located by staff standing outside at the main entrance. Resident #89 was escorted back to his room and assessed with no injuries noted. A phone interview conducted with Nurse #1 on 4/08/26 at 9:24 AM revealed he worked from 7:00 PM to 7:00 AM on Fridays and Saturdays and was assigned to Resident #89 on 6/27/25 and 6/28/25. He stated Resident #89 was cognitively impaired, wandered the hall every night and was exit seeking at times. He stated when Resident #89 was exit seeking he continuously pushed on the emergency door to see if it would open. Nurse #1 revealed Resident #89 ambulated independently but was at risk for falls due to orthostatic blood pressure and poor balance. He stated Resident #89 did not use a walker or wheelchair but would hold on to stationary items like furniture and handrails to stabilize himself and would lean against a wall as needed to rest. Nurse #1 on revealed when his shift began on 6/27/25 at 7:00 PM Resident #89 was exhibiting his normal wandering and exit seeking behaviors which included verbalizing he had somewhere to go and needed to leave. Nurse #1 stated on 6/28/25 in the early morning, he did not recall the exact time, but it was still dark outside, he noticed Resident #89 was not walking in the hallway and was not in his room. He indicated Resident #89's assigned Nurse Aide (NA), NA #1, was on the other end of the hallway near emergency exit door and reported she had not seen Resident #89 but that she had just heard the exit door close. Nurse #1 revealed when he pushed on the emergency exit door it was still unlocked and opened immediately and did not alarm. Nurse #1 stated he assumed Resident #89 exited the building when NA #1 heard the exit door slam shut and he (Nurse #1) exited the door just a few minutes later, and walked for 5 to 7 minutes from the back of the building around to the front where he located Resident #89 standing at the main entrance, so he estimated Resident #89 was outside unsupervised for approximately 10 minutes before he located him at the main entrance, but where Resident #89 walked during that time was unknown. He stated Resident #89 was wearing light colored sweatpants, a red sweatshirt and shoes. Nurse #1 stated he walked Resident #89 back into the facility through the door at the main entrance and Resident #89's wander alarm bracelet triggered the alarm on the door; he entered a code in the keypad to turn off the alarm and then escorted Resident #89 back to his room. Nurse #1 indicated he assessed Resident #89 and he was not injured and his vital signs were within normal limits. Nurse #1 stated if the push bar on the emergency exit door was held for 15 seconds the door unlocked and opened without alarming and he thought that was how Resident #89 was able to open the door. Nurse #1 indicated he thought the emergency exit door locked automatically and the alarm re-engaged after the door was closed for an extended period of time, so he did not check the door after the incident or before the end of his shift to ensure it was locked. Nurse #1 further stated he was unaware the alarm was turned on and off with a key and could not say what staff had a key to the alarm. Nurse #1 revealed he documented in a nurse's note that Resident #89 exited the facility and reported it to Nursing Supervisor #1 and the oncoming nurse (Nurse #2) at shift change, but no additional monitoring or interventions were implemented at that time. A phone interview was conducted with NA #1 on 4/08/26 at 1:42 PM. NA #1 revealed she worked third shift (11:00 PM to 7:00 AM) on 6/27/25 and was assigned to Resident #89. NA #1 revealed Resident #89 wandered the hall all night every night, went in and out of other resident's rooms and had to be redirected back to his room several times. She indicated when she redirected Resident #89 back to his room, she encouraged Resident #89 to lay down in bed and rest, but he typically would only lay down for a few minutes. NA #1 revealed Resident #89 was exit seeking at times (not every night) and would push on the emergency exit door attempting to leave the facility. NA #1 indicated when her shift began on 6/27/25 at 11:00 PM Resident #89 was wandering as he normally did, but she had not seen him pushing on the emergency exit door or exhibit exit seeking behavior. She stated she did not recall the exact time but in the early morning on 6/28/25 she heard a door slam near the emergency exit door on the west hall. She indicated the resident that resided in the room next to the emergency door was known to slam her room door closed and since the alarm on the emergency door did not go off, she assumed that was what she heard. NA #1 revealed a few minutes later, Nurse #1 approached her looking for Resident #89 and she reported hearing a door slam near the emergency exit. NA #1 indicated when Nurse #1 pushed on the emergency exit door it was unlocked, opened and did not alarm. NA #1 stated Nurse #1 proceeded to look for Resident #89 outside while she began looking for him in the facility. NA #1 indicated Nurse #1 found Resident #89 standing at the front of the building uninjured and walked him back to his room. NA #1 indicated she thought a staff member on a previous shift had left the emergency door unlocked and turned off the alarm but was unable to provide any further details as to who the staff member was or why they would have used that door to exit the building. NA #1 revealed she had never used the emergency door to exit the building and did not know how to unlock the door or turn off the alarm. NA #1 stated she did not recall any additional monitoring being initiated for Resident #89 after the incident on 6/28/25. A phone interview was conducted with Nurse #2 on 4/08/26 at 4:37 PM. Nurse #2 stated she was assigned to Resident #89 on 6/28/25 from 7:00 AM to 7:00 PM. She stated Nurse #1 reported to her at shift change on 6/28/25 that Resident #89 had exited the facility earlier that morning through the emergency exit door on the west hall, which was unlocked and did not alarm, and Resident #89 was found at the front of the facility without injury. She revealed Nurse #1 did not report why the exit door was unlocked and did not alarm but because both the alarm and the lock were disabled manually, she assumed a staff member had unlocked the door and disabled the alarm. Nurse #2 indicated Resident #89 did not exhibit wandering or exit seeking behaviors during the day, only at night so she did not check the exit door to ensure it was locked and the alarm was turned on. She stated when she made her first rounds Resident #89 was sleeping in bed and was at his baseline for the remainder of her shift. Nurse #2 revealed 30-minute checks were initiated for Resident #89 at the end of her shift (7:00 PM) on 6/28/25 which she reported to Nurse #1 during shift change. A nurse's note dated 6/29/25 at 4:21 AM written by Nurse #1 revealed at 1:30 AM Resident #89 was observed lying in bed but at 2:00 AM was no longer in his room. Nurse #1 walked down the west hallway to the emergency exit door which was not locked or alarming and observed Resident #89 outside the door walking away from the building. Nurse #1 redirected Resident #89 back into the facility through the emergency exit door and walked with him to his room. Resident #89 was assessed with no injuries, and his vital signs were within normal limits. During the phone interview with Nurse #1 on 4/08/26 at 9:24 AM he stated when his shift began on 6/28/25 at 7:00 PM Resident #89 was wandering normally in and out of his room and up and down the hallway. Nurse #1 indicated at 1:30 AM on 6/29/25 he observed Resident #89 lying in bed but at 2:00 AM he observed Resident #89 was no longer in his room. Nurse #1 revealed he immediately walked down the hall to the emergency exit since that was the door Resident #89 exited out of on 6/28/25 and observed him outside the door walking away from the building through the glass window on the door. Nurse #1 stated when he pushed the emergency exit door open it was unlocked and did not alarm. Nurse #1 revealed Resident #89 had only walked a few steps away from the door before he stopped him and redirected him back inside. Nurse #1 stated Resident #89 was unable to tell him where he was going and just said I have to go. Nurse #1 revealed he assessed Resident #89 with no injuries, and his vital signs were within normal limits. Nurse #1 indicated he immediately notified Nursing Supervisor #1 of the incident and received instructions to initiate one to one supervision for Resident #89 as well as 30-minute checks to be completed by the nurse. A phone interview was conducted with NA #1 on 4/08/26 at 1:42 PM. NA #1 revealed she worked third shift (11:00 PM to 7:00 AM) on 6/28/25 and was assigned to Resident #89. NA #1 stated Resident #89 was wandering the hall throughout the night as normal, and she redirected him back to his room a few times and encouraged him to rest but did not recall the exact times. NA #1 revealed she did not observe Resident #89 pushing on the exit door or exhibit exit seeking behavior and did not recall any incidents occurring with Resident #89 exiting the facility during her shift. NA #1 indicated she was not aware of 30-minute checks being initiated for Resident #89 but that one on one supervision was put in place at some point however she did not recall when. A phone interview was conducted with Nurse #2 on 4/08/26 at 4:37 PM. Nurse #2 stated when she returned for her shift on 6/29/25 from 7:00 AM to 7:00 PM she was assigned to Resident #89 and Nurse #1 reported to her that Resident #89 had exited the building a second time earlier that morning through the emergency door which was unlocked and did not alarm. She stated 30-minute checks were to continue and 1 on 1 supervision was initiated for Resident #89 on 6/29/25. Nurse #2 stated the emergency exit door was unlocked by a wall switch and the alarm was turned on and off with a key. Nurse #2 stated she did not recall having a key to the alarm and was unsure what staff had a key. She indicated the emergency door exited at the back of the facility and she was unsure what purpose staff would have to exit through that door or who the staff were that left the door unlocked with the alarm disabled. Nurse #2 further stated she was not aware of any staff working during her shift that used the west hall emergency door to exit the building. A nurse's note dated 6/29/25 at 6:29 AM written by Nursing Supervisor #1 indicated he notified the Former Administrator that Resident #89 attempted to exit the facility, and she gave instructions for 1 to 1 supervision to start immediately and to continue until further notice.During a phone interview with Nursing Supervisor #1 on 4/08/26 at 9:00 AM he stated he was the weekend (Fridays and Saturdays) nursing supervisor from 7:00 PM to 7:00 AM and was working on 6/27/25 and 6/28/25. He stated Resident #89 was cognitively impaired and exhibited wandering behaviors at night, but he did not recall being notified by Nurse #1 on 6/28/25 or 6/29/25 that Resident #89 exited the facility or that there were any concerns related to the emergency exit door on the west hallway not working properly. Nursing Supervisor #1 indicated although he did not recall the incidents involving Resident #89 if he wrote a nurse's note then the information he documented was accurate.A nurse's note dated 6/29/25 at 12:17 PM documented as a late entry for 6/28/2025 at 7:09 PM by Nurse #2 revealed Resident #89 was placed on 30-minute checks via paper report due to leaving the building on previous shift. Resident #89 remained in his room this nurse's entire shift resting in bed. Reported to oncoming nurse (Nurse #1) that 30-minute checks were initiated and to document on paper. A review of Resident #89's records revealed no documentation that 30-minute checks were initiated or completed beginning on 6/28/25. A review of Resident #89's active physician orders revealed an order dated 6/29/25 to check resident's whereabouts every 30 minutes. A review of Resident #89's treatment administration record from June 2025 through April 2026 revealed 30-minute checks were documented as completed beginning on 6/29/25 and have been ongoing.A review of the facility's staffing schedules from 6/29/25 through 7/31/25 revealed one-to-one supervision for Resident #89 was added as an assignment on the daily schedule and an NA was assigned to Resident #89 on every shift. The NP note dated 6/30/25 indicated Resident #89 had diagnoses including intracranial injury, dementia with behaviors and insomnia and was seen for a follow up visit after eloping from the facility on 6/28/25 and 6/29/25. Resident #89 was gone from the facility for no longer than 20 minutes. Resident #89 exhibited wandering behaviors at his baseline, wore a wander bracelet and following the incidents was placed on one to one supervision. Resident #89 was assessed and observed lying in bed and appeared comfortable with no concerns. Resident #89's medications and vital signs were reviewed with no new orders given but to continue monitoring for acute changes.A phone interview was conducted with the NP on 4/13/26 at 7:38 AM. She stated she was aware that Resident #89 was up most nights wandering and exhibited exit seeking behaviors. The NP revealed treating Resident #89's insomnia and dementia related behaviors was difficult due to his risk for falls and diagnosis of orthostatic blood pressure. She stated the medications typically prescribed for sleep and anxiety also increased the risk for falls and lowered blood pressure. The NP indicated she was notified on 6/30/25 that Resident #89 exited the facility unsupervised 6/28/25 and 6/29/25 and per her note was gone no more than 20 minutes and was not injured. The NP indicated Resident #89 was not oriented to time or place and had very poor safety awareness which severely impaired his ability to recognize or navigate potential safety hazards independently. The NP revealed Resident #89 exiting the facility unsupervised, even for less than 20 minutes was extremely unsafe and could have resulted in serious injury.An interview was conducted with the Maintenance Director on 4/08/26 at 4:10 PM. He stated the emergency exit door on the west hallway had a magnetic lock that was controlled by a wall switch. He stated when the wall switch was turned on the door remained lock and when the wall switch was turned off the door remained unlocked. The Maintenance Director indicated holding the metal push bar on the door for 15 seconds would not unlock the door. He revealed there was a red alarm box secured to the door that alarmed when the door was pushed open. He stated the alarm sound came directly from the red box and there was not an announcer for the alarm at the nurse's station. He stated the red alarm box could only be turned on and off with a key and was not controlled by the wall switch. He indicated nurses, medication aides, nursing supervisors and department heads all had a key to the red alarm box. The Maintenance Director revealed he was notified by the Former Administrator on 6/29/25 that Resident #89 exited the building through the emergency door on the west hallway and the door was unlocked and did not alarm but was not aware or notified by anyone that Resident #89 exited the facility through the same door on 6/28/25. He stated when he arrived at the facility on 6/29/25 at approximately 7:15 AM he immediately inspected the emergency door on the west hall. He stated the wall switch and the red box alarm were turned on and the door was locked. He revealed he proceeded to inspect the magnet lock, the wall switch and the red box alarm and they were all working properly. The Maintenance Director indicated the emergency door did not malfunction and that a staff member must have turned off the wall switch and used a key to turn off the alarm for the door to open and not alarm. He stated he was unsure who the staff member was or what purpose they would have had to exit to the back of the building through the emergency door. The Maintenance Director stated the door at the main entrance and the employee entrance door were the only doors in the facility that had wander alarm sensors. He stated the emergency exit doors did not have wander alarm sensors and did not lock or alarm when a wander bracelet was near the door. An independent observation was conducted of the west hallway on 4/07/26 at 3:12 PM revealed Resident #89 was located in the first room on the right side of the hallway, and the emergency exit door was approximately 50 feet from Resident #89's room on the other end of the hall. A red alarm box shaped like a stop sign was secured to the door and read STOP, alarm will sound. On the wall to the right of the door was a paper sign that read do not turn off switch that was hanging over a wall switch covered by a clear plastic box. The metal push bar on the exit door was pushed and held for 15 seconds but the door remained lock and would not open. The wall switch beside the door was turned off which unlocked the magnetic door lock and the emergency exit door pushed open. Once the emergency exit door was pushed open the red alarm box secured to the door began to alarm and when the emergency exit door was pulled shut the alarm continued to sound but the door remained unlocked and could be pushed back open. An observation and interview were conducted on the west hall with Nurse #3 on 4/07/26 at 3:22 PM when she responded to the emergency exit door alarm. Nurse #3 was observed using a key on the red box alarm to turn off the alarm coming from the red box alarm secured to the door and then turning the wall switch back on to engage the magnetic lock on the door. Nurse #3 stated she was sitting at the nurse's station located on the other end of the west hall when the red alarm box on the emergency exit door started to sound and she did not initially hear the alarm. She indicated there was not an announcer for the red box alarm at the nurse's station. Nurse #3 stated the red box alarm was turned on and off with a key and the magnetic lock on the door was turned on and off by the wall switch. Nurse #3 revealed she was assigned to Resident #89 from 7:00 AM to 3:00 PM today, but he did not exhibit wandering/exit seeking behaviors during the day when she worked, he only wandered at night.A follow up phone interview conducted with Nurse #1 on 4/10/26 at 11:01 AM revealed he was unaware that the emergency exit door had a magnetic lock that was turned on and off with a wall switch or that the alarm was controlled with a key. Nurse #1 indicated he was unaware that the door would not unlock when the push bar was held for 15 seconds nor was he aware the door lock and alarm could only be disabled manually. Nurse #1 stated he was not aware of and had not observed any staff using the emergency door on the west hall to exit the building.An observation was conducted outside of the facility from the emergency exit door on the west hall to main entrance door on 4/09/26 at 9:12 AM. The emergency door exited at the back right side of the facility with a sidewalk that curved immediately to the left and then continued 190 feet up a hill with an approximate 9 percent incline. The sidewalk then turned left and ran directly parallel to a two-lane road that was heavily trafficked and had a posted speed limit of 30 miles per hour. The sidewalk along the road was curbed but when stepping off the curb you would be standing on the road in front of oncoming traffic. The sidewalk ran along the road for approximately 142 feet and then turned left running along the main driveway used to enter the facility's parking lot and continued in front of the building approximately 180 feet to the main entrance door. Additionally, when exiting the emergency door if you walked straight ahead and did not follow the sidewalk path, approximately 8 feet in front of the door was a concrete drain box (a concrete structure around a water drain underground). The concrete box opening was approximately 3 feet by 3 feet had no safety covering and was 3 to 4 feet deep into the ground. A follow-up interview conducted with the Maintenance Director on 4/13/26 at 10:42 AM revealed when he started working at the facility in April of 2025, he observed that the concrete drain box outside of the west hall emergency door was not covered and mentioned it to administration however sometimes it took a while to get things done. He stated when the incident occurred with Resident #89 on 6/28/25 and 6/29/25 the concrete drain box was uncovered and a safety hazard. The Maintenance Director indicated on 4/10/26 he installed a safety cover over the drain box.A review of the weather records for [NAME], North Carolina found on the Weather Underground website revealed on 6/28/25 at 2:00 AM the temperature was 77 degrees Fahrenheit with no precipitation and south-southwest winds at a speed of 6 miles per hour (mph) and on 6/29/25 at 2:00 AM the temperature was 74 degrees Fahrenheit with no precipitation and southwest winds at a speed of 3 mph.During an interview with the Director of Nursing (DON) on 4/08/26 at 3:24 PM she revealed she was notified by the Former Administrator on 6/29/25 at approximately 7:00 AM that Resident #89 exited the building at approximately 2:00 AM and was immediately redirected back into the facility. She indicated the emergency exit door on the west hall was unlocked and did not alarm and there was a concern the door malfunctioned. She stated one to one supervision for Resident #89 was initiated immediately following the incident. She stated the emergency exit door was also inspected by the Maintenance Director and was working properly and they were unsure why the door was unlocked and did not alarm. The DON indicated she was not aware prior to today that Resident #89 exited the facility unsupervised on 6/28/25. She stated she reviewed Resident #89's record and per a nurse's note written by Nurse #2, 30-minute checks were initiated on 6/28/25 and documented on paper. The DON indicated she was unable to locate the 30-minute checks documented on paper however they were documented on the TAR beginning 6/29/25 and continued in addition to the one-to-one supervision which was added to the staffing schedule. She stated due to Resident #89's cognitive impairment and risk for falls it was very unsafe for him to exit the facility unsupervised due to the potential of getting lost or falling which could result in injury. The DON revealed she should have been notified of the incident on 6/28/25 and one to one supervision for Resident #89 should have been initiated immediately. A phone interview was conducted with the Former Administrator on 4/08/26 at 2:41 PM. Nursing Supervisor #1 called her on 6/29/25 at approximately 2:30 AM and notified her that Resident #89 exited the facility through an emergency exit door that was unlocked and did not alarm. She revealed she instructed Nursing Supervisor #1 to initiate 1 on 1 supervision for Resident #89 immediately and to have a staff member assigned to monitor the emergency exit door on the west hall until it was inspected by the Maintenance Director. The Former Administrator indicated that the Maintenance Director inspected the door and it was in good working order and they were unsure why the door was unlocked and did not alarm. The Former Administrator stated the wander alarm bracelets only activated the locks and alarms on the main entrance door and the employee entrance door. The Former Administrator revealed she was not aware of the incident involving Resident #89 on 6/28/25 prior to this interview. The Former Administrator stated she should have been notified of the incident on 6/28/25 and one to one supervision should have been implemented immediately for Resident #89. She stated that a cognitively impaired resident that was at risk for falls exiting the facility unsupervised was unsafe and could result in the resident being seriously injured. The Administrator was notified of immediate jeopardy on 4/09/26 at 12:15 PM. The facility provided the following credible allegation for immediate jeopardy removal:Identify those recipients who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #89 had an order for a wander bracelet dated 3/3/25 which was applied to his right wrist. According to Nurse #1's progress note dated 6/28/25 at 7:06am, Resident #89 was noted walking around the facility and exited through the emergency exit door on the west hallway near room W4. Resident #89's wander alarm bracelet was in place. Nurse #1 pursued Resident #89 and they re-entered the facility through the main entrance and walked back to Resident #89's room. There was no acute distress or injury to Resident #89 noted in the progress note. Resident #89 has a diagnosis of insomnia and has scheduled melatonin 3 milligrams (mg) and trazodone 50 mg at bedtime. Resident #89's medications were documented as given but he was still awake and wandering throughout the facility at night. An order was initiated on 6/29/25 for 30-minute checks of Resident #1's whereabouts. The Licensed Nurses indicated on the Medication Administration Record that staff were completing 30-minute checks during the shift they worked. On 6/29/25 at 4:21am, Re[TRUNCATED]

Based on observations, record review, and staff interviews, the facility failed to label and date leftover food items stored for use, keep a food preparation area clean and orderly and store a scoop without the potential for cross-contamination. These practices occurred in 1 of 2 walk-in coolers, 1 of 1 food preparation areas, and 3 of 3 Nourishment rooms (Nourishment room [ROOM NUMBER], Nourishment room [ROOM NUMBER], Nourishment room [ROOM NUMBER]). These practices had the potential to affect food served to residents. The findings included:a. An initial tour of the main kitchen occurred on 4/6/26 at 10:05 AM with the Dietary Manager. The following concerns were identified:- Visible dirt and grime build up present on the three water spigots above the cooking range.- A plastic scoop was left in the rice bin with the handle and bottom touching the rice in the food preparation area. - A cardboard flat of 9 croissants was cut open with no open or use by date was found in walk-in cooler #2. Seven croissants had been used from the container and not resealed. An interview with the Dietary Manager on 4/6/26 at 10:10 AM the vent hood had been cleaned by an outside vendor a few months prior. She stated she would have water spigots included in the next cleaning. The Dietary Manager also stated the open croissants were missed by kitchen staff and the rice scoop should be stored in the appropriate holder on the bin.b. Items found in the refrigerator in Nourishment room [ROOM NUMBER] on 4/6/26 at 10:18 AM that were open and not labeled with an open or use by date included: - One half-eaten creme pie with three used plastic forks in the pan,- One small reusable container of ranch dressing.c. Items found in the refrigerator in Nourishment room [ROOM NUMBER] on 4/6/26 at 10:20 AM that were open with an open date, but no use by date included: -One vanilla pudding cup dated 4/6,-One wrapped fast-food sandwich dated 3/9. d. One fast food milkshake was found in the refrigerator in Nourishment room [ROOM NUMBER] on 4/6/26 at 10:22 AM with no open or use by date. A second interview with the Dietary Manager occurred on 4/6/26 at 10:20 AM and revealed all food in the nourishment rooms needed to be labeled with an open date and a use by date which should be seven days after the open date. The Dietary Manager stated the pudding cup should have been thrown away by nursing staff after it was opened. A third interview with the Dietary Manager on 4/9/26 at 3:02 PM revealed she had a few new staff members who were not labelling the opened items correctly in the coolers by forgetting to add the appropriate dates. The Dietary Manager stated the nourishment rooms were inspected by kitchen staff each morning and had not yet been completed on the morning of 4/6/26. She stated nursing staff often left items in the nourishment room refrigerators and did not label them appropriately.An interview with the Administrator on 4/9/26 at 4:40 PM revealed he had the expectation for the kitchen staff to properly store food served in the facility.

Based on observations, record review, and staff interviews, the facility failed to maintain a resident's dignity when Nurse Aide (NA) #6 quickly pulled Resident #67 backward down the hall approximately 30 feet from the day room to her room while reclined in a geriatric chair for 1 of 3 sampled residents reviewed for dignity (Resident #67). A reasonable person would have expected to be treated with dignity and would have wanted to be wheeled forward in their geriatric chair.Findings included:Resident #67 was readmitted to the facility on [DATE]. A review of the quarterly MDS dated [DATE] revealed Resident #67 was assessed as having clear speech and severe cognitive impairment. The assessment indicated Resident #67 required the use of a wheelchair for mobility. During a continuous observation on 4/6/26 at 2:45 PM in the South Hall, NA#6 was observed quickly pulling Resident #67 backward down the hall approximately 30 feet from the day room to her room while she was reclined in a geriatric chair.During an interview on 4/9/26 at 2:39 PM, NA #6 indicated the Resident #67 used a reclining geriatric chair. He stated when he took Resident #67 from the day room to her room, he felt it was better to pull her backward down the hall because it was harder to push her chair moving forward even when she was reclined. NA #6 stated he was not aware of any problems with the reclining geriatric chair.An interview and observation with Social Worker #1 were completed on 4/9/26 at 3:36 PM. While Resident #67 was resting in bed, SW #1 pushed Resident #67's reclining geriatric chair forwards and backwards in the South Hallway. There were no noted concerns with the chair not functioning properly. SW #1 stated Resident #67's reclining geriatric chair was working fine and needed no repairs.A telephone interview with the Staff Development Director on 4/13/26 at 12:06 PM revealed all staff were educated during orientation and received ongoing education on residents' rights and dignity. He also stated staff were frequently educated on resident wheelchair use, including caution with speed and when or if footrests should be used. The Staff Development Director stated Resident #67 should not have been pulled backwards in her geriatric chair and he would make a note to include the term geriatric chair along with wheelchairs for future staff education.An interview with the Director of Nursing on 4/9/26 at 3:58 PM revealed she expected staff to push residents in their wheelchairs forward and not at a fast pace. An interview with the Administrator on 4/9/26 at 4:34 PM revealed he expected staff to push residents in wheelchairs and geriatric chairs forward in a dignified manner and at a normal pace.

Based on observations, record reviews, resident and staff interviews, the facility failed to provide hair washing services for 1 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #144). The findings included:Resident #144 was admitted to the facility on [DATE] with diagnoses which included senile degeneration of the brain, chronic obstructive pulmonary disease, and heart failure.Resident #144's care plan, last revised 3/23/26, had a focus area for ADL deficits due to generalized weakness Interventions included set up for hair and oral hygiene daily and assist with bathing and dressing, encouraging Resident #144 to do as much as possible. Resident #144's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired and extensive assistance from staff for ADL. The MDS further revealed Resident #144 had no behaviors, and there was no rejection of care noted. A review of the facility shower schedule revealed Resident #144 was to be showered on Tuesday and Friday mornings on first shift.An observation of Resident #144 on 4/6/26 at 11:30 AM revealed Resident #144 lying in her bed watching television. Her hair was long, stringy and visibly greasy.A second observation of Resident #144 on 4/7/26 (Tuesday) at 10:00 AM revealed Resident #144 sleeping in her bed and her hair was visibly greasy and dirty and stuck flat against her head.A third observation of Resident #144 on 4/9/26 at 10:40 AM revealed Resident #144 watching television in her bed. Her hair was stringy, visibly dirty and stuck against her head.A review of Resident #144's Electronic Medical Record (EMR) indicated she received a shower on the morning of 4/7/26 by Nurse Aide (NA) #5.An interview with NA #5 on 4/9/26 at 2:33 PM revealed she was assigned to Resident #144 on 4/7/26 and gave her a bed bath. NA #5 stated she did not give Resident #144 a full shower but always gave her a bed bath on her shower days. She stated she would typically wet down Resident #144's hair during the bed bath but stated her hair was becoming all tangled up, especially in the back. NA #5 also stated a bathing team from Hospice services came a couple of times a week for additional bath visits but was unsure what they did when they visited Resident #144. NA #5 stated Resident #144 used to go to the beauty shop to have her hair washed and trimmed, but she believed it had been over two months since Resident #144 had gone, and she was not sure why her hair was not being done in the beauty shop. A telephone interview with the Hospice Nurse occurred on 4/9/26 at 4:09 PM. She stated the Hospice team visited Resident #144 a couple of times a week for bath visits and they would provide bed baths and use a no-rinse shampoo product for her hair. She was not sure when Resident #144's last bath visit was during the week of 4/6/26. The Hospice Nurse stated Resident #144 was able to get up out of bed, but she found Resident #144 to be in her bed on most of her visits. The Hospice Nurse stated she was not sure what type of showers or baths the facility provided Resident #144 regularly. A telephone interview with the Beauty Shop Operator occurred on 4/13/26 at 12:16 PM. She indicated she had seen Resident #144 before in her shop, but she had not seen her recently. The Beauty Shop Operator stated she was in another facility and did not have her full schedule with her to verify Resident #144's appointments but stated the Unit Secretary at the facility kept track of a monthly beauty shop list for the residents who received Medicaid. She stated if a resident missed an appointment for whatever reason, they were added to the next month's schedule. The Beauty Shop Operator stated she would add Resident #144 to her list to be seen the following week.A telephone interview with the Unit Secretary on 4/13/26 at 12:22 PM revealed it had been a while since Resident #144 was in the beauty shop. She indicated she kept a book with a beauty shop list for the Beauty Shop Operator for the last two months but had just cleaned out some of the previous lists. The Unit Secretary stated she believed it had been longer than two months since Resident #144 had visited the beauty shop and her name had been left off the list by mistake.An interview with the Director of Nursing (DON) on 4/9/25 at 4:02 PM revealed Resident #144 received additional bath visits from the Hospice team two to three times a week. She indicated that any NA assigned to Resident #144 was expected to bathe her twice a week and she knew they performed a thorough wash down of each resident. The DON stated she did not know when Resident #144's hair had been washed last and indicated the NAs assigned to her would know. An interview with the Administrator on 4/9/25 at 4:35 PM was conducted. He expected when Resident #144 was scheduled for a shower, her hair would be properly washed.

Based on observations, record reviews, and staff interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions (EBP) when Nurse #5 did not wear a gown while providing catheter care for Resident #132 and Nurse Aide (NA) #3 and NA #4 failed to wear a gown while conducting a mechanical lift transfer of Resident #161 who had a feeding tube. The deficient practice occurred for 3 of 10 staff members observed for infection control practices (Nurse #5, NA #3, and NA #4).The findings included: A review of the facility's policy titled Enhanced Barrier Precautions, revised on 7/26/2022, indicated: Enhanced Barrier Precautions (EBP) referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact resident care activities. High-contact activities included dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, device care or use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, Peripherally Inserted Central Catheter (PICC) lines, midline catheters, and wound care if deemed chronic by a medical provider or if MDRO was present. An observation of catheter care for Resident #132 provided by Nurse #5 was made on 4/08/2026 at 1:47 PM. Resident #132's room had an enhanced barrier precautions sign posted outside the door with personal protective equipment (PPE) stored in a plastic bin on the door including gowns. The signage on the door instructed staff to apply a gown and glove during high contact resident care activities. Nurse #5 entered the room without wearing a gown. She washed her hands and put gloves on. She then removed the residents brief and proceeded to provide catheter care for Resident #132. Nurse #5 then discarded any unused supplies and her gloves and proceeded to wash her hands with soap and water at the sink. An interview with Nurse #5 on 4/08/2026 at 1:55 PM revealed she was aware that Resident #132 was on enhanced barrier precautions. Nurse #5 stated that she only needed to wear a gown if she were changing the catheter, not while providing catheter care. She explained she had received the infection control training on EBP but must have just misunderstood the instructions. An interview with the Infection Preventionist was completed on 4/09/26 at 9:43AM. The Infection Preventionist stated he completed rounds daily to ensure that all residents had the appropriate infection precaution signs posted and staff had available PPE. The Infection Preventionist reported that all staff were trained during orientation on proper use of PPE and proper PPE use was reviewed in monthly staff meetings on all shifts by the Infection Preventionist and shift supervisors. The facility most recently had an Infection Control in-service covering EBP two weeks prior. The Infection Preventionist stated that the staff should wear the appropriate PPE according to the infection precaution signs posted for each resident and that included wearing PPE (gown and gloves) while providing catheter care for residents on EBP. An interview with the Director of Nursing (DON) was completed on 4/08/2026 at 2:55 PM. The DON stated she expected all staff members to use the appropriate PPE according to the infection precaution sign posted for each resident. 2. An observation was conducted with Resident #161 on 4/6/2026 at 12:36 PM. Resident #161's room had an Enhanced Barrier Precautions (EBP) sign posted on the door with a hanging plastic holder containing Personal Protective Equipment (PPE) on the door. A partially filled container of tube feeding formula was hanging by the bedside. Resident #161 was returning from an outside appointment and was seated in his wheelchair. Nurse Aide #3 (NA) and NA #4 were observed entering the room with the mechanical lift to assist Resident #161 into bed. NA #3 and NA #4 were not wearing gowns. Both were wearing gloves. NA #3 and NA #4 completed the mechanical lift transfer. An interview with NA #3 was conducted on 4/6/2026 at 12:56 PM as he exited Resident #161's room. NA #3 was shown the Enhanced Barrier Precautions sign and asked what it meant. NA #3 stated he was aware Resident #161 was on Enhanced Barrier Precautions due to having a gastrostomy tube for tube feeding. NA #3 stated a gown was only required when performing some type of care not when transferring a resident. When shown the portion of the sign that indicated both a gown and gloves were required for transferring a resident, NA #3 stated again that transferring was not performing care and he did not consider a transfer to be a high-contact resident care activity. An interview with NA #4 was conducted on 4/6/2026 at 1:05 PM. NA #4 indicated she usually worked on the [NAME] unit and was unsure what was required on the East unit. NA #4 stated that 4/6/2026 was the first time she had worked with Resident #161. When asked how NA #4 knew who was on EBP on the [NAME] unit, NA #4 stated she followed the EBP signage. When asked if the EBP sign on Resident #161's door was different than the signs used on the [NAME] unit, NA #4 stated, No. NA #4 stated she sometimes used a gown when transferring residents on EBP but not all of the time. An interview was conducted on 4/9/2026 at 11:00 AM with the Infection Preventionist. The Infection Preventionist stated that NA #3 and NA #4 should have worn a gown when entering the room to provide a mechanical lift transfer for Resident #161 as that was considered a high-contact resident care activity. The Infection Preventionist indicated that the EBP sign was posted on the door along with the hanging plastic holder containing PPE as he rounded daily to make sure the signage was accurate and PPE was available. The Infection Preventionist further stated that he had completed an all staff Infection Control in-service approximately 2 weeks ago which included training on EBP and PPE use. NA #3 and NA #4 had received this recent training as well as EBP training during orientation when hired, monthly EBP/PPE use reviews during staff meetings and yearly through online training modules. An interview was conducted on 4/9/2026 at 4:10 PM with the Director of Nursing (DON). The DON stated all staff members should utilize the appropriate PPE according to the infection control signage posted for each resident. The DON stated NA #3 and NA #4 should have worn a gown when conducting the mechanical lift transfer for Resident #161. An interview was conducted on 4/9/2026 at 4:28 PM with the Administrator. The Administrator stated he expected staff to wear the required PPE when providing care to residents on EBP. The Administrator stated NA #3 and NA #4 should have worn gowns when transferring Resident #161.

Based on record review, and staff and Medical Director interviews, the facility failed to correctly transcribe a verbal physician's order for twice daily blood sugar checks resulting in no blood sugar checks being performed during a resident's admission. This affected 1 of 3 residents reviewed for services provided meet professional standards (Resident #3).The findings included:Resident #3 was admitted to the facility on [DATE] with diagnoses which included sepsis, diabetes mellitus, failure to thrive and end stage renal disease which required hemodialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer able to do so) three times weekly.A review of Resident #3's electronic medical record revealed a physician verbal order dated 9/5/2025 at 9:12 PM for check blood sugar twice daily. Resident #3 was not on any diabetic medication.A care plan dated 9/10/2025 indicated Resident #3 had a diagnosis of diabetes mellitus and was at risk for complications related to the disease process with a goal that Resident #3 would not experience any complications of diabetes mellitus. Interventions included monitor for signs and symptoms of hyperglycemia (high blood sugar), monitor for signs and symptoms of hypoglycemia (low blood sugar), and obtain lab work as ordered.A review of Resident #3's electronic medical record (EMR) indicated no record of blood sugar being drawn from the date of admission 9/5/2025 to discharge 9/10/2025. An interview on 10/1/2025 at 4:40 PM with the Director of Nursing (DON) revealed that the physician's verbal order dated 9/5/2025 at 9:12 PM for check blood sugar twice a day had been provided to Nurse #2 by the Medical Director. The DON indicated when Nurse #2 entered the verbal order, Nurse #2 neglected to choose an option under the Flow Sheet box (treatment versus medication) which resulted in the order never being displayed on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). The DON stated a blood sugar was not taken while Resident #3 was a resident. The DON stated orders written within the last 24 hours are reviewed by nursing staff for accuracy and she was not sure why the transcription error was not discovered.An interview on 10/1/2025 at 5:08 PM with Nurse #2 indicated she took the verbal order for check blood sugar twice a day from the Medical Director. Nurse #2 stated she was new to entering orders and made a mistake when entering the order.An interview on 10/1/2025 at 5:43 PM with the Administrator indicated that all physician orders should be entered correctly.An interview on 10/2/2025 at 8:40 AM with the Medical Director revealed Resident #3 was a very sick individual and had an extended hospital stay prior to admission to the facility. The Medical Director stated the verbal order dated 9/5/2025 at 9:12 PM for check blood sugar twice daily was provided as Resident #3 had a history of low blood sugar episodes while in the hospital prior to admission to the facility. The Medical Director stated Resident #3 was not on any diabetic medication. The Medical Director indicated that all orders should be transcribed correctly.

Based on observations, and resident, staff, Family Member #1, and Pest Control Representative interviews, the facility failed to effectively manage pests in 1 of 3 resident rooms (Resident #1) reviewed for pest control and for 1 of 1 observation for pest control in the conference room.Findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis of peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Resident #1's Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated he had moderately impaired cognition. An interview and observation were conducted on 09/30/25 at 10:31 AM with Resident #1. During the interview he stated he had observed flies/gnats in his room, but it was in a previous room. Resident #1 stated he had been to the hospital recently but could not recall what for and told the surveyor he had the wounds on his left lower leg prior to entering the facility. During the observation there were no flies or gnats noted in Resident #1's room. An interview was conducted on 09/30/25 at 3:00 PM with Family Member #1. During the interview she stated Resident #1's room was observed with flies and gnats on multiple occasions in August 2025. She stated on 08/02/25 she had to personally go out and purchase an ultraviolet (UV) insect trap and place it into Resident #1's room. Family Member #1 explained she had received permission for the insect trap from a previous Administrator. The interview revealed the flies/gnats were so bad in Resident #1's room the family was, swatting at them. Family Member #1 stated they had told numerous facility staff members during August 2025. The interview revealed Resident #1 went to the hospital on [DATE] and had since changed rooms. An interview and observation were conducted on 09/30/25 at 3:40 PM with Resident #2. During the interview Resident #2 stated he was Resident #1's former roommate. He stated he had always experienced flies and gnats in his room and had even purchased a spray to help with the insects. No insects were observed at the time of the observation, however, snacks, bread and a small refrigerator were observed in Resident #2's room. He explained his former roommate (Resident #1) had purchased a blue light to catch insects in. He stated the facility attempted to remove his trash, but he had never seen anyone spray the room for insects. An interview conducted with the Wound Nurse on 09/30/25 at 1:53 PM revealed Resident #1 was admitted into the facility with venous ulcers (a wound on the leg or ankle caused by abnormal or damaged veins). She explained the resident had been receiving treatment to the wounds since admission and the areas were improving. The interview revealed Resident #1 was in the room with a roommate who had a refrigerator and would often leave open food in the room attracting flies and gnats. The Wound Nurse stated she had observed flies and gnats in Resident #1's room to the point Resident #1's Family Members had purchased a blue light ultraviolet (UV) insect trap and placed it in the room. She stated on 08/21/25 she went into Resident #1's room to clean and dress his wound to the left leg without any issues. She did not remember seeing flies or gnats on that date. The wound was wrapped with a bandage from the resident's toes to his left shin. The interview revealed the area to Resident #1's left leg was changed on Mondays and Thursdays. The Wound Nurse stated she saw Resident #1 on 08/22/25 and he was at his baseline, up sitting in his wheelchair with the bandage to his left leg in place. An interview conducted with Nurse Aide (NA) #1 on 09/30/25 at 11:23 AM revealed she worked in the facility on Resident #1's hall during the Monday through Friday shift 7:00 AM to 3:00 PM. NA #1 explained she had observed flies and gnats in the resident's room and administrative staff were aware of the situation because of the resident's roommate (Resident #2). An interview conducted with NA #2 on 10/01/25 at 11:30 AM revealed she had taken care of Resident #1 on 08/21/25 during the 7:00 AM to 3:00 PM shift. She stated she observed one or two flies in the resident's room due to snacks left open in the room and trash in the trash can. NA #2 stated she observed Resident #1's ultraviolent insect trap in his room with insects inside, on the trap. She explained that she removed the trash from his room and tried to clean up as much as she could but also housekeeping staff had come by to assist. Hospital records dated 08/23/25 revealed Resident #1 was admitted into the hospital on this date due to generally feeling weak and the need for increased oxygen. Upon assessment in the hospital Resident #1 was noted to have left lower extremity venous ulcers and blisters to the mid left shin. Resident #1 was admitted and treated for sepsis to chronic venous statis ulcer and returned to the facility on 9/12/25. On 09/30/25 at 4:06 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated Resident #1's wounds were always dressed and cleaned. The DON explained on 08/23/25 Resident #1 had experienced a change of condition and was sent to the hospital. The DON stated she had physically seen small flies or gnats in Resident #1's room on one occasion due to a half-eaten banana. She explained Family Member #1 had asked to bring in an ultraviolent insect trap in August 2025 because of insects in his room. She explained Resident #1 never wanted to eat outside of his room and would always eat snacks in the room. Environmental staff were completing extra rounding to attempt to keep the room clean and meal trays were removed immediately with completion of the meal. The DON stated the Maintenance Director completed pest control rounding and the main issue that arose were ants not gnats or flies. On 10/01/25 at 10:32 AM an interview was conducted with the Maintenance Director. The Maintenance Director stated he did not keep a log of every time an issue with insects was reported. He stated if there was an issue with flies or gnats he would just go directly to the room and spray to take care of the concern. He stated the facility had a contract with a pest control company that came out monthly to spray the facility. The interview revealed he could not recall being told there was a concern with flies or gnats in Resident #1's room. On 10/02/25 at 9:25 AM an interview was conducted with the Director of Housekeeping. During the interview she stated Resident #1's room was always cleaned twice a day and throughout the day because of trash and debris in the room. She explained the residents in the room would keep dirty napkins and snack bags in the room. The Director of Housekeeping stated the room would smell and she had observed gnats in the room and a couple of flies. She stated she had let the Maintenance Director know about the situation and if she saw food open, she would place it in a bag to try to eliminate the insects that were attracted to the area because of food items. On 10/01/25 an interview was conducted with the Pest Control Representative. The Representative stated the Pest Control company had most recently been to the facility in September and prior to that was in the facility on 08/13/25 to treat rodent stations and in the kitchen area due to cockroaches. No flies or gnats were mentioned in the report. The interview revealed the Pest Control company had no record of issues with flies or gnats from the facility. A continuous observation on 09/30/25 and 10/01/25 revealed small, winged gnats in the facility conference room. An interview conducted on 10/01/25 at 5:00 PM with the Administrator revealed he was new to the facility and was not aware of a fly or gnat problem. He stated there should be no flies or gnats in resident rooms to create a safe, comfortable environment for the residents. The Administrator acknowledged the gnats in the conference room during the conversation.

Based on record review and interviews with the Family Member, facility staff, Nurse Practitioner, and Medical Director, the facility failed to resume Eliquis, an anticoagulant commonly known as blood thinner, for Resident #1. Upon admission in March 2025, Resident #1 was prescribed Eliquis due to a history of deep vein thrombosis and pulmonary embolus. The medication was temporarily discontinued on 7/2/2025, in preparation for a scheduled medical procedure performed on 7/7/2025. However, the facility did not restart Eliquis until 10/1/2025, nearly three months later, after the resident began exhibiting symptoms including shortness of breath, bilateral lower extremity (BLE) edema, and a need for supplemental oxygen. On 10/7/2025, Resident #1 was transferred to the Emergency Department, where he was diagnosed with bilateral pulmonary emboli (blood clot in the lungs), including a complete occlusion (blockage) in the right lower lobe suggestive of pulmonary infarction (death of lung tissue due to occlusion of blood flow). The resident required a heparin (a blood thinner) drip and underwent thrombectomy (a surgical procedure) to remove the clots. Resident #1 was readmitted to the nursing home on [DATE] after a nine day stay at the hospital. This deficient practice affected 1 of 3 sampled residents reviewed for quality of care (Resident #1). Immediate jeopardy began on 7/7/25 when the facility failed to restart Eliquis for Resident #1. Immediate jeopardy was removed on 10/26/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heart rhythm) and benign prostatic hyperplasia (a condition where the prostate gland enlarges, causing symptoms such as difficulty urinating and a frequent need to urinate), type 2 diabetes, urinary retention, a history of deep vein thrombosis (DVT), and a history of pulmonary embolus. On 3/19/25, the physician ordered Eliquis 5 milligrams (mg) by mouth every 12 hours. Resident #1's care plan included an anticoagulant therapy problem with the start date of 3/24/25. The goal read the resident will have no complications related to anticoagulant therapy through next review. Approaches included monitoring for signs and symptoms of bleeding and provide lab work and medications as ordered. On 6/2/25, Resident #1 was seen for a urology consultation. The progress note indicated that due to the resident's medical history and ongoing use of chronic anticoagulation therapy, medical clearance would be required to minimize bleeding risks prior to the planned procedure. The note also stated that a follow-up visit was pending based on the availability of the outpatient surgery schedule for a suprapubic catheter replacement. However, the urologist's documentation did not include a confirmed date for the procedure or any preoperative orders. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. He was coded for supervision, moderate assistance, and substantial assistance for activities of daily living. He was coded to have an indwelling urinary catheter and for anticoagulant medication use. Medication Administration Records (MAR) from 4/21/25 through 7/2/25 revealed Eliquis was administered as ordered. Eliquis was not administered to Resident #1 after 7/2/25. A Nurse Practitioner's (NP) progress note dated 7/2/25 indicated Resident #1 was seen, had no complaints of shortness of breath (SOB), was awake and alert and appeared comfortable in his wheelchair. Resident #1 had an indwelling catheter and would be seen on Monday (7/7/25) at the urologist for a suprapubic catheter placement procedure. Resident #1 was to be nothing by mouth on Sunday night (7/6/25) and Resident #1's Eliquis would be held per the urologist pre-operation instructions. Additionally, the progress note wrote the NP had discussed the information with nursing. A review of Resident #1's physician's orders dated 7/2/25 found Eliquis 5 mg by mouth every 12 hours was discontinued. Nurse Practitioner notes were reviewed for 7/8/25, 7/9/25, 7/15/25, 7/16/25, 7/24/25 and 7/28/25. Each note included this statement, I have reviewed the resident's medications in the facility chart (MAR). Refer to the facility's Medication Administration Record (MAR) for a complete and up to date list of active medications. The only visits with findings that were not at baseline were 7/16/25 that included a notation for catheter site intact with mild tenderness and on 7/28/25 that included a notation for redness and mucous at catheter site. Every plan in the six notes included a mention of medication, such as active medication includes a blood thinner, medications reviewed, continue Eliquis, continue current medication including blood thinner. The Medical Director's notes were reviewed for 8/18/25, 9/5/25, 9/11/25 and 9/12/25. Each note indicated the resident's medications were reviewed in the MAR and to refer to the MAR for a complete and updated list of active medications. Each note indicated the resident was on Eliquis 5 mg twice daily. The 8/18/25 findings noted mild tenderness to the catheter site. On 9/30/25 the NP wrote a progress note that read Resident #1 was seen for a follow-up visit for BLE swelling. The resident showed slight improvement in BLE swelling. The NP discussed with the resident and Family Member the need for Resident #1 to wear compression stockings and would order a venous doppler for bilateral lower extremity to rule out a deep vein thrombosis (DVT).A review of Resident #1's medical record did not find a written order for the venous doppler. Nurse #3 wrote on 10/01/25 at 2:56 PM Resident #1 was having difficulty breathing and placed on 2 liters of oxygen via nasal cannula. His oxygen saturation was at 95%. (The normal range for oxygen saturation is 95% - 100%.) The results of the venous doppler dated 10/1/25 indicated non-occluding DVT (a blood clot that partially blocks a blood vessel) identified at the right common femoral vein (major deep vein in the thigh). The results read the DVT could have been chronic (recurring). An NP progress note dated 10/1/25 was reviewed. The note included the resident had been advised to elevate his legs and use compression stockings. Resident #1 reported dyspnea (shortness of breath), which was exacerbated on 9/30/25. He was requiring supplemental oxygen. On 10/1/2025, he did not require the use of oxygen. The NP noted that later, nursing reported that the resident's venous doppler showed non-occluding DVT (blood clot with some blood flow around the clot) of right common femoral vein (large blood vessel in the thigh) that could be chronic. The NP's plan was to reinitiate prescription medication management with Eliquis 10 mg twice daily x 7 days, then continue Eliquis 5 mg twice daily. The NP note included that the resident's chronic anticoagulation was stopped in July 2025 prior to procedure to have suprapubic catheter placed and the anticoagulation was not restarted. Will reinitiate Eliquis with loading dose 10 mg twice daily and then continue Eliquis 5 mg daily, with no stop date. The NP wrote she will order a 2-view chest x-ray for shortness of breath requiring supplemental oxygen use. On 10/1/25 a physician's order was written for two (2) Eliquis 5 mg tablets and to administer every 12 hours for total 10 mg for 7 days then continue Eliquis 5 mg one (1) tablet every 12 hours. Additionally, on 10/1/25 a physician's order was written for a 2-way chest x-ray for dyspnea. A review of physician's orders revealed on 10/1/25 furosemide (diuretic) 20 mg; administer 0.5 tablet (10 mg) once a day was ordered at 2:00 PM. Also, on 10/1/25 furosemide 20mg 1 tablet 2 times daily was ordered for 9:00 AM and 5:00 PM. Review of the October MAR revealed Resident #1 received the furosemide as ordered from 10/1/25 through 10/7/25.An interview on 10/22/25 at 4:07 PM with the NP revealed she had followed the urology consult order recommendations to hold Resident #1's Eliquis. The NP explained that the electronic health record system the facility uses does not permit medication to be held, it had to be discontinued, and a new order entered to restart the medication. The NP did not remember if there was a specific restart date for the medication after the procedure. She stated it was an oversight and there was so much going on, she forgot to enter an order to restart the Eliquis after the procedure. She stated she was notified on 10/01/25 of the resident's increased leg swelling, ordered a venous doppler which showed a DVT, and restarted him on Eliquis. A chest x-ray was ordered 10/1/25 and completed on 10/02/25 which showed no acute cardiopulmonary process. An interview on 10/22/25 at 11:16 AM with Resident #1's Family Member revealed that Resident #1 had been on Eliquis for several years due to a history of blood clots and a stroke. The Eliquis was held on 7/02/25 for an outpatient urology procedure to insert a suprapubic urinary catheter scheduled on 7/07/25. The Family Member stated she did not recall the nurse she asked about the Eliquis being restarted after the procedure and was told it would be restarted. The Family Member stated she talked to the Assistant Director of Nursing (ADON) but was unable to recall the specific date concerning the resident's increased swelling in his legs. She stated a venous doppler study was ordered and completed which showed a blood clot in his right leg. The ADON notified her of the blood clot and told her they were going to start him on Eliquis. She questioned the ADON about starting him on Eliquis and stated he should have already been on Eliquis. The ADON wrote a progress note on 10/01/25 at 5:13 PM. The note revealed the Family Member was informed the treatment in related to the bilateral lower extremity doppler result and that Eliquis 10 mg twice a day (BID) x 7 days then Eliquis 5 mg BID (no stop date) was ordered. Resident #1 was told a chest x-ray would be done this afternoon and the Family Member would be notified. The ADON explained to the Family Member that last July, prior to suprapubic catheter surgery, the Eliquis was stopped. An interview on 10/23/25 at 8:11 AM with the Assistant Director of Nursing (ADON) revealed that on 10/01/25, she had a conversation with Resident #1's Family Member to provide an update. During this conversation, the Family Member stated that the resident was already on Eliquis and had been on the medication for 10 years due to a history of blood clots. The ADON reviewed the resident's discontinued medications and discovered his Eliquis had been discontinued on 7/02/25. The ADON indicated she notified the NP. An interview on 10/22/25 at 1:45 PM with the Director of Nursing (DON), in the presence of the Administrator, revealed Resident #1 was seen and assessed by the Nurse Practitioner (NP) on 10/01/25. The NP had ordered a venous doppler which was completed on 10/01/25. The venous doppler revealed a non-occluding deep vein thrombus (DVT) identified at the right common femoral vein. The DON stated that Resident #1 was restarted on Eliquis 10 mg every 12 hours for 7 days as ordered by the NP on 10/2/25. The DON stated that the ADON had figured out that the NP had discontinued the Eliquis on 7/02/25 and had not restarted it after his urology procedure. An interview on 10/22/25 at 3:52 PM with the Medical Director revealed she had been notified of the failure to restart Resident #1's Eliquis and his venous doppler results on 10/01/25. She stated his Eliquis should have been restarted and believed someone forgot to restart it after his urology procedure. The Medical Director stated this was a combination of human and computer error. The electronic health record system the facility uses does not have a medication hold function and the medication order must be discontinued and a new order entered. Resident #1's October 2025 MAR revealed Resident #1 received Eliquis 10 mg 2 times daily at 9:00 AM and 9:00 PM on 10/2/25 through 10/6/25 and at 9:00 AM on 10/7/25. On 10/2/25 Resident #1's vital signs were recorded. The oxygen saturation was 93% at 12:24 PM on room air. The normal range for oxygen saturation is 95% - 100%. The chest x-ray was ordered by the NP on 10/1/25 and was completed in the facility on 10/2/25. The reviewed results of the chest x-ray indicated no focal consolidation (dense tissue), no pleural effusion (excess fluid), no prominent lung markings (increased blood flow due to infection), no pneumothorax (collapsed lung). An NP progress note dated 10/2/25 Resident #1 was seen for a follow-up of a chest x-ray. The NP wrote Resident #1 had previously reported having shortness of breath requiring supplemental oxygen. The resident was not using supplemental oxygen when evaluated at this time and appeared comfortable. Resident #1 noted he felt he needed it at bedtime. The chest x-ray results were negative for any acute cardiopulmonary disease. The resident's labs were unremarkable. Resident # 1 had recently restarted Eliquis for DVT. The note included the resident had bilateral leg extremity swelling present with no evidence of infection. The NP wrote Resident #1's medications and vitals were reviewed and unremarkable, his blood pressure was stable, and to continue to monitor for any acute changes. The NP's exam of Resident #1 found he had shortness of breath, and his lungs had equal breath sounds with no wheezing, rales, or rhonchi. Additionally, the plan for the resident included treating the right leg DVT with Eliquis 10 mg 2 times daily for 7 days and then continuing Eliquis 5 mg 2 times daily with no stop date. A progress note written by Nurse #3 on 10/3/25 at 5:22 AM read Resident #1 started screaming and said he was having an anxiety attack. His blood pressure was 106/60 (normal range <120 and <80), his pulse was 109 (normal range 60-100), his oxygen saturation was 82% on room air (normal range 95%-100%), and his temperature was 98.9 (average normal temperature is 98.6 degrees Fahrenheit). The resident started oxygen via nasal cannula, and his oxygen saturation went to 88%. The resident asked the nurse to find his phone to call his wife. The resident was told by his wife she was coming to sit with him, and he immediately stopped screaming. A call was placed to the on-call doctor with a new order to give hydroxyzine 10 mg, an antihistamine that can be used for anxiety, and to increase oxygen to 3-4 liters per minute via nasal cannula. There was no physician order entered on 10/3/25 to increase the resident's oxygen to 3-4 liters per minute via nasal cannula. Review of Resident #1's October 2025 MAR revealed he was administered hydroxyzine HCl 10 mg one (1) tablet on 10/3/25 at 4:30 AM. On 10/3/25 at 2:48 PM Nurse #1 wrote Resident #1's Family Member and nurse suggested he go back to bed because he was falling asleep, he was very lethargic, and his legs were swollen. The resident refused to lie down and stated he would go back to bed at bedtime. A Medical Director progress note dated 10/3/25 indicated Resident #1 was seen at the request of nursing staff. Resident #1 was reported to have lethargy (sleepiness) this AM. Nursing staff reported Resident #1 was agitated overnight, yelling out for his family. Resident #1 did receive hydroxyzine overnight due to his agitation. The family at bedside reported concern that Resident #1 had a UTI and requested he be checked. Additionally, the note revealed the nursing staff had no further reported issues or concerns. The Medical Director wrote the resident was examined in his room and appeared awake, tired, and was responsive. He did not have a cough, shortness of breath, chest pain or palpitations, fever or chills. The Medical Director added given Resident #1's change in status and history of recurrent UTIs she will obtain STAT (immediate) labs that included a CBC (complete blood count), CMP (comprehensive metabolic panel), and a urinalysis with a culture and sensitivity (UA with C&S). The progress note included vital signs dated 10/2/25 with heart rate 72 bpm (beats per minute) at 11:00 PM, blood pressure 128/72 at 12:23 PM, oxygen saturation 93% on room air at 12:24 PM, temperature 98.2 at 12:23 PM, and respiratory rate 17 per minute at 12:23 PM. The Medical Director's plan included starting empiric antibiotic ceftriaxone (broad-spectrum antibiotic) one (1) mg IM (intramuscular) 5 days and to closely monitor and follow as clinically warranted. The Medical Director wrote an order dated 10/3/25 for STAT UA with C&S, CBC, and CMP. A review of Resident #1's October MAR revealed ceftriaxone 1 gram injection intramuscular once daily was ordered on 10/3/25. The medication was administered once daily from 10/3/25 through 10/7/25. On 10/3/25 at 5:37 PM the DON wrote a progress note that read Resident #1 had new orders from the Medical Director for Ceftriaxone, daily x 5 days, and STAT CMP, UA C&S for Dysuria (pain or burning when urinating). Unfortunately, the medical lab system was down today, and all stat services were unavailable. The labs ordered will be done in the AM and the urine specimen was collected and currently in the lab specimen refrigerator for pick up. The resident had increased lethargy on 7-3 pm shift from not resting well the previous shift. Staff attempted to lay him down, but he refused. The DON stated during interview on 10/23/25 at 9:35 the physician ordered labs on 10/3/25 were not drawn until 10/6/25. On 10/4/25 the lab was called for the ordered labs, but the lab did not arrive. The DON said she had communicated to the Medical Director verbally that the laboratory was having problems and the first availability to draw the CMP and CBC labs, and send the UA was on 10/6/25. The results were not completed prior to Resident #1 being sent out to the hospital on [DATE]. On 10/04/25 at 1:03 PM a progress note written by Nurse #2 read she was called to Resident #1's room by his family to observe swollen left leg and draining clear fluid. Nurse #2 was not interviewed about the progress note on 10/4/25.A progress note dated 10/6/25 revealed the Medical Director Resident #1 was examined and appeared improved overall and he stated overall he was feeling better. The resident was seated upright in his wheelchair and denied any urinary discomfort, abdominal pain, chest congestion, cough, or current shortness of breath. He remained on supplemental oxygen intermittently and continued to have bilateral lower extremity edema with weeping of clear fluid. The resident did respond to some increase in diuretic. A chest x-ray was done and without any acute findings. Resident #1 remains on treatment for right lower extremity DVT with blood thinner, based on venous doppler done on 10/1/25. The Eliquis was recently restarted after having been stopped for a surgical procedure when his suprapubic catheter was placed. Resident #1's vitals remained stable overall and nursing reported no other concerns or issues. Resident #1's vital signs recorded on 10/6/25 at 8:35 AM were heart rate 86 bpm, blood pressure 126/90, oxygen saturation 97% on room air, temperature 98, and respiratory rate was 18 breaths per minute. The Medical Director ordered a CT scan (computed tomography scan, an imaging procedure) of the chest to rule out any pulmonary embolism, given the resident's ongoing intermittent shortness of breath and supplemental oxygen requirement. The note read, Should a CT scan not be able to be scheduled within the next 1-2 days, I would recommend sending patient out to hospital to have scan completed. The Medical Director wrote to send Resident #1 to the emergency department should he have any acute changes or decompensation (the failure of an organ, especially the liver or heart), but the resident was currently medically stable. On 10/6/25 a physician's order was written for a chest CT scan with contrast. Please refer to the VA (Veteran's Administration hospital). An interview on 10/23/25 at 10:29 AM with Nurse #1 revealed she had been assigned to Resident #1's hall on 10/07/25 on the 3:00 PM to 11:00 PM shift. She stated she did not remember if he was on oxygen at that time but had started on oxygen a few days before when he stated he could not breathe even with an oxygen saturation reading of 95% on room air. She also noted he had increased anxiety and had stated he did not feel good, his skin was crawling, and he had a bad feeling. The ADON wrote a progress note dated 10/07/25 at 5:09 PM. The note read the Medical Director was notified the Veteran's Administration hospital would not do the chest CT urgently, and if in need of urgent CT to consider sending to a local hospital. The Medical Director gave a telephone order to send Resident #1 to the hospital for evaluation due to hypoxia and dyspnea. The Family Member was notified, and 911 was called at approximately 5:00 PM. The hospital admission notes included the Emergency Department progress notes dated 10/7/25 and revealed Resident #1's blood pressure was 213/96 (hypertensive), his respirations were 33 breaths per minute (normal range 12-20 per minute, and his oxygen saturation was 93% (normal range 93%-100%). Resident #1 reported tightness in his chest and shortness of breath. The emergency department lab results dated 10/7/25 revealed he was positive for a UTI. A chest x-ray result found mild pulmonary congestion, an ultrasound of his legs found a DVT in his right femoral vein of his lower leg and a CT scan of his chest found bilateral pulmonary embolism within the distal aspect of the main pulmonary arteries. Resident #1 was started on a heparin drip (an intravenous infusion of heparin, an anticoagulant used to prevent and treat blood clots) and was admitted to the hospital. Resident #1's hospital Discharge summary dated [DATE] indicated Resident #1 was taken to the emergency room on [DATE] and underwent a CT scan of the chest. The CT results found bilateral pulmonary embolism of the main pulmonary arteries extending into the upper and lower lobes (lung section). Additionally, the results read the findings were worrisome for the presence of complete occlusion within the right lower lobe and for the presence of an infarction. Furthermore, the discharge summary read that a venous ultrasound of Resident #1's lower legs was completed on 10/7/25 and found a partially blocked thrombus (blood clot) of the right femoral vein. The resident received IV (intravenous) heparin in the emergency department. The discharge summary included Resident #1's admitting MD note. The MD note read Resident #1 was admitted with a medical history that included atrial fibrillation and CVA (stroke) with left sided weakness, and chronic suprapubic catheter. Resident #1 was presented to the emergency department due to exertional shortness of breath of the last several days and had oxygen started at his facility 2 days ago. The admitting physician's note included Resident #1's family stated the resident was on a blood thinner for several years that was held 2.5 months ago for suprapubic catheter placement. Resident #1 started back on the blood thinner 4 days ago (10/2/25). While admitted to the hospital Resident #1 underwent a pulmonary angiography and catheter directed thrombectomy (procedure to remove lung blood clot). Resident #1 was diagnosed with a UTI and received IV Rocephin (antibiotic). Resident #1 was discharged to the facility with the order for Eliquis 5 mg tablet every 12 hours. An additional interview on 10/23/25 at 12:10 PM with the Medical Director revealed the NP had seen Resident #1 on 10/01/25. The doppler was ordered due to increased swelling in both his legs. The chest x-ray was ordered due to shortness of breath. After the doppler results, the Eliquis was ordered. The Medical Director saw Resident #1 on 10/03/25 and she ordered labs, urinalysis, and started him on antibiotics for a suspected urinary tract infection. The labs and the urinalysis were ordered to be done 'stat' (immediately). The urinalysis was collected on 10/03/25 The Medical Director stated when interviewed she was made aware by the DON; the lab orders could not be completed on 10/3/25 and the first availability for a lab draw was on 10/6/25. The Medical Director said the resident was receiving antibiotic for suspected UTI and the delayed UA would not have delayed the resident's treatment. The Medical Director stated the CMP and CBC were not completed before the resident went to the hospital on [DATE] and that she had reviewed them for the first time today (10/23/25). After reviewing the lab results, the Medical Director explained there was nothing in the lab results that would have changed how the resident was treated. The Medical Director stated the reason she sent him to the hospital on [DATE] was due to the inability to the CT scan of the chest which was ordered on 10/06/25 completed in a timely manner. The Medical Director acknowledged the significant medication error when the Eliquis had not been restarted following the urology procedure which placed the resident at increased risk for blood clot. The Medical Director stated ideally the pharmacy medication regimen review should have caught the medication error and brought it to her attention. She also stated there was no way to know for sure if the blood clots were chronic or acute unless he had previous ultrasound. The Medical Director stated on 10/23/25 at 12:25 PM she was made aware the lab orders (CBC, CMP, UA) could not be completed on 10/3/25 and the first availability of a lab draw was on 10/6/25. The Medical Director said the resident was receiving an antibiotic for a suspected UTI and the delayed UA would not have delayed the resident's treatment. An additional interview on 10/23/25 at 4:18 PM with the Administrator and DON revealed the medications should have been reviewed by the NP and Medical Director and the failure to restart the Eliquis should have been caught. The Administrator was notified of immediate jeopardy on 10/23/25 at 4:30 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those residents who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #1 was admitted to the facility on [DATE] with a diagnosis that included, but not limited to, chronic atrial fibrillation and had an admitting order for Eliquis (anticoagulant) 5mg, 1 tablet, every 12 hours. Resident #1's spouse reported a history of anticoagulant use and deep vein thrombosis (DVTs) upon admission. On 6/2/25, Resident # 1 had an urology appointment due to feeling a burning sensation with the indwelling catheter. It was determined the resident needed to have a suprapubic catheter placed. The urology consult indicated that the patient would need medical clearance regarding past medical history and use of chronic anticoagulation to reduce his bleeding risk in preparation of his upcoming procedure. On 07/02/25, the Nurse Practitioner (NP) made the determination to discontinue the anticoagulant (Eliquis 5mg 1 tablet daily) for a suprapubic catheter placement on Monday, 07/07/25. The NP did not enter another order to restart the Eliquis after the catheter placement. The NP thought she entered an order to restart the medication but failed to do so. On 07/08/25, NP conducted a post-op follow-up with documentation stating that the medication was reviewed and the Eliquis was listed as being ordered. On 7/11/25, Resident #1 had post-op appointment at the VA, and no Eliquis was added to Resident #1's medication list on the consultation. On 10/01/25, the Licensed Nurse requested an order from the Healthcare Practitioner for a venous doppler to the bilateral lower extremities due to swelling to lower extremities. The doppler concluded there was non-occluding thrombus (DVT) identified at the right common femoral vein and that the finding could be chronic. The Licensed Nurse notified the NP, and the NP inquired if Resident #1 was on a blood thinner. The Licensed Nurse reviewed the chart and noted the resident was not on a blood thinner but had been on Eliquis in July 2025 and it was discontinued prior to the suprapubic catheter placement, and it was not restarted after the procedure. The anticoagulant was then restarted (Eliquis 10mg, every 12 hours x 7 days and then Eliquis 5mg, 1 tablet, every 12 hours). On 10/03/25, Resident #1 was noted to be anxious and vital signs indicated blood pressure 106/60, oxygen saturation 82 % on room air. New order received from Healthcare Practitioner to administer hydroxyzine (helps to reduce anxiety) 10mg now and to increase oxygen to 3-4 liters per minute via nasal canula. On 10/04/25, the Resident's spouse reported swelling to Resident's left leg which was draining clear liquid, but Resident had no pain or discomfort. The concern was provided to Healthcare Practitioners to follow up. On 10/07/25, Resident #1 was transferred to the hospital due to being hypoxic with supplemental oxygen and having to wait for a Veteran Affairs (VA) follow-up appointment. Resident #1 was transferred and admitted to acute care hospital. Hospital records revealed pulmonary embolism, pulmonary artery of the upper and lower lobes necessitating a thrombectomy. On 10/14/25, the Director of Nursing (DON) and the Interim Administrator had an in-person meeting with the Resident's spouse and discussed the concerns regarding the Resident's anticoagulant being held for 85 days. Formal apology provided on behalf of the facility. Official grievance was completed and resolved with spouse. Spouse agreed to allow the Resident to return to the facility. On 10/16/25, Resident readmitted to the facility with an order for anticoagulant (Eliquis 5mg, 1 tablet, every 12 hours). An audit of current residents in the month of October on anticoagulant therapy was completed by running current orders for anticoagulants and reviewing the orders for accuracy to determine whether any changes or adjustments with the anticoagulant were made, and verifying the appropriate administering or discontinuing of the medication as ordered. The audit was completed by the DON on 10/13/25. The DON ensured residents had their anticoagulant ordered and administered as required, and verified that the medication was available in the medication cart. No further concerns were identified. Another audit of current residents on anticoagulant therapy and residents that had discontinued anticoagulant orders for the month of October 2025 was completed on 10/23/25 by the DON and the Assistant Director of Nursing (ADON). There were no other concerns identified. A further audit will be completed by reviewing the Healthcare Practitioner's progress notes and provider's consultations for the month of October 2025 to identify any other medication that have been discontinued specifically focused on anticoagulant medications and have not been restarted. The audit will be completed on 10/24/25 by the DON, ADON and the Pharmacy Consultant. If any further concerns are identified from the audit, the Healthcare Practitioner will be notified, and the resident will be evaluated. Current and newly admitted residents on anticoagulants, residents with newly ordered for anticoagulants and anticoagulant that have been discontinued have the potential to be affected. The facility will ensure the residents' medications will be administered, discontinued and restarted appropriately.Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Licensed Nurses were originally re-educated on the importance of ensuring a resident's medication, such as an anticoagulant, that is temporarily discontinued due to a procedure, treatment or hospitalization, has been restarted. The Licensed Nurse must verify that the medication that the resident was taking prior to being discontinued has been reentered, verified and activated, if still deemed medical necessary. If the medication is held for a certain number of days, the Licensed Nurse is to [TRUNCATED]

Based on record review, and staff, Nurse Practitioner, and Physician interviews, the medical providers failed to review the total plan of care and ensure the medication list on the Nurse Practitioner and Physician progress notes were accurate for 1 of 3 residents reviewed to ensure the facility is free of medication errors (Resident #1).Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation and benign prostatic hyperplasia. Resident #1's Nurse Practitioner (NP) progress note dated 7/02/25 untimed, read that the resident's Eliquis (blood thinner medication) would be held prior to a suprapubic catheter placement procedure. The medication list included Eliquis 5 milligrams (mg) oral (by mouth) every 12 hours. An order dated 7/02/25 at 1:37 PM was created by the NP to discontinue the Eliquis. Resident #1's NP progress note dated 7/31/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read 'I have reviewed the resident's medications in the facility chart (MAR) (Medication Administration Record). Refer to the facility's Mediation Administration Record (MAR) for a complete and up to date list of active medications.' Resident #1's NP progress note dated 8/07/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read 'I have reviewed the resident's medications in the facility chart (MAR) (Medication Administration Record). Refer to the facility's Mediation Administration Record (MAR) for a complete and up to date list of active medications.' Resident #1's NP progress note dated 8/11/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read 'I have reviewed the resident's medications in the facility chart (MAR) (Medication Administration Record). Refer to the facility's Mediation Administration Record (MAR) for a complete and up to date list of active medications.' Resident #1's Physician (MD) progress note dated 8/18/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read 'I have reviewed the resident's medications in the facility chart (MAR) (Medication Administration Record). Refer to the facility's Mediation Administration Record (MAR) for a complete and up to date list of active medications.' There was an addendum clinical clarification electronically signed by the MD on 10/22/25 which read that the patient was not taking Eliquis on the date of the progress note. Resident #1's MD progress note dated 9/05/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read 'I have reviewed the resident's medications in the facility chart (MAR) (Medication Administration Record). Refer to the facility's Mediation Administration Record (MAR) for a complete and up to date list of active medications.' There was an addendum clinical clarification electronically signed by the MD on 10/22/25 which read that the patient was not taking Eliquis on the date of the progress note. Resident #1's MD progress note dated 9/11/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read 'I have reviewed the resident's medications in the facility chart (MAR) (Medication Administration Record). Refer to the facility's Mediation Administration Record (MAR) for a complete and up to date list of active medications.' There was an addendum clinical clarification electronically signed by the MD on 10/22/25 which read that the patient was not taking Eliquis on the date of the progress note. Resident #1's MD progress note dated 9/12/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read 'I have reviewed the resident's medications in the facility chart (MAR) (Medication Administration Record). Refer to the facility's Mediation Administration Record (MAR) for a complete and up to date list of active medications.' There was an addendum clinical clarification electronically signed by the MD on 10/22/25 which read that the patient was not taking Eliquis on the date of the progress note. Resident #1's NP progress note dated 9/17/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read 'I have reviewed the resident's medications in the facility chart (MAR) (Medication Administration Record). Refer to the facility's Mediation Administration Record (MAR) for a complete and up to date list of active medications.' Resident #1's NP progress note dated 9/24/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read 'I have reviewed the resident's medications in the facility chart (MAR) (Medication Administration Record). Refer to the facility's Mediation Administration Record (MAR) for a complete and up to date list of active medications.' Resident #1's NP progress note dated 9/30/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read 'I have reviewed the resident's medications in the facility chart (MAR) (Medication Administration Record). Refer to the facility's Mediation Administration Record (MAR) for a complete and up to date list of active medications.' Resident #1's NP progress note dated 10/01/25 read that the patient's chronic anticoagulation stopped in July 2025 prior to procedure to have suprapubic catheter place. Anticoagulation was not restarted. Will reinitiate Eliquis with loading dose. An order to restart the Eliquis was given by telephone from the NP on 10/01/25 at 2:46 PM. The order was for Eliquis 5 mg 2 tabs (total 10 mg) oral every 12 hours for 7 days, then 5 mg oral every 12 hours with no stop date. An interview on 10/22/25 at 3:51 PM with the NP revealed the progress notes medication list indicated that Eliquis was an active medication for Resident #1. She stated that the medications carried over from the previous note may not always be accurate or reflect medication changes. She stated the failure to restart the Eliquis was an oversight. An interview on 10/22/25 at 3:52 PM with the MD revealed Resident #1's Eliquis should have been restarted after the suprapubic catheter insertion procedure. The medication list on the progress notes were active medications and were carried over from previous progress notes. The MD stated she reviewed the facility Medication Administration Record for an accurate resident medication list. The MD was unable to explain how the Eliquis medication was missed and had not been restarted after the urology procedure. An interview on 10/23/25 at 4:18 PM with the Administrator and the Director of Nursing (DON) revealed they were aware the MD and NP progress note medication lists were not always accurate but were unaware of the specific process of how the medication list got on the progress note. The Administrator stated that the medications should have been reviewed and the failure to restart the Eliquis should have been caught.

Based on record review and interviews with the Consultant Pharmacist, Nurse Practitioner, Medical Director and Director of Nursing, the facility's Consultant Pharmacist failed to identify a significant lapse in anticoagulant therapy. Specifically, Eliquis (an anticoagulant, also known as a blood thinner) was discontinued on 7/2/25 for a surgical procedure and was not resumed until 10/1/25. This interruption in therapy was not addressed in the drug regimen reviews following the procedure, thereby failing to ensure the continuation of chronic anticoagulant treatment for Resident #1. This deficient practice was identified in 1 of 3 residents reviewed for unnecessary medications (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, type 2 diabetes, and a history of pulmonary embolus. On 3/19/25, the physician ordered Eliquis 5 milligrams (mg) by mouth every 12 hours. Resident #1's physician orders for July 2025 revealed Eliquis 5 mg by mouth every 12 hours was discontinued on 7/2/25. The Consultant Pharmacist review of Resident #1 dated 7/30/25, 8/25/25, and 9/24/25 revealed no recommendations for restarting the Eliquis medication.On 10/1/25 a physician's order was written for 2 Eliquis 5 mg tablet and to administer every 12 hours for total 10 mg.The Consultant Pharmacist was interviewed via phone on 10/23/25 at 9:07 AM. He stated a pharmacy review for Resident #1 was completed on 7/30/25, 8/25/25 and on 9/24/25. The Consultant Pharmacist stated he did review NP and Medical Director's notes along with labs and it was an oversight that the Eliquis was not included on his July 2025 pharmacy review. The Consultant Pharmacist stated Eliquis was not on Resident #1's medication list for August 2025 and September 2025 because he knew Eliquis had been stopped by the physician. The pharmacist stated the Eliquis might have been stopped because of bleeding after the procedure or other reasons, but he did not remember specifics. The Medical Director was interviewed on 10/23/25 at 12:10 PM and stated the monthly pharmacy reviews should have caught the Eliquis was not restarted and brought it to her attention. An interview on 10/23/25 at 4:18 PM with the Administrator and DON revealed the Eliquis medication should have been reviewed and captured on the pharmacy reviews for Resident #1.

Based on observations and staff interviews, the facility failed to ensure dishware (divided plates and bowls) were clean for use for 1 of 1 meal service observation and failed to ensure the plate warmer was free of food debris. This practice had the potential to affect food served to residents. The findings included: On 03/26/25 at 11:30 AM observations of the lunch meal tray line revealed there were divided plates stacked on a cart to the side of the steam table in preparation for the lunch service. Seven of the divided plates were noted to have dried egg particles on the plates. There were also dried egg particles noted on the plate warmer that contained the regular plates for lunch meal service. In addition, there were plastic bowls stacked for meal service and two of the bowls were noted to have dried food particles inside the bowls and around the outside of the bowls. On 03/26/24 at 11:41 AM the food particles on the plate warmer, crumbs and dried egg particles on the divided plates and the food particles on and in the bowls were shown to the Registered Dietitian (RD) and the Regional Dietary Manager. The RD started examining the divided plates and confirmed most of the divided plates had crumbs or dried egg particles on them. An interview on 03/26/25 at 3:00 PM with the Dietary Manager and the Regional Dietary Manager revealed the procedure for assuring dishes were clean before using was a three-step process. The first check occurred when dishes were removed from the dishwasher, the second check occurred when the dishes were put on drying racks or in storage and then a third check when dishes were moved to the tray line for use. The Dietary Manager and [NAME] Dietary Manager stated the Dietary Aides had not paid close attention to the dishes prior to putting them on the tray line for meal service. An interview on 03/27/25 at 3:11 PM with the Administrator revealed she would have expected the dishes and the equipment to have been clean and free of debris and food particles prior to the meal service.

Based on record review, and resident and staff interviews, the facility failed to provide a safe transfer for 1 of 6 residents reviewed for accidents (Resident #51). The findings included: Resident #51 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and type 2 diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #51 was cognitively intact and dependent on staff for transfers. The care plan dated 12/02/24 revealed Resident #51 required 2-person assistance using the sit-to-stand lift for all transfers. An incident report dated 1/29/25 at 8:00 PM written by Nursing Supervisor #1 indicated Nurse Aide (NA) #3 was assisting Resident #51 to stand, pivot and transfer from the wheelchair to the bed and they both fell on to the bed. Resident #51 was assessed, and no injuries were noted. NA #3's written statement dated 1/29/25 indicated at approximately 8:00 PM she entered Resident #51's room to assist her into bed. Resident #51 stated she had been working with therapy, was feeling stronger and wanted to stand and pivot to transfer without using the sit-to-stand lift. NA #3 agreed to assist Resident # 51 with a stand and pivot transfer and positioned her close to the bed in the wheelchair. Resident #51 used the bedrail and pulled herself up to a standing position, but her legs were weak, and she started lowering down to the floor. NA #3 was able to pivot Resident #51 and they both landed in a seated position on the bed. An interview with NA #3 on 3/26/25 at 2:24 PM revealed she was Resident #51's assigned NA on 2nd shift (3pm-11pm) on 1/29/25. She stated Resident #51 required 2-person assistance with the sit-to-stand lift for all transfers. NA #3 indicated on 1/29/25 at approximately 8:00 PM Resident #51 was ready to lay down in bed. She revealed Resident #51 told her she was feeling stronger and instead of using the sit-to-stand lift she requested NA #3 assisted her to stand and pivot to the bed. NA #3 stated she wanted to honor Resident #51's choice, so she positioned her close to the bed Resident #51 used the bed rail to pull up into a standing position. She stated Resident #51 was able to pull up to a standing position, but her legs started shaking and she started lowering down to the floor. NA #3 indicated she pushed the wheelchair out of the way, put her arms around Resident #51, turned her around, and they both landed in a seated position on the bed. NA #3 revealed she then assisted Resident #51 to lay down and asked her if she was injured. She indicated Resident #51 stated she was not injured and that her legs must have been weak from sitting in the wheelchair too long. NA #3 stated she went out into the hall and notified a staff member that she needed the nurse. She revealed Nurse #4 responded to Resident #51's room, completed an assessment and no injuries were noted. NA #3 stated assisting Resident #51 to stand, pivot and transfer to the bed was not safe and she should have used the sit-to-stand lift. A phone interview with Nurse #4 on 3/27/25 at 1:41 PM revealed she was the 2nd shift nurse assigned to Resident #51 on 1/29/25. Nurse #4 stated she responded to Resident #51's room per NA #3's request and observed Resident #51 lying comfortably in bed. She stated NA #3 reported to her that Resident #51 requested to stand and pivot to transfer to the bed and did not want to use the sit-to-stand lift. Nurse #4 stated during the transfer Resident #51's legs became weak, and NA #3 had to put her arms around Resident #51 to turn her body and they both landed in a seated position on the bed. Nurse #4 revealed Resident #51 was not in any distress, her vital signs were stable, and no injuries were noted. An interview conducted with Resident #51 on 3/26/25 at 12:24 PM revealed staff used a mechanical lift to transfer her in and out of the bed. Resident #51 stated she was unsure if a NA had ever assisted her with a stand/pivot transfer and she did not recall the incident that occurred on 1/29/25. During an interview with the Director of Nursing (DON) on 3/27/25 at 12:13 PM she stated she was aware of the incident that occurred on 1/29/25. The DON indicated NA #3 assisting Resident #51 with a stand and pivot transfer was unsafe and she should have used the sit-to-stand lift. An interview conducted with the Administrator on 3/27/25 at 1:50 PM revealed Resident #51 required 2-person assistance and the sit-to-stand lift for all transfers. She indicated NA #3 wanted to honor Resident #51's request but should have used the sit-to-stand lift to ensure the transfer was safe.

Based on observations, record reviews, resident, staff, and Physician Assistant (PA) interviews, the facility failed to ensure oxygen was delivered at the prescribed rate (Resident #41 & Resident #101). These deficient practices occurred for 2 of 2 residents reviewed for respiratory care and services. The findings included: 1. Resident #41 was admitted to the facility on [DATE]. Resident #41 had diagnoses which included chronic respiratory failure with hypoxia. Review of the care plan dated 03/26/2024 and revised on 02/25/2025 revealed Resident #41 was at risk for respiratory complications secondary to chronic respiratory failure with hypoxia requiring supplemental oxygen. The interventions included administer oxygen as ordered and observed for signs and symptoms of respiratory complications. Review of Resident #41's electronic medical record (EMR) revealed a physician's orders dated 07/29/2024 for oxygen at 3 liters per minute (LPM) via nasal cannula continuous. Review of Resident #41's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact. The MDS also indicated Resident #41 was receiving oxygen. Observations of Resident #41 were completed on 03/24/2025 at 2:16 PM, 03/25/2025 at 10:53 PM, 03/26/2025 at 8:53 AM, and 03/27/2025 at 8:24 AM. During each of the observations Resident #41 was observed in bed with her nasal cannula in her nostrils and the oxygen concentrator set at 4 liters per minute. An interview was completed on 03/27/2025 at 10:01 AM with Nursing Assistant (NA) #1 who was assigned to Resident #41. NA #1 stated she did not do anything with oxygen settings. NA #1 further stated she did make sure the nasal cannula was in place and applied correctly for residents receiving oxygen. An interview was conducted on 03/27/2025 at 10:06 AM with Nurse #2 who was assigned to Resident #41 on 03/27/2025 from 7:00 AM to 3:00 PM. Nurse #2 stated that all residents receiving oxygen should have a physician's order for oxygen which would include the flow rate. Nurse #2 also stated the flow rate should be set as ordered by the physician. Nurse #2 further stated she reviewed Resident #41's physician's orders and stated that Resident #41 should be on 3 liters per minute of continuous oxygen via nasal cannula. An interview was completed with Resident #41 on 03/27/2025 at 10:20 AM. Resident #41 stated that she used to be able to manage her oxygen, but her health had gotten so bad over the years that she could no longer do that. Resident #41 also stated that she did not touch her oxygen concentrator or adjust the flow rate. Resident #41 further explained that she did not know what her oxygen should have been set at. An interview was completed on 03/27/2025 at 10:39 AM with the Director of Nursing (DON). The DON stated Resident #41 did get up to the chair with assistance and Resident #41 could have changed the flow rate on the concentrator. The DON stated she expected the nursing staff to check the physician's order for the prescribed oxygen flow rate and check to make sure residents were receiving the correct oxygen flow rate. The DON further explained that three days of observations for an incorrect oxygen flow rate was not acceptable nursing practice. An interview was conducted on 03/27/2025 at 10:58 AM with the Administrator. The Administrator stated she expected all staff to follow the physician's order for oxygen settings. A telephone interview was conducted with the Physician Assistant (PA) on 03/27/2025 at 2:15 PM. The PA stated all residents receiving oxygen required an active physician's order for the prescribed liters per minute of oxygen they were to receive. The PA further stated nursing staff should follow the physician's orders for providing oxygen including the prescribed flow rate. 2. Resident #101 was admitted to the facility on [DATE]. Resident #101 had diagnoses which included congestive heart failure (CHF), respiratory failure with dependence on supplemental oxygen, and atrial fibrillation (AF). Review of the care plan dated 08/27/2024 and updated 02/05/2025 revealed Resident #101 was at risk for respiratory complications secondary to congestive heart failure and respiratory failure requiring supplementary oxygen. The interventions included to administer oxygen as ordered, encourage rest periods as appropriate, and observed for signs and symptoms of respiratory complications. Review of the electronic medical record (EMR) revealed a physician order for Resident #101 dated 08/28/2024 for oxygen at 3 liters per minute via nasal cannula (NC) continuous for shortness of breath related to CHF. A review of Resident #101's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 had severely impaired cognition. The MDS also indicated Resident #101 was receiving oxygen. Observations were completed of Resident #101 on 03/24/2025 at 3:16 PM, 03/25/2025 at 10:58 AM, 03/26/2025 at 8:58 AM, and 03/27/2025 at 8:28 AM. During each of the observations Resident #101 was observed resting in bed with her nasal cannula in her nostrils, the oxygen concentrator was set at 1.5 liters per minute, and Resident #101 was observed to not be in distress. An interview was completed on 03/27/2025 at 10:01 AM with NA #2 who was assigned to Resident #101. NA #2 stated she did not do anything with oxygen settings. NA #2 further stated she did make sure the nasal cannula was in place and applied correctly for residents receiving oxygen. NA #2 also stated she also checked to make sure the oxygen concentrator was plugged up correctly into the electrical outlet. An interview was conducted on 03/27/2025 at 10:27 with Nurse #3. Nurse #3 was assigned to Resident #101 from 7:00 AM to 3:00 PM on 03/24/2025, 03/25/2024, and 03/26/2025. Nurse #3 stated Resident #101 could not change her oxygen settings independently. Nurse #3 also stated she did not check Resident #101's oxygen flow rate on 03/24/2025, 03/25/2025, or on 03/26/2025. An interview was completed on 03/27/2025 at 10:39 AM with the Director of Nursing (DON). The DON stated Resident #101 could not change her oxygen setting independently. The DON stated she expected the nursing staff to check the physician's order for the prescribed oxygen flow rate and check to make sure residents were receiving the correct oxygen flow rate. The DON further explained she expected the nursing staff to provide oxygen at the prescribed flow rate. An interview was conducted on 03/27/2025 at 10:58 AM with the Administrator. The Administrator stated that she expected all staff to follow the physician's order for oxygen settings. A telephone interview was conducted with the Physician Assistant (PA) on 03/27/2025 at 2:15 PM. The PA stated all residents receiving oxygen required an active physician's order for the prescribed liters per minute of oxygen they were to receive. The PA further stated nursing staff should follow the physician's orders for providing oxygen to all residents including the prescribed flow rate.

Based on record reviews, observations and staff interviews, the facility failed to discard expired medications in 1 of 2 medication rooms (South Hall Medication Room) and failed to store a lidded container of prescription topical medicated cream that treats fungal infections in a secure locked storage area for 1 of 1 resident observed with medicated cream at the bedside (Resident #126). The findings included: 1. An observation of the South Hall Medication Room was conducted on 03/25/2025 at 3:19 PM with the Director of Nursing (DON). The observation revealed an unopened bottle of Red [NAME] Oil (omega 3 vitamin) containing 60 soft gel tablets available for use. The expired bottle of Red [NAME] Oil was located in the top cabinet of the medication storage room. A review of the pharmacy label affixed to the bottle of Red [NAME] Oil indicated the expiration date was 07/16/2024. The printed manufacturer's expiration date was illegible. During the observation, an interview with the DON was conducted. The DON confirmed the expiration date and stated there should be no expired medications in the medication storage room or in the medication carts. She also stated the bottle of Red [NAME] Oil tablets should have been discarded. The DON further explained that all nursing staff were responsible for checking the medication rooms weekly for expired medications and the bottle of Red [NAME] Oil should have been discarded. An interview was conducted with the Administrator on 03/27/2025 at 8:23 AM. The Administrator stated that she expected all expired medications be discarded and not available for use. 40476 2. Resident #126 was admitted to the facility on [DATE] with diagnoses including generalized weakness and diabetic neuropathy. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #126 cognitively intact requiring extensive assistant of one staff member for most activities of daily living (ADL). Resident #126 was assessed as having no skin conditions during the assessment period. On 03/24/25 at 12:25 PM Resident #126 was observed to have a lidded container of prescription topical medicated cream that treats fungal infections on his bedside table. Resident #126 stated, I put it on my legs and use it for itching. Resident #126 explained he had the cream prior to admission into the facility and had always applied it as he wanted. Resident #126 did not recall where the cream came from. He stated he left it sitting at his bedside and no staff member had ever said anything to him. During an observation of Resident #126's room on 03/25/25 at 2:26 PM the lidded container of prescription topical medicated cream that treats fungal infections remained on his bedside table. During an observation of Resident #126's room on 03/26/25 at 10:27 AM the lidded container of prescription topical medicated cream that treats fungal infections remained on his bedside table. An interview conducted on 03/26/25 at 10:35 AM with Unit Manager #1 revealed she was not aware of any medication on Resident #126's bedside table. She stated no residents in the facility were allowed to keep medications at the bedside. On 03/26/25 at 10:42 AM Unit Manager #1 was accompanied to Resident #126's room and observed the lidded container of prescription topical medicated cream that treats fungal infections located on Resident #126's bedside table. Resident #126 stated to Unit Manager #1, I put it on my groin. Unit Manager #1 removed the container of medicated cream from Resident #126's room. The container had an expiration date of January/2024. On 03/26/25 at 2:55 PM an interview was conducted with Nurse #1. During the interview she stated she was Resident #126's nurse during the 7:00 AM to 3:00 PM shift on 03/24/25, 03/25/25 and 03/26/25. She stated she had not noticed the container of medicated cream on the resident's bedside table. The interview revealed she felt the container was missed because the resident had a lot of items on his bedside table, and it was just missed. On 03/27/25 at 10:00 AM an interview was conducted with the Medical Director. During the interview she stated the medicated cream was appropriate but not for the resident to apply himself. The facility did not know Resident #126 had the container of medicated cream in his room. The Medical Director indicated Resident #126 was alert and oriented but had intermittent confusion and was not assessed to administer his own medications. She stated she had evaluated him on 03/26/25 and there was no harm caused by using the medicated cream. However, it was removed, and he received a new order for a cream to be administered by nursing staff. The Medical Director stated the label on the container indicated the medicated cream had been originally prescribed for application to the resident's groin. On 03/27/25 at 9:55 AM an interview was conducted with the Director of Nursing (DON). She stated a physician's order was required to have any medication at a resident's bedside. The DON stated the facility was unaware Resident #126 had the medicated cream at his bedside otherwise it would have been removed. The medicated cream was not prescribed in-house by the Medical Director. On 03/27/25 at 9:50 AM an interview was conducted with the Administrator. She stated the medicated cream was immediately removed from the resident's room when it was brought to Unit Manager #1's attention. Resident #126 kept it at his bedside without staff knowing. She stated she expected the nurses to be observant of medication at bedside.

Based on observations, record review, and staff interviews, the facility failed to follow their Hand Hygiene policy when the Treatment Nurse did not perform hand hygiene before each donning of clean gloves while providing wound care to Resident #63. This deficient practice occurred for 1 of 5 staff members observed for infection control practices (Treatment Nurse). The findings included: Review of the facility's policy and procedure entitled Hand Hygiene read in part: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: - Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident) - After contact with a resident's mucous membranes and body fluids or excretions; - After handling soiled or used linens, dressings, bedpans, catheters, and urinals; - After removing gloves or aprons; and - After completing duty. A wound observation was made on 03/25/25 at 2:13 PM on Resident #63 with the Treatment Nurse. The Treatment Nurse was observed cleaning the bedside table with disinfectant wipe and placed her wound supplies on wax paper on the table after it dried. The treatment nurse donned a clean gown and sanitized her hands and donned clean gloves and removed the old dressing from the resident's right lateral leg and measured the wound with a disposable paper measuring tape. The Treatment Nurse then doffed her gloves and without sanitizing her hands, donned a clean pair of gloves and proceeded to rub cream on the resident's right leg and foot. She then doffed her gloves and without sanitizing her hands, donned clean gloves and cleansed the wound with normal saline soaked gauze from the inside of the wound outward. The Treatment Nurse then doffed her gloves, sanitized her hands and donned clean gloves and patted the wound dry with gauze, doffed her gloves, sanitized her hands and donned clean gloves and applied silver alginate to the wound bed and covered it with bordered gauze and then covered the resident's leg with his sheet. She then proceeded to Resident #63's left leg posterior skin tear for treatment. The Treatment Nurse doffed her gloves, sanitized her hands and donned clean gloves and rubbed cream on the resident's left lower leg and foot. She doffed her gloves, sanitized her hands and donned clean gloves and removed the old dressing from the resident's left posterior lower leg skin tear. The Treatment Nurse doffed her gloves and without sanitizing her hands, donned clean gloves and cleansed the wound with normal saline soaked gauze from inside of the wound outward, doffed her gloves, and without sanitizing her hands, donned clean gloves and patted the wound dry with gauze. She doffed her gloves, sanitized her hands and donned clean gloves and applied xeroform to the wound bed and covered with a bordered gauze dressing. The Treatment Nurse doffed her gloves, sanitized her hands and donned clean gloves and cleaned her scissors she had used to cut the xeroform with soap and water and then placed them in her pants pocket. She then doffed her gown, washed her hands with soap and water, collected her supplies and trash and wiped down the table and left the resident's room. An interview on 03/25/25 at 2:47 PM with the Treatment Nurse revealed she was not aware that she had not sanitized her hands each time she had doffed her gloves. She stated she had to change gloves so much during the wound care that she must have forgotten to always sanitize her hands when she removed her gloves. The Treatment Nurse further stated she knew she was supposed to always sanitize her hands when she removed her gloves each time and before putting on clean gloves. An interview on 03/27/25 at 11:38 AM with the Infection Preventionist (IP) revealed he was aware of the errors made by the Treatment Nurse during wound care. He stated his expectation was that she would sanitize her hands every time that she removed her gloves and before putting on clean gloves during wound care. The IP further stated staff received education on infection control annually and multiple times during the year. An interview on 03/27/25 at 11:54 AM with the Director of Nursing (DON) revealed she was aware of the Treatment Nurse's errors during wound care and said she had been provided with additional education regarding doffing and donning and sanitizing in between glove changes. The DON stated it was her expectation that the Treatment Nurse follow infection control best practices to avoid introducing microorganisms into the wounds. She further stated there was a lot of donning and doffing and in the Treatment Nurse's mind she thought she had done the appropriate practice. An interview on 03/27/25 at 3:14 PM with the Administrator revealed she would expect the Treatment Nurse to follow the Hand Hygiene policy for wound care. The Administrator stated it was her understanding that the Treatment Nurse did do another dressing change in which she didn't make any errors in the procedure.

Based on observations, resident, family and staff interviews and record review, the facility failed to provide a dignified dining experience when Nurse Aide (NA) #4 fed Resident #10 while 5 residents who were seated at the same table did not have their lunch. This failure occurred for 5 of 5 residents sampled for dignity (Residents #8, #39, #119, #70 and #100). The reasonable person concept was applied as individuals have the expectation of dining in a dignified environment. The findings included: 1a. Resident #8 was readmitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #8 with clear speech, adequate hearing/vision, no corrective lenses, or hearing aids, understood, able to understand, severely impaired cognition and fed herself after staff provided set up assistance. A care plan revised October 2023 recorded Resident #8 required assistance with setting up her meal tray, she fed herself and staff were to give her assistance to complete the task as needed. Resident #8 was observed on 12/4/23 at 12:45 PM seated in her wheelchair at a table in the 500/600 hall parlor with Residents #10, #39, #119, #70 and #100 while she waited for her lunch meal. During the observation, Resident #8, when asked how she was doing, replied to the surveyor, I'm hungry. NA #4 was observed on 12/4/23 to assist Resident #10 to eat from 1:13 PM until 1:25 PM, Resident #100 fed himself from 1:17 PM until 1:31 PM, and NA #4 fed Resident #39 at 1:32 PM while Resident #8 waited. Resident #8 received her lunch meal from NA #5 at 1:41 PM, twenty-eight minutes after NA #4 began assisting Resident #10. At the time of the observation, NA #5 stated Resident #8's meal tray was not on the meal delivery cart, so she went to the kitchen to get it. During an interview on 12/07/23 at 2:21 PM NA #4 stated she was a Restorative Aide and a NA who assisted residents with their meals. NA #4 stated Resident #8 ate her meals well, but that she was not that familiar with the Resident's care needs. NA #4 stated she sat down to feed Resident #10 lunch on Monday, 12/4/23, but once she noticed the other Residents who were seated at the same time did not have their lunch, she knew the meal trays were not delivered to the unit at the same time, so she went ahead and fed Resident #10 so that her meal would not get cold. NA #5 was interviewed on 12/06/23 at 12:06 PM. NA #5 stated she was the scheduler and a NA. She stated she was familiar with Resident #8 and described the Resident as able to make her needs known to staff. NA #5 stated she realized Resident #8 did not have a lunch meal when the last cart came on the unit around 1:20 PM, so she went to the kitchen to get her tray. NA #5 stated as it related to dignity she was trained that residents should not have to wait while others ate in front of them at the same table, but that was a frequent occurrence for residents who ate in the parlor on the 500/600 hall because their meal trays were delivered on different carts. NA #5 stated Residents who ate in the 500/600 hall parlor waited 15 minutes or so before the next cart was delivered, so residents without a meal tray sat and waited. A family interview occurred by phone for Resident #8 on 12/4/23 at 2:38 PM. When asked by the surveyor if Resident #8 would consider it undignified to wait at the dining table for her meal while other residents ate in front of her, the family member stated that he was not certain if Resident #8 would prefer to eat at the same time as her tablemates, but that he felt it was important for all residents seated at the same table to eat at the same time. 1b. Resident #39 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] assessed Resident #39 with clear speech, adequate hearing, impaired vision, no corrective lenses, or hearing aids, understood, able to understand, severely impaired cognition and fed herself after staff provided set up assistance. A care plan revised September 2023 recorded Resident #39 required assistance with setting up her meal tray, she fed herself and staff were to give her assistance to complete the task as needed. Resident #39 was observed on 12/4/23 at 12:45 PM seated in her wheelchair at a table in the 500/600 hall parlor with Residents #10, #8, #119, #70 and #100 while she waited for her lunch meal. During the observation, Resident #39 asked Nurse #4 Where is my lunch? Nurse #4 replied, It's coming we are waiting on it now. Resident #10 was assisted with her lunch meal by NA #4 from 1:13 PM until 1:25 PM and Resident #100 fed himself from 1:17 PM until 1:31 PM while Resident #39 waited. Resident #39 received her lunch meal at 1:32 PM, nineteen minutes after NA #4 began assisting Resident #10. NA #4 set up her lunch meal and assisted Resident #39 with eating. During an interview on 12/07/23 at 2:24 PM NA #4 stated she was a Restorative Aide and a NA who assisted residents with their meals. NA #4 indicated over the last few months Resident #39 required more assistance with her meals. NA #4 stated she sat down to feed Resident #10 lunch on Monday, 12/4/23, but once she noticed the other Residents who were seated at the same time did not have their lunch, she knew the meal trays were not delivered to the unit at the same time, so she went ahead and fed Resident #10 so that her meal would not get cold. 1c. Resident #119 was readmitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] assessed Resident #119 with clear speech, impaired hearing with the use of hearing aids, moderately impaired vision, no corrective lenses, sometimes understood, sometimes able to understand, memory problems with moderately impaired decision-making, and fed herself after staff provided set up assistance. A care plan revised November 2023 recorded Resident #119 required assistance with setting up her meal tray, she fed herself and staff were to give her assistance to complete the task as needed. Resident #119 was observed on 12/4/23 at 12:45 PM seated in a chair at a table in the 500/600 hall parlor with Residents #10, #8, #39, #70 and #100 while she waited for her lunch meal. During the observation, NA #4 was observed on 12/4/23 to assist Resident #10 with eating from 1:13 PM until 1:25 PM, Resident #100 fed himself from 1:17 PM until 1:31 PM and Resident #70 received her lunch at 1:19 PM and fed herself while Resident #119 waited. Resident #119 received her lunch meal from NA #6 at 1:24 PM, eleven minutes after NA #4 began assisting Resident #10. Resident #119 fed herself after her meal was set up. A family interview occurred by phone for Resident #119 on 12/4/23 at 3:45 PM. The family member stated that Resident #119 was very social and that she would prefer to eat together with her tablemates. 1d. Resident #70 was admitted to the facility 4/16/18. An annual MDS assessment dated [DATE] assessed Resident #70 with clear speech, adequate hearing, moderately impaired vision, no corrective lenses, understood, able to understand, severely impaired cognition, and required staff assistance with meal set up and feeding. A care plan revised September 2023 recorded Resident #70 required assistance with setting up her meal tray, she could feed herself at times, but required staff to give her assistance to complete the task as needed. Resident #70 was observed on 12/4/23 at 12:45 PM seated in her wheelchair at a table in the 500/600 hall parlor with Residents #10, #8, #119, #39 and #100 while she waited for her lunch meal. During the observation, NA #4 was observed on 12/4/23 to assist Resident #10 with eating from 1:13 PM until 1:25 PM while Resident #70 waited for her lunch meal. Resident #70 received her lunch meal from NA #6 at 1:19 PM, seven minutes after NA #4 began assisting Resident #10. Resident #70 fed herself after her meal was set up. Attempts to interview family for Resident #70 were unsuccessful. 1e. Resident #100 was admitted to the facility 3/7/22. A quarterly MDS assessment dated [DATE] assessed Resident #100 with clear speech, adequate hearing, moderately impaired vision, no corrective lenses, understood, able to understand, severely impaired cognition, and required staff assistance with meal set up and able to feed himself. A care plan revised September 2023 recorded Resident #100 required assistance with setting up his meal tray and was able feed himself. Resident #100 was observed on 12/4/23 at 12:45 PM seated in his wheelchair at a table in the 500/600 hall parlor with Residents #10, #8, #119, #70 and #39 while he waited for his lunch meal. During the observation, NA #4 was observed on 12/4/23 to assist Resident #10 with eating from 1:13 PM until 1:25 PM while Resident #100 waited for his lunch meal. Resident #100 received his lunch meal from NA #6 at 1:17 PM, four minutes after NA #4 began assisting Resident #10. Resident #100 fed himself after his meal was set up until 1:31 PM. A family interview occurred by phone for Resident #100 on 12/4/23 at 3:30 PM. When asked by the surveyor if Resident #100 would consider it undignified to wait at the dining table for his meal while other residents ate in front of him, the family member stated that he was not certain if Resident #100 would prefer to eat at the same time as his tablemates, but that he felt it was important for all residents seated at the same table to eat at the same time. NA #6 was interviewed on 12/07/23 at 1:32 PM. NA #6 stated that the meal trays for residents who ate in the 500/600 hall parlor were delivered at different times on different carts. NA #6 stated that sometimes the Residents in the parlor sat there and waited for their meal while other Residents ate because the meal trays were on different carts. NA #6 stated that meal trays were given to residents who fed themselves first, and those Residents who needed assistance received their meal tray last so that staff could assist them with their meal. During an interview on 12/07/23 at 2:39 PM, Nurse #4 stated she worked on the 7 AM - 3 PM shift since August 2023 and when asked by the surveyor about her training for dining she stated she was trained related to dignity not to feed a resident in front of residents who were not eating. Nurse #4 stated that since she had been a Nurse in the facility, the meal trays for residents who ate in the 500/600 hall parlor were delivered to the unit at different times which caused residents who ate in the parlor on that unit to wait for their meal tray while other residents ate. Nurse #4 stated that on 12/4/23, she recognized that Resident #10 received her lunch meal and was fed by NA #4 while Residents #8, #39, #70, #100 and #119 remained in the parlor but did not have their lunch tray. Nurse #4 stated she advised NA #4 that Residents were still waiting for their lunch tray while she fed Resident #10, but NA #4 stated that since she had already started feeding Resident #10, she did not want to take her tray away from her. Nurse #4 stated she did not think about asking NA #4 to ask Resident #10 if NA #4 could feed her in her room until the other Resident's trays came on the unit. Nurse #4 also stated staff did not want the meal trays to get cold, so staff served the meal as the trays came onto the unit. Nurse #4 stated Resident #8 was the last Resident to be fed because her meal tray was not delivered to the unit and staff had to go to the kitchen to get her tray. Nurse #4 stated Resident meal trays were delivered to the unit by room number and Residents who required assistance with meals ate in the parlor, but their trays were not delivered together. An interview with the Dietary Manager (DM) on 12/06/23 at 5:01 PM revealed she was the DM for the past 4 months. The DM stated residents were asked on admission where they preferred to eat their meals. She stated that the meal carts were delivered to the units and the meal trays were ordered by room number for residents who preferred to eat in their rooms. The DM stated the dietary staff were not aware of which residents ate meals in the parlors on the units, that was nursing staff's responsibility to distribute meal trays to residents who ate meals in their rooms or in the parlor on the unit. The DM stated that as it related to dignity, she was aware that residents who ate together at the same table should receive their meals at the same. The Assistant Director of Nursing (ADON) stated in an interview on 12/06/23 at 2:27 PM that it was brought to her attention when she and a surveyor observed Residents on the South unit that day (12/6/23) who ate in the parlor on that unit receive lunch meals at different times. The ADON stated staff were re-educated on 12/06/23 to provide a dignified dining experience by not giving a resident a meal tray if the rest of the trays were not available to provide to residents who ate together. The Administrator stated in an interview on 12/08/23 at 1:06 PM that she was the Administrator in the facility since July 2023. When asked by the surveyor her expectation for a dignified dining experience, the Administrator stated that she expected all residents eating in the same area or table would be served together and she was not aware this was an ongoing concern.

Based on record review, policy review, resident and staff interviews, the facility failed to provide a written decision/resolution regarding a grievance related to missing bras belonging to Resident #52 and failed to submit a grievance per the facility's grievance policy for 3 of 3 residents (Resident #52's missing supply of salad dressing, Resident #446's missing property and Resident #141's concerns related to a disrespectful staff). Findings included: A review of the facility Grievances Policy dated 2/2018 revealed in part The facility recognizes two levels of communication: 1. Concern- A concern is defined as an oral communication that can be resolved immediately. 2. Grievance- A grievance is a written statement, which implies a breach of care or service. A follow-up telephone call or on-site conference shall be held within 5 working days from receipt of a grievance with a complainant outlining corrective action taken. A written decision regarding grievance issued to the resident and/or representative. A review of the facility's Lost or Missing Articles Grievance Policy (undated) revealed in part If the lost article is a piece of clothing, the Nurse or Social Service staff will notify the laundry department. If the article is a personal supply item or an article that would not be going to the laundry, the article may be considered misplaced, and the resident will be provided assistance in searching for the lost item/ article. All attempts will be made to locate the missing article. A Lost or Missing Articles Report will be completed and submitted to the Administration. The Administrator or his/ her designee will notify the Resident and/ or Family of the findings. 1 a. Resident # 52 was admitted to the facility on [DATE]. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #52 was cognitively intact. A review of the grievance log dated August 2023 revealed grievances for Resident #52, including a Lost/ Missing Articles Grievance dated 8/10/23. The grievance indicated Resident #52 had 3 bras missing (1 bra had been gone for 3 weeks and 2 bras had been missing for 3 months) and one bra was found. The findings section of the report indicated the article was not located. The report further indicated the facility was still looking for 2 more missing bras. The follow-up section of the report indicated the resident was notified on 8/17/23 that they were still looking for the other bras. The report was signed by the Social Worker and Administrator that the issue was resolved on 8/17/23 although 2 of the bras were still missing. During an interview on 12/5/23 at 10:43 AM Resident #52 revealed she was missing 5 (front snap) bras since July 2023. She stated she completed a grievance for 6 missing bras around that time and one bra was recovered from the laundry in August 2023. However, she was still missing 5 (front snap) bras that were labeled with her name. However, she continued to ask for the remaining missing bras and was told the facility was still looking for them. She last asked the Social Service Director (SSD) #1 about the remaining missing bras in November 2023. She further revealed she believed there was only one staff member working in the laundry room at that time. The resident explained that other than receiving the one found bra from in August, she had received no communication regarding the outcome of the grievance which was filed. During an interview on 12/6/23 at 5:34 PM, the Laundry Supervisor indicated the laundry department was short staffed until October 2023 and she was the only laundry staff person during the summer and fall months. She further indicated the laundry department labeled resident items with a quick press label device and if the label came off, the items may end up in lost/ found pile and held for 90 days before being donated or discarded. The Laundry Supervisor stated Resident #52 informed her about two weeks prior (mid- late November 2023) she was missing 3-4 bras. The Laundry Supervisor looked for the missing items, could not locate them, then told the SSD #1 that she would continue to look for them. The Laundry supervisor stated she had not filed a grievance regarding the missing bras because there was already a grievance in place from August regarding the missing bras. The Laundry supervisor further stated the resident continued to ask about the lost bras from August to November 2023. During an interview on 12/6/23 at 5:24 PM SSD #1 revealed she began working at the facility in July 2023 and Resident #52 reported she was missing 3 bras on 7/28/23 and one bra was found on 8/10/23. She further revealed she and the Laundry Supervisor looked for the bras and they were continuing to look for the bras. SSD #1 stated the laundry department had been short staffed until October 2023 and there was only one staff person working prior to being fully staffed. However, she had not followed up with a written resolution for the grievance regarding the outcome of the remaining missing bras. During a follow-up interview on 12/8/23 at 11:43 AM SSD #1 indicated she ordered 2 bras on 12/7/23 per Resident #52's selection. She further indicated there was no excuse why the grievance that was submitted in August 2023 was not resolved in a timely manner. She stated the facility should have come to a decision to reimburse or replace the bras long before 12/7/23 and she planned to reimplement the resident inventory log, which would include clothing. During an interview on 12/7/23 at 6:07 PM the Administrator revealed SSD #1 was the Grievance Official who wrote up the grievance, assigned it to the appropriate department supervisor for an investigation/ resolution, and provided the resident or family member with the resolution before the Administrator would sign off on it. The Administrator further revealed it was her understanding that her staff was still looking for Resident #52's bras. However, if items were misplaced or damaged by the facility, it would be replaced, or the resident would be reimbursed. She further stated SSD #1 had since ordered replacement bras for Resident #52 on 12/7/23 and the remaining missing bras from August 2023 should have been replaced long before 12/7/23. The Administrator clarified the follow-up to the resident was the facility staff continued to tell the resident they were still looking for the bras. b. During an interview on 12/6/23 at 2:55 PM Resident #52 revealed she ordered a box of salad dressing, and she discovered it was missing from her room when she was returned from recently being hospitalized in October 2023. She further revealed she reported it to the SSD #1 on multiple occasions and was told the salad dressing was locked in storage along with some of her other belongings that were packed up and stored while she was hospitalized . Resident #52 stated she asked the SSD #1 about the status of the salad dressing for over a month. She further stated that she was unaware if the SSD #1 completed a written grievance regarding Resident # 52's missing salad dressing. During an interview on 12/6/23 at 5:24 PM the SSD #1 indicated she was the Grievance Official and had mentioned on four occasions during morning meetings with clinical staff that Resident #52 made several requests for her salad dressing to be returned from the storage and the Administrator directed the Maintenance Director to obtain the salad dressing from the storage. SSD #1 further indicated Resident #52 continued to inquire about the return of her salad dressing long after the Maintenance Director was to retrieve it from the onsite storage. SSD #1 stated she was unaware why the salad dressing had not been returned to Resident #52 and she did not feel the need to submit a grievance on the Resident's behalf. During an interview on 12/7/23 at 12:40 PM the Maintenance Director revealed he placed 5-6 storage boxes of Resident #52's belongings in an onsite storage unit between the end of October and the beginning of November 2023. He further revealed he was asked during that time to retrieve the salad dressing from storage. After he searched Resident #52's belongings in the storage, he did not locate the salad dressing and did not follow-up with the Administrator, staff member or Resident #52 with the outcome of his search. During an interview on 12/7/23 at 12:22 PM the Assistant Director of Nursing (ADON) indicated she was made aware in morning meetings (which included the Maintenance Director) that Resident #52's salad dressing was supposed to be returned to her. During an interview on 12/7/23 at 6:00 PM the Administrator revealed it was her understanding Resident #52's salad dressing was in storage and upon her request, would receive a box at a time. She further revealed she had the Maintenance Director go to the storage and check Resident #52's storage boxes the same day as the interview (12/7/23) and no salad dressing was found. The Administrator stated a grievance was not completed and probably should have been. 2. Resident #446 was admitted to the facility on [DATE] and discharged on [DATE]. A quarterly MDS assessment indicated Resident #446 had moderate cognitive impairment. During a phone interview on 12/5/23 at 8:50 AM Resident #446's family member revealed when they came back to the facility after the Resident was hospitalized in October 2023 and was not expected to return to the facility, they were unable to go to the Resident's room to collect his belongings. Instead, the family member waited in the front lobby while the SSD #1 packed Resident #446's belongings and brought them to her, in the lobby. The family member further stated the SSD #1 reassured her that the Resident's dentures and eyeglasses were in his packed belongings that consisted of two boxes and a duffle bag. The family member stated when they returned home and checked Resident #446's belongings, there were clothing items that did not belong to the Resident and the dentures, eyeglasses, and hall of fame certificate were missing. The family member stated they sent 2 emails to the Administrator and received a voice mail from the SSD#1 instead of the Administrator. The family member stated they did not have a good interaction with SSD #1 previously and preferred to speak to the Administrator, since she was in charge. However, the Administrator never replied to family member's emails. The family member further stated the facility lost Resident #446's wheelchair that was issued by the Veterans Administration and offered to replace the wheelchair with another wheelchair, but the family member refused it because it belonged to another resident. The family member preferred to have the personal wheelchair that was admitted with the Resident. The family member stated the Resident did have an appointment to get assessed for a new wheelchair from the Veterans Administration but was hospitalized the day before the appointment. Further, the family member was unaware if the facility initiated a grievance investigation regarding the missing items. During an interview on 12/8/23 at 11:24 AM the SSD #1 indicated the facility had not implemented inventory sheets for resident belongings until July 2023. She further indicated she and (former) SSD #2 packed Resident #446's belongings and she could only recall packing clothing items, eyeglasses, framed pictures, and items from the nightstand into 2 boxes and a duffle bag that was already packed with clothing items. She brought the belongings to Resident #446's family member who was in the lobby and the facility offered to replace the lost wheelchair with a high back wheelchair. However, the spouse refused it. The SSD #1 stated she assisted Resident #446's family member pack the Resident's belongings into the family member's vehicle. SSD #1 stated she called and left a voice mail message for the family member after the family member sent emails to the Administrator regarding the missing items. SSD #1 further stated she did not feel the need to complete a grievance or missing/ lost grievance because Resident #446 was not returning to the facility and the family had been restricted from visiting beyond the lobby and visitations needed to be scheduled due to the family member's conflict with facility staff. During an interview on 12/8/23 at 12:42 PM the Administrator revealed she received 2 emails from the family member of Resident #446, after the family member came to the facility to retrieve the Resident's belongings. The emails indicated requests to have missing and damaged items (dentures, eyeglasses, cell phone, clothing, damaged picture frames). She further stated she had the SSD #1 contact the family member after the first email was received. The Administrator stated SSD #1 left a voice mail message for Resident #446's family member and there was no further communication from the family member. The Administrator stated a grievance report was not submitted and it would have been a good idea to submit one due to the previous conflicts with the Resident's family member. 20934 3. The facility Grievance Policy, reviewed 2018, recorded in part, Residents may express a grievance and may expect prompt efforts from the facility to resolve voiced concerns or grievances. Resident #141 was admitted to the facility on [DATE] from the hospital and discharged home on 10/20/23. An admission nursing assessment dated [DATE] recorded Resident #141 was alert and oriented and required staff assistance with toileting. A social services admission progress note dated 10/10/23 written by Social Services Director #2 (SSD #2), recorded Resident #141 admitted to the facility for a short-term rehab stay with plans to return home. SSD #2 documented she introduced herself to Resident #141 in her room after the Resident had just returned from a therapy session. The SSD documented Resident #141 was very alert and oriented to surroundings and situations. A Minimum Data Set assessment, dated 10/20/23, assessed Resident #141 with intact cognition, required supervision of one staff with toileting, occasional bladder incontinence, independent with toilet transfers and active discharge plans for a return to the community. An interview with Nurse #2 occurred on 12/07/23 at 3:25 PM. Nurse #2 stated she was the assigned Nurse for Resident #141 on the 7AM - 3PM shift and she remembered Resident #141 stated to her that some of the nursing staff on the 11 PM - 7AM shift was disrespectful to her. Nurse #2 stated she did not recall if Resident #141 gave her the names of staff, but the Resident stated that she did not like the tone of some of the staff and it made her feel like she was being spoken to like a child. Nurse #2 stated she reported this to the Nurse Supervisor, SSD #2 and either the Director of Nursing (DON) or the Assistant Director of Nursing (ADON). Nurse #2 stated she did not record this in the Resident's medical record because she expected the SSD to write the concern as a grievance. Resident #141 was interviewed by phone on 12/08/23 at 11:02 AM. Resident #141 stated that the staff were disrespectful, she stated They didn't say ugly things but ignored me, the first night I was there I rang the bell, and they didn't come, I needed to get to bathroom, but it was locked, and somebody had to come unlock it. She stated that the Nurse Aide (NA) from that evening Came in after I peed on the floor, and talked loudly to me, I guess it was just the way she talked. Resident #141 stated she reported this to Nurse #2 and stated, It made me feel like what's coming up next, that was my first night there. Resident #141 stated no one came to talk to her about her concern after she expressed it to the Nurse, so she just learned to manage and care for herself. Review of the October 2023 grievances revealed there was no grievance documented regarding Resident #141. NA #3 was interviewed by phone on 12/07/23 at 6:09 PM. NA #3 stated she worked at the facility for the past three years on the 11 PM - 7AM shift during the week and the 7 AM to 3 PM shift on the weekends. NA #3 stated she did not recall being assigned to Resident #141, but when she met residents for the first time, she introduced herself, responded to the call bell, assisted the resident with anything they needed and if she was made aware that a resident felt disrespected, she would tell the Nurse. NA #3 stated if a resident said she was yelling, she would apologize and try to lower her voice. NA #3 stated she had not been advised that a resident felt like she talked to them like a child. An interview with Nurse #3 occurred on 12/07/23 at 6:02 PM. Nurse #3 stated she worked the 11 PM - 7 AM shift since May 2023. Nurse #3 stated she did not remember Resident #141, but if she were made aware of a resident grievance, she would talk to the resident to find out what happened, then talk to the Nurse Supervisor or the ADON. Nurse #3 stated she did not recall being informed of a resident expressing they were disrespected. The Nurse Supervisor was interviewed on 12/07/23 at 5:48 PM. She stated that she was the 3 PM - 11 PM shift supervisor, but that she did not recall Resident #141 or being told by Nurse #2 the Resident expressed that she was disrespected by staff. The Nurse Supervisor stated if the Nurse had notified her of this Resident's grievance, the Nurse Supervisor stated she would have talked to the Resident and staff, re-educated staff, left a note for the SSD to file a grievance, and removed the staff involved from the Resident's assignment. The ADON was interviewed on 12/07/23 at 4:59 PM. The ADON stated she did not remember Resident #141, but if a Resident filed a grievance with the Nurse, the ADON stated she expected the Nurse to notify the Nurse Supervisor, the Nurse Supervisor would notify the SSD, the SSD would follow the facility's grievance policy, record the concern as a grievance and notify either the ADON/DON. The ADON stated staff would follow the grievance policy. A phone interview with SSD #2 occurred on 12/07/23 at 4:44 PM. SSD #2 stated that she was the SSD in the facility from May 2023 to November 2023. SSD #2 stated she did not recall Resident #141 or being informed by Nurse #2 of a grievance. SSD #2 stated if she was notified, she would talk to the Resident, obtain a statement, write the concern as a grievance, and notify the Administrator. SSD #2 stated she would also check the nursing schedule to make sure the staff member involved was not assigned to care for the Resident again. SSD #2 stated after the grievance was documented, she would follow up with the Nurse and the Administrator or DON within the next 24 hours to see if the grievance was resolved. An interview with the DON occurred on 12/06/23 at 11:19 AM, the DON stated she did not recall Resident #141 or being advised that this Resident filed a grievance with a Nurse. The Administrator was interviewed on 12/08/23 at 1:06 PM. The Administrator stated she was the Administrator since July 2023. She stated if a resident expressed to the Nurse, they felt disrespected by staff, she would expect the Nurse who was informed to notify the Nursing Supervisor and the SSD so that the facility could implement the grievance policy. The Administrator stated she was not made aware of the concern voiced by Resident #141.

Based on record review, resident/ family and staff interviews, the facility failed to schedule, invite residents/representatives, and hold care plan meetings for 3 of 3 residents (#52, #28, #4) reviewed for care planning. Findings included: A. Resident # 52 was admitted to the facility on [DATE] with diagnoses inclusive of respiratory failure. A review of the medical record indicated the last care plan meeting for Resident #52 took place on 3/15/22. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact. During an interview on 12/5/23 at 10:43 AM Resident #52 revealed she had not been invited to a care plan meeting since 2022. B. Resident #28 was admitted to the facility on [DATE] with diagnoses inclusive of anxiety and acid reflux. A review of the medical record indicated the last care plan meeting for Resident #28 took place on 7/19/22. A quarterly MDS assessment dated [DATE] indicated Resident #28 had moderate cognitive impairment. During an interview on 12/4/23 at 10:15 AM the family member of Resident #28 revealed the Resident had not been invited to a care plan meeting since July 2022. During an interview on 12/6/2023 at 5:08 PM the Social Service Director #1 (SSD) indicated Resident #52 had not had a care plan meeting since 3/15/22 and Resident #28 had not received a care plan meeting since 7/19/22. She stated she had only been in her position a few weeks and was working on a new process for care plan meetings. She further stated she expected care plan meetings to be scheduled quarterly with a phone call invite or an invitation letter mailed which would include the resident and/ or resident representative. She further indicated she had had only been in the SSD #1 position since July 2023 and was aware that care plan meetings were behind. She also stated it would be the SSD #1's responsibility to create and maintain the care plan meeting calendar, send out the care plan meeting invitations, and hold the care plan meeting. During a phone interview on 12/7/23 at 5:06 PM the (former) SSD #2 as of July 2023 revealed there were several barriers to completing the care plan meetings to include time constraints, training the current SSD #1 replacement, discharge planning and over all resident case load. She further indicated she was able to complete some care plans and some residents and families did complain about not having a care plan meeting. She also stated care plan meetings were to be scheduled one week after the MDS was completed. During an interview on 12/7/23 at 5:52 PM the Corporate Social Work Consultant indicated she was recently made aware that the facility was falling behind on care plan meetings. Her expectation was for care plan meetings to be scheduled within 1-1 and a half weeks after the MDS was completed. She further indicated prioritizing, increased census and staffing turnover contributed to missed care plan meetings. During an interview on 12/7/23 at 5:57 PM the Administrator revealed she started role at the facility in July 2023 and in September she was made aware that care plan meetings were not being conducted. She further revealed the SSD #1 had been working on creating a care plan meeting schedule. The Administrator's expectation was for care plan meetings to be scheduled, care plan invitations to be sent to residents/ representatives and care plan meetings to be conducted. 48006 C. Resident #4 was admitted to the facility on [DATE] with diagnoses that includes dementia, cerebral vascular accident (CVA), diabetes mellites, and high blood pressure (HTN). Review of Resident #4's medical record revealed the last documented care plan meeting occurred on 11/30/2022. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had severe cognitive impairment. A phone interview was conducted with Resident #4's responsible party (RP) on 12/05/2023 at 9:01 AM. The RP revealed she had not been invited or attended a care plan meeting for Resident #4 in many months. She further stated she does not know the exact length of time since the last care plan meeting was held but it was quite a long time ago. The Social Service Director #1 (SSD) was interviewed on 12/6/2023 at 12:37 PM. The SSD confirmed Resident #4 had not had a care plan meeting since 11/30/2022. She stated she had only been in her position a few weeks and was working on a new process for care plan meetings. She further stated she expected care plan meetings to be scheduled quarterly with a phone call invite or an invitation letter mailed which would include the resident's RP. She also indicated she had been working on developing a care plan meeting calendar for all residents. She also stated it would be the SSD #1's responsibility to create and maintain the care plan meeting calendar, send out the care plan meeting invitations, and hold the care plan meeting. An interview was completed on 12/07/2023 at 10:06 AM with the Administrator. The Administrator stated that she realized the care plan meeting process was behind schedule and the SSD was currently working on a new process to ensure care plan meetings were being held.

Based on record review interviews with the Hospital Case Manager, Veterans Affairs (VA) Case Manager and staff, the facility failed to allow a resident to return the facility after a facility-initiated transfer to the hospital for 1 of 1 (Resident #445) resident reviewed for readmission from the hospital. The findings included: Resident #445 was admitted to the facility on [DATE]. His diagnoses included epilepsy, acute respiratory failure with hypoxia, schizophrenia, delirium. The face sheet of Resident #445 stated that his discharge status was anticipated to return to the community from his short term stay at the facility. He had VA benefits that paid for the 32 day stay through the Corporate Nursing Home contract. A nurses note dated 6/20/23 at 10:56 PM read in part, Resident #445 was noted to be in bed with wet/clammy skin, drooling, and body jerking. Resident #445 was able to respond to name being called. Medical Doctor (MD) notified, and orders were to send Resident #445 to the hospital with a diagnosis of seizure activity. Resident #445 was transported to hospital. Resident #445 had a discharge Minimum data Set assessment dated [DATE] that was coded for discharge returned anticipated. A review of an email thread from the Admission Director and VA case manager on 7/3/23 at 12:23 PM stated that the Admission Director updated the VA case manager that Resident #445 was ready to discharge from the hospital to the facility on [DATE]. The Admission Director requested the VA case manager send a new authorization for respite stay at the facility due to the length of stay at the hospital. A review of hospital referral to the facility dated 7/3/23 revealed that Resident #445 was ready to return to the facility. The referral showed that the facility accepted Resident #445's referral for readmission on 7/3/23 at 3:08PM per Admission Director. A review of Pre-Admission Snapshot dated 7/11/23 at 12:34 PM stated that Resident #445 was not admitted because Resident #445 was not appropriate financially. The pre-admission snapshot was communicated from the hospital case manager and the admissions person at the facility. An interview with Resident #445's family member was conducted on 12/8/23 at 10:13 AM and revealed that Resident #445 did not return to the facility and was discharged home from the hospital with home health care. The family member further stated that Resident #445 had returned to the hospital two weeks later due to seizure activity and was readmitted to the hospital. Resident #445 was currently at another facility in a different town. The family member confirmed that the VA was paying for Resident #445's stay at the new facility. The family member stated that they wanted Resident #445 to return however they were upset about the back and forth with the hospital and the facility. An interview with the VA Case Manager on 12/8/23 at 1:48 PM revealed that the VA can authorize short term rehab care or respite stay at the facility. They further explained that the start date of benefits for the nursing facility stay for Resident #445 was 6/16/23 with an approved end date of benefits on 7/18/23. They stated that Resident #445 was discharged to the hospital on 6/20/23. If the VA veteran was out of the facility for more than 3 midnights, the VA would discharge them which meant that the authorization ends for the short-term rehab stay. The VA Case Manager stated that Resident #445 was expected to return to the facility after the hospital stay once medically stable. They stated that Resident #445 was re-evaluated on 7/7/23 and approved for a new authorization with a 32-day Corporate Nursing Home contract from the date that they would re-admit from the hospital. The VA Case Manager noted that Resident #445 was discharged from the hospital on 7/18/23 with home health care in place due to the facility's refusal to readmit. The VA Case Manager stated that all conversations were with the Admission Director. The authorization form would have been sent to the facility on his re-admitted to the facility. A phone interview with the Admission Director was conducted on 12/7/23 at 10:50 AM who stated that Resident #445 was eligible for short term stay benefits. The Admission Director further stated if the resident had been accepted for readmission to the facility the VA authorization would have been approved. The interview further revealed if anyone had asked or contacted her, she would have informed them that the VA authorization was valid. A phone interview with the Hospital Case Manager was conducted on 12/7/23 at 10:45 AM and revealed that Resident #445 had been discharged home from the hospital with home health care on 7/18/23. The Hospital Case Manager stated that the family ended up taking the resident home due to the back and forth between the facility and hospital. They further stated that the facility declined to readmit Resident #445 back to the facility due to no financial source for Resident #445. The Hospital Case Manager stated that the authorization was approved and that the finances were covered for the facility stay after readmission from the hospital. The Hospital Case Manager stated that she spoke with the VA Case Manager around 7/5/23 and was informed of the approval for Resident #445's return to the facility. The Hospital Case Manager stated that she informed the Admission Director of all of this in an email which included the pre-admission snap shot. She further stated that the authorization was approved on 7/7/23 and she informed the Admission Director through the pre-admission snap shot information. An interview with the Director of Nursing (DON) was conducted on 12/6/23 at 11:18 AM and revealed that the DON did not recall any denials of readmission for residents from the hospital. The DON further stated that the Admission Director followed up with the hospital around 7/7/23. The DON stated that the Business Office Manager would have verified that the VA authorization had been approved for readmission. The DON stated that the VA made the decision to deny Resident #445 to return to facility and was not made aware of any issues. The DON stated that Resident #445 did not come back and was not denied readmission. A phone interview with the Business Office Manager on 12/7/23 at 10:40 AM revealed that Resident #445 had short term VA benefits. The Business Office Manager did not recall any issues with the VA authorization and did not recall asking the VA for the authorization form for Resident #445. The Business Office Manager stated that the Admission Director handled that. An interview with Corporate Business Office Consultant was conducted on 12/8/23 at 10:37 AM and revealed that the Admission Director gave information to the business office regarding payor sources that would come from the hospital. The Corporate Business Office Consultant confirmed that they did have a contract with the VA. They stated that the VA authorization would be re-authorized for a 32-day Corporate Nursing Home contract with the current authorization on file for Resident #445. The Corporate Business Office Consultant stated that with the re-authorization for Resident #445 from the VA, they would have been able to re-admit from the hospital. An interview with the Administrator was conducted on 12/8/23 at 1:07 PM and revealed that they had been the administrator since 7/10/23 and was not the administrator at the time of Resident #445's re-admission discussion. The Administrator stated that the VA veteran would have been eligible for re-admission if the facility was able to care for them and if the restriction did not limit the number of admissions for VA veterans in the facility. The administrator further explained that the facility had a limitation on how many VA Veterans were able to be admitted to the facility with a cut off of 30 at a time. However, upon review of the census with the number of Veterans for this time frame, they would have been allowed to re-admit him if the limitation was in effect because they did not have 30 veterans in the facility during the proposed readmission time frame. The Administrator explained that the facility was limited to 30 residents with VA benefits. They further stated that the facility has around 28 to 30 residents that are veterans that used VA benefits monthly. During an interview with the VA Case Manager on 12/8/23 at 1:48 PM she stated that there was no cap for VA veterans' admission to facilities until October 2023 and would not have been in effect for Resident #445 during this specific time.

Based on observations, resident and staff interviews and record review, the facility failed to honor food preferences for 2 of 2 residents reviewed for food preferences (Resident #19 and #52). The findings included: 1. Resident #19 was admitted to the facility on [DATE]. Diagnoses included hypertension, gastroesophageal reflux disease, and renal insufficiency. Review of a Physician (MD) Orders diet list revealed a MD order dated 3/19/20 for a regular diet for Resident #19. An annual Minimum Data Set assessment dated [DATE] assessed Resident #19 with clear speech, adequate hearing, impaired vision without corrective lenses, understood, able to understand, moderately impaired cognition and fed herself after staff provided set up assistance. A care plan revised October 2023 recorded that Resident #19 was at risk for nutritional decline due to her diagnoses and a history of weight loss. Interventions included providing food preferences when possible. Resident #19 was observed in her room and interviewed on 12/04/23 at 1:54 PM. During the observation, Resident #19 fed herself her lunch meal which included chicken breast (white meat). The tray card on her lunch meal tray recorded Dislikes: Chicken [NAME] Meat. Resident #19 ate her remaining food but did not eat the chicken. Resident #19 stated I don't like white meat, they serve it to me all the time, I will ask for a peanut butter and jelly sandwich instead. Nurse #4 was interviewed on 12/07/23 at 2:54 PM. Nurse #4 stated that she was the 7 AM - 3 PM Nurse for Resident #19 and often observed her with breakfast and lunch meals. Nurse #4 stated that if Resident #19 received food she did not like, she went to the kitchen to get something else. Nurse #4 stated she observed Resident #19 receive white meat chicken before, but that she did not like white meat chicken and that she did not eat it. Nurse #4 stated that if a resident received food, they did not like the staff should offer the resident a substitute. An interview with the Dietary Manager (DM) on 12/06/23 at 5:01 PM revealed she was the DM for the past 4 months. The DM stated that meal preferences were obtained on admission, updated during care plan meetings, and the DM entered the preferences into the facility's tray card system. The DM stated that sometimes a resident received food that was listed on the tray card they disliked, but that the dietary aides were responsible to review the tray card and provide foods according to the resident's preferences. The DM stated that sometimes dietary staff did not always identify preferences correctly that were listed on the tray card and when that occurred the DM provided education. The DM stated that it was possible that the dietary aides did not know the difference between white/dark meat chicken and therefore did not tell the cook not to plate white meat chicken for Resident #19 during the meal tray line service. The DM stated that at times she checked meal trays for accuracy, her focus was to check for allergies and consistency, but during her checks, she did not lift the lid to look at the resident's plate. The Administrator stated in an interview on 12/08/23 at 1:06 PM that she was the Administrator in the facility since July 2023. The Administrator stated that she expected dietary staff to review tray cards when meals were plated and for nursing staff to review tray cards when they assisted a resident to set up their meal. The Administrator stated that resident meal preferences should be honored. 45358 2a. Resident # 52 was admitted to the facility on [DATE] with diagnoses inclusive of hypertension, malnutrition, and colitis. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #52 was cognitively intact and required set up or cleanup with food. A review of Resident #52's lunch menu ticket dated 12/7/23 indicated no tomatoes as a preference. A review of a grievance report dated 4/3/23 indicated Resident #52 continued to receive tomatoes on her salad meal although she had an allergy to tomatoes and did not eat meat. Action taken included making dietary staff aware of Resident #52's allergy to tomatoes and that she did not eat meat. The grievance was investigated and signed by the Registered Dietician. An interview on 12/6/23 2:55 PM Resident #52 revealed she was served tomatoes on her lunch tray on 12/6/23 and tomatoes were listed on her meal ticket as dislikes. She further revealed tomatoes had been placed on her food tray in the past, despite being listed as dislikes on her meal ticket. She stated she submitted a grievance dated 4/3/23 related to receiving tomatoes on her salad and that she had an allergy to tomatoes. Resident #52 stated when she discovered the tomatoes on her salad on 12/6/23, she went to the kitchen and was given another salad without tomatoes. An interview on 12/6/23 at 3:37 PM the Dietary Director stated she and her dietary staff were very familiar with Resident #52's preferences. However, a new dietary aide, who was not familiar with the Resident's preferences, did not call out to the cook that the Resident should not receive tomatoes on her salad. The Dietary Director revealed she was aware Resident #52 received tomatoes on her salad on 12/6/23 although her meal ticket indicated no tomatoes. She stated it was the responsibility of the dietary aide to communicate resident preferences while building food trays. She further revealed she would have to re-train the dietary aides on communication with the cook. An interview on 12/7/23 at 6:35 PM the Administrator indicated she expected dietary staff to review and honor meal tray tickets before they leave the kitchen and for nurse aides to review the tray tickets upon delivery to residents. She further indicated, Resident #52's preferences should have been honored as indicated on her meal ticket. 2b. A review of Resident #52's breakfast and lunch menu tickets dated 12/7/23 indicated no options for plant-based meats and was not indicated as a preference. During an interview on 12/5/23 at 10:43 AM Resident #52 revealed she became a vegetarian in 2022 and during a recent Resident Council meeting, she requested alternative plant-based meat options. Resident #52 further revealed the Dietary Director attended that meeting and agreed to offer plant-based meat options as a menu item. The Resident received plant-based meat once or twice in October 2023 and had not been offered plant-based meat since then. The Resident also stated it was never added to the printed menu as a preference, although the Dietary Director was made aware of the Resident's preferences. During an interview on 12/6/23 at 3:37 PM the Dietary Director indicated the facility had been offering plant-based options to residents since August 2023 when residents requested the options during a Resident Council meeting. She further indicated plant-based options had not been added to the printed menu and would be written on the menus or discussed during the admission process. The Dietary Director stated although she was aware Resident #52 preferred plant-based options, she did not update Resident #52's preferences to include plant-based options because she assumed the Resident would write it on her menu when she wanted it. She stated there were only two vegetarians in the facility and did not think other residents were interested in plant-based options. During an interview on 12/6/23 at 2:34 PM the RD revealed she assessed residents at admission, significant weight loss, and at the request of residents and families. She further revealed she met with Resident #52 in September 2023 and plant-based options were never discussed. Further, she was not aware the Resident wanted plant-based options. During a follow-up interview on 12/7/23 at 1:39 PM Resident #52 indicated plant-based options were never placed on her preference list, although she recommended it during a Resident Council meeting during July or August 2023. She further indicated the Dietary Director told her it would be written on the menu ticket, but it was not written or offered since October 2023. Resident #52 stated if plant-based options were offered/ listed on the menu as promised, she would certainly choose those options, since she became vegan in 2022. During an interview on 12/7/23 at 1:53 PM Nurse Aide #1 (NA) revealed she never discussed plant-based options with Resident #52. She further revealed the Resident often complained about her food and periodically requested meat. During an interview on 12/7/23 at 11:56 AM Nurse #1 indicated Resident #52 said she was not getting plant- based options but Nurse #1 was unsure if the Resident was offered the plant-based options after she first received them in September or October 2023. During an interview on 12/7/23 at 6:25 PM the Administrator revealed the facility attempted to accommodate plant-based options requested by Resident #52 although it was not part of their menu. She further revealed she was aware the facility started ordering plant-based items in late summer 2023 but was not aware the plant-based items were not regularly offered to the Resident or any other resident via the menu. She expected the plant-based options to be added to Resident #52's menu and preferences honored.

Based on record review, staff interviews and physician interview, the facility failed to protect 2 of 3 sampled residents (Residents #2 and #3) from sexual abuse from Resident #1. Immediate Jeopardy began on 12/27/18 when Resident #1 verbally told direct care staff that he had stuck his finger up a cognitively impaired resident's (Resident #2) vagina and staff failed to put into action an effective plan to address and monitor his behaviors resulting in Resident #1 being observed attempting to have sexual intercourse with Resident #3 on 01/04/19. Immediate Jeopardy was removed on 01/14/19 when the facility provided and implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at the lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. admission orders [REDACTED].e. [MEDICATION NAME] an antipsychotic medication) 25 milligrams (mg) every day at bedtime for unspecified dementia with behavioral disturbance; [MEDICATION NAME] (i.e. [MEDICATION NAME] an antidepressant medication) 15mg take one tablet at bedtime for major [MEDICAL CONDITION] unspecified; and Donepezil (i.e. [MEDICATION NAME] treatment for [REDACTED]. Occupational therapy (OT) notes dated 12/18/18 at 4:55 PM stated Resident #1 demonstrated the ability to unlock/lock wheelchair brakes. The OT aide used 12 percent verbal cues for safety awareness and Resident #1 needed stand by assistance during ambulating in room with a rolling walker. Resident #1 was able to manage door and maneuver rolling walker with stand by assistance. Resident #1's admission Minimum Data Set ((MDS) dated [DATE] coded him with being understood and understanding, having intact cognition, rejecting care 1 to 3 days during the previous 7 days, requiring extensive assistance with bed mobility, transfers, walking, dressing, and toileting, and limited assistance with locomotion and eating. A care plan was initiated on 12/20/18 for the issue that Resident #1 made inappropriate comments of a sexual nature to female staff. The goal was that Resident #1 would have no increase in making inappropriate comments. Interventions included redirect the resident in a professional manner when he makes inappropriate comments, refer to psychiatric consult as needed and liaison with family as needed. The Care Plan Assessment (CAA) for cognition dated 12/21/18 stated Resident #1 had dementia which affected his cognition. His mood state can also impact cognition. Over the look back period, nursing notes indicated times of disorientation and confusion. The CAA for behaviors dated 12/27/18 stated the resident's cognitive status problems may also contribute to his behavioral symptoms. He has a [DIAGNOSES REDACTED]. Although the resident displays behavioral symptoms that may impact himself or others, he is not an immediate threat to himself or others at this time. The OT notes dated 12/26/18 at 10:31 AM stated Resident #1 had improved in standing tolerance allowing for improvements with toileting and lower body dressing. He was able to propel his wheelchair through the facility. Resident #1 was no longer in the facility as he was discharged to the hospital for surgery on 01/09/19. No interview with Resident #1 could be conducted. Resident #3 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her most recent MDS, a quarterly dated 12/20/18 coded her with severely impaired cognitive skills, being nonambulatory and requiring extensive to total assistance with all activities of daily living skills. Review of an occurrence report dated 01/04/19 at 12:08 AM revealed that Resident #1 was in Resident #3's room with socially inappropriate behavior involving resident to resident altercation. This was witnessed by Nurse Aide (NA) #3 with NA #4 and Nurse #5 assigned to resident care. The investigation summary stated Resident #1 was noted lying on top of Resident #3 with his penis out. Resident #3's brief was open on the right side. The residents were separated and a body audit of Resident #3 revealed no redness or blood noted in the vaginal area. The facility immediately began an investigation including written statements and a body audit of Resident #3. A body audit picture signed by Nurse #5 and Nurse #6 on 01/04/19 stated no bleeding no discharge noted at 12:15 AM but also noted on the right side of her labia was excoriation. A written statement by NA #3 dated 01/03/19 stated that while she was doing her first round, she entered Resident #3's room and saw Resident #1 on top of Resident #3. Resident #3 was crying for help and pushing his head away. The statement stated He was trying to (penis in hand) position 'himself' better in her vaginal area. After the incident he continued to make inappropriate sexual remarks and indicated he was looking for more sexual activity. Interview via phone with NA #3 on 01/10/19 at 1:49 AM revealed that she was assigned to Resident #3 beginning 11 PM on 01/03/19 through 7 AM on 01/04/19. She stated that she began her normal rounds around midnight on 01/04/19 with Resident #3. NA #3 stated she entered the resident's room and when she pulled back the curtain she saw Resident #1 on top of Resident #3. Resident #3 was asking for help and pushing Resident #1's head away. NA #3 stated Resident #3's dress was up and her periarea was very much exposed. Resident #1 was also exposed and he had his penis in his hand positioning himself. NA #3 stated it was obvious to her he was trying to have intercourse with Resident #3. She immediately yelled for the nurse and started to separate the residents. At the time he did not say what he was doing, but afterwards Resident #1 was saying how good it was and how Resident #3 squealed with enjoyment. Resident #3 kept repeating 'Don't let me die this way .I don't want to die this way.' NA #3 stated she had not seen Resident #1 before to this encounter during this shift and was not assigned to care for Resident #1. NA #3 stated that after this incident, Resident #3 was more fidgety and apprehensive during the provision of care than previously. A written statement by Nurse #5 dated 01/04/19 revealed she heard the NA #3 call her name for help. Upon entering Resident #3's room, she observed Resident #1 lying on top of Resident #3. Resident #3's brief was open on one side and Resident #1 had his penis out trying to position himself. Resident #1 was removed and a body audit of Resident #3 revealed no redness or bleeding to the vaginal area. Nurse #5 was interviewed via phone on 01/09/19 at 7:16 PM. Nurse #5 stated she immediately entered Resident #3's room upon the NA calling for help. Resident #1 was observed on top of Resident #3. She stated the right side of Resident #3's brief was open and Resident #1 had his pants partially down exposing his penis. It appeared to Nurse #5 Resident #1 was trying to position himself to have intercourse with Resident #3. Nurse #5 stated she screamed at Resident #1 and screamed for NA #4. Resident #3 was lying there saying 'please don't hurt me, please don't hurt me, please don't let me die like this.' After Resident #1 was removed, Resident #3 continued to just lie there and cry. Nurse #5 stated NA #3 had pulled Resident #1 off of Resident #3. Nurse #5 stated she assisted Nurse #6 with the body audit and noted the brief was open and she was exposed. Nurse #5 stated afterward, Resident #1 was bragging about how he got himself one tonight and she liked it. Upon a follow up phone interview with Nurse #5 on 01/11/19 at 9:33 AM, she stated it was her duty to document the 30 minute checks on Resident #1. She estimated she saw him at the nursing station at approximately 11:45 PM on 01/03/19. Interview with NA #4 occurred on 01/09/19 at 3:51 PM via phone. NA #4 stated he was assigned to Resident #1 starting 11 PM to 7 AM beginning 01/03/19. NA #4 stated he had seen Resident #1 during initial rounds around 11:15 PM to 11:30 PM. He had been in bed with a brief and pajama bottoms on. He heard a NA call out for help and found NA #3 and Nurse #5 in Resident #3's room. By this time, Resident #1 was observed standing and leaning over the resident. NA #4 then stated Resident #1 was sitting on the edge of the bed with his penis exposed. Resident #1 was placed in a wheelchair and moved to the parlor where he was immediately placed under one on one supervision. Phone interview with Nurse #6 on 01/09/19 at 7:30 PM revealed he was the supervisor during the night shift beginning 01/03/19. He stated Nurse #5 called him and when he arrived to Resident #3's room, Resident #1 was sitting on the edge of the bed his pants were partially down and Resident #3's brief was open on one side. When he asked Resident #1 what happened, Resident #1 said he was sorry. Nurse #6 immediately reported the incident to the administrator and the Director of Nursing (DON). Resident #3 appeared afraid and was visibly frightened despite her usual lethargy. A phone interview with Resident #1's physician occurred on 01/09/19 at 3:12 PM. She stated that she saw him initially after admission and twice more, once after each incident relating to sexual behaviors. She described Resident #1 as alert and oriented but delusional with a [DIAGNOSES REDACTED].#3. Resident #1 had stated that he can ambulate to(NAME) drive a car and has had 2 children by 2 different women at the same time which the spouse denied. The physician stated she was unaware he could walk until talking with therapy last week. When asked if Resident #1 could have delusions of grandeur, meaning he does something but talks about it in more grandiose detail to make it sound like more occurred and she stated Resident #1 was incompetent. An attempt to interview Resident #3 was made on 01/09/19 at 9:50 AM with her family member present. Resident #3 was lethargic and would not answer but one question which was do you feel safe here to which she responded yes. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. admission orders [REDACTED].e. [MEDICATION NAME] an antipsychotic medication) 25 milligrams (mg) every day at bedtime for unspecified dementia with behavioral disturbance; [MEDICATION NAME] (i.e. [MEDICATION NAME] an antidepressant medication) 15mg take one tablet at bedtime for major [MEDICAL CONDITION] unspecified; and Donepezil (i.e. [MEDICATION NAME] treatment for [REDACTED]. Occupational therapy (OT) notes dated 12/18/18 at 4:55 PM stated Resident #1 demonstrated the ability to unlock/lock wheelchair brakes. The OT aide used 12 percent verbal cues for safety awareness and Resident #1 needed stand by assistance during ambulating in room with a rolling walker. Resident #1 was able to manage door and maneuver rolling walker with stand by assistance. Resident #1's admission Minimum Data Set ((MDS) dated [DATE] coded him with being understood and understanding, having intact cognition, rejecting care 1 to 3 days during the previous 7 days, requiring extensive assistance with bed mobility, transfers, walking, dressing, and toileting, and limited assistance with locomotion and eating. A care plan was initiated on 12/20/18 for the issue that Resident #1 made inappropriate comments of a sexual nature to female staff. The goal was that Resident #1 would have no increase in making inappropriate comments. Interventions included redirect the resident in a professional manner when he makes inappropriate comments, refer to psychiatric consult as needed and liaison with family as needed. The Care Plan Assessment (CAA) for cognition dated 12/21/18 stated Resident #1 had dementia which affected his cognition. His mood state can also impact cognition. Over the look back period, nursing notes indicated times of disorientation and confusion. The CAA for behaviors dated 12/27/18 stated the resident's cognitive status problems may also contribute to his behavioral symptoms. He has a [DIAGNOSES REDACTED]. Although the resident displays behavioral symptoms that may impact himself or others, he is not an immediate threat to himself or others at this time. The OT notes dated 12/26/18 at 10:31 AM stated Resident #1 had improved in standing tolerance allowing for improvements with toileting and lower body dressing. He was able to propel his wheelchair through the facility. Review of the nursing notes for Resident #1 revealed on 12/27/18 at 1:11 PM the Director of Nursing wrote that Resident #1 was reported by staff to be saying he had used his fingers on another resident in their private area and that she liked it. Resident #1 had been verbally inappropriate with staff but not with other residents. Family was contacted who reported that prior to admission when Resident #1 was diagnosed with [REDACTED]. The note continued stating Due to the limitations of the resident's physical body habitus, he would not be able to do anything to another resident. However, he is placed on q (every) 30 minute monitoring by staff. The resident also has delusions that the female resident is his new wife. The next nursing note dated 12/27/18 at 1:35 PM identified the female resident involved as Resident #2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her cognition Care Area assessment dated [DATE] stated Resident #2 was alert and exhibited impaired ability to communicate. She was nonverbal during the interview with occasional smiles. Her communication was impaired as related to understanding and relating information. She received assistance in all phases of care with her participation involving staff cueing and hands on assistance. She could stand and ambulate without assistance. She walked on and off the unit with assistance given as needed for redirection and safety. Her most recent MDS, a quarterly dated 10/30/18 coded her with unclear speech, sometimes understanding, sometimes being understood, not being able to assess her cognition, being ambulatory, and requiring limited assistance with most activities of daily living skills. She was not coded for behavior or mood issues. In Resident #2's nursing notes, written by the Director of Nursing (DON), was an entry dated 12/27/18 at 2:01 PM that stated a male resident stated he put his fingers in the resident's vagina. A body audit was conducted on the female resident and no signs or symptoms of redness, bruising or discharge were noted. The resident clamped her thighs together when assessed. It appeared that the male resident had fixated on the female resident. The male resident was placed on 30 minute checks. The next nursing note written by the Social Service Director dated 12/28/18 at 12:15 PM identified the male resident as Resident #1. Review of the facility's investigation of the alleged incident between Resident #1 and Resident #2 included the following written statements and follow up interviews made by the surveyor: *A hand written statement dated 12/27/18 at 7:06 AM signed by Nurse Aide (NA) #1 stated that at 7 AM he went to check on Resident #1 who stated last night he went into Resident #2's room and he tried to stick the head in and it wouldn't fit so he just used his finger. On 01/09/19 at 1:40 PM NA #1 was interviewed. He stated he worked first shift. He stated that when Resident #1 told NA #1 that he had fingered Resident #2, Resident #1 actually used her name. NA #1 stated that Resident #1 tried to put his penis (referring to his head) inside Resident #2 but ended up using his finger. He further stated that he had not seen anything inappropriate between Resident #1 and Resident #2 previous to the allegation. He immediately reported this to his supervisor. *A hand written statement dated 12/27/18 at 8:30 AM signed by NA #2 stated during breakfast, she noticed Resident #1 was in Resident #2's room. Resident #1 was immediately asked to leave and he said he was feeding Resident #2 and he said that's not all I did. He then stated to NA #2 in the presence of Nurse #2 that he stuck his finger inside her vagina yesterday and that she wanted him to do it again. Both the NA and Nurse reported this to their supervisor. NA #2 was interviewed on 01/09/19 at 3:39 PM via phone. NA #2 stated she saw Resident #1 by Resident #2's bed the morning of 12/27/18. Resident #1 referred to Resident #2 as his wife and then stated he stuck his finger inside of her. NA #2 stated that he was bedridden the first couple of days following his admission but after the first few days he could transfer himself and walked by himself. She stated he had called out to female residents before to come here. NA #2 stated she, NA #1 and Nurse #2 all had to write statements and Resident #1 was placed on 30 minute checks. *A hand written note dated 12/27/18 at 8:30 AM signed by Nurse #2 stated while at the med cart, NA called her to be a witness to what the resident (#1) was stating in that he stuck his middle finger inside Resident #2 and she liked it. Nurse #2 was interviewed on 01/09/19 at 1:31 PM. Nurse #2 stated Resident #2 did not verbalize anytime. She stated Resident #2 wandered independently around the halls and they tried to watch her for elopement risk. Resident #1 became more vocal to staff, not residents in a flirtatious manner during his stay at the facility. Nurse #2 stated that on 12/27/18 a nurse aide called to her to witness what Resident #1 was saying, which was that he stuck his finger and motioned to indicate inside the resident. She stated she immediately informed her supervisor. She did not recall Resident #2 acting any differently following this accusation. *A hand written statement dated 12/27/18 at 9:00 PM signed by Nurse #1 stated she caught Resident #1 trying to go into Resident #2's room and shut the door. Nurse #1 noted she removed Resident #1 and reported the incident to Nurse #3. At first Resident #1 did not answer the nurse's question as to why he tried to shut the door and later stated he wanted to put her to sleep. Nurse #1 was interviewed via phone on 01/10/19 at 1:50 PM. Nurse #1 stated that she caught Resident #1 going into Resident #2's room and he was trying to shut the door when she caught him. This occurred in the evening on 12/27/18. When she asked him what he was doing, Resident #1 said he was trying to put her to sleep then asked Nurse #1 if he was going to be going to jail and immediately said never mind. She stated she had heard bits and pieces of what Resident #1 had said about Resident #2 and knew he was being watched. She stated she wrote her statement on her own and left it for the next shift after informing her supervisors. Interview on 01/09/19 at 2:59 PM via phone with Nurse #3, the supervisor the evening of 12/27/18, revealed she had been aware of the allegations Resident #1 was saying about what he did to Resident #2 and that he had been placed on 30 minute checks. *A hand written note dated 12/27/18 at 12:45 PM signed by the DON stated Resident #1's family member stated Resident #2 was sitting on the bed in Resident #1's room his second Sunday at the facility. She reported this on 12/27/18. Resident #1's family member reported this occurred twice. A second note, no date but noted at 10:45 AM, revealed Resident #1's family member called and stated Resident #1 stated he was guilty of the offense of putting his fingers inside of the resident. He stated Resident #2 was fully clothed, had a brief on and was unable to speak. The plans noted included that the social worker discussed concerns with Resident #1's representative, his wife and the physician.; he was placed on 30 minute monitoring for location; he was moved to another unit; and he was placed on [MEDICATION NAME] (an antidepressant). The DON was interviewed on 01/09/19 at 2:00 PM. The DON stated Resident #1 did verbalize to her that he had his fingers inside Resident #2. She stated she talked to the supervisor and staff on the night shift and was unable to obtain proof to the allegations. The DON based this proof off the body audit of Resident #2 having no signs or symptoms of bruising, blood or discharge and staff reports that he was not seen near her prior to his allegations. Once she determined this allegation did not happen she placed him on 30 minute checks for location to be on the safe side. On 01/09/19 at 1:52 PM Nurse #4 was interviewed. She stated she was the supervisor on 12/27/18 first shift. Once the NA #1 and NA #2 brought Resident #1's allegation to her attention, she notified the DON and got written statements. She did not talk to Resident #1 nor did she hear him make the allegations. An attempt to interview Resident #2 was made on 01/09/19 at 12:58 PM. She was nonverbal and did not follow directions to shake her head to yes and no questions. She started dancing. Interview with the Administrator on 01/09/19 at 11:53 AM revealed that she believed that if Resident #1 had tried anything inappropriate with Resident #2, she would have gotten physical with him. She further stated there was nothing to the allegation because Resident #1 was delusional, could not perform marital duties per family interview and that his talk about sexual things occurred because he had a pituitary tumor. The family indicated there was no sexual criminal behaviors they knew of previously. Upon follow up interview on 01/09/19 at 4:09 PM the administrator stated the allegation did not occur because Resident #1 was delusional and Resident #2 had no physical evidence upon a body audit completed 12/27/18. As a precaution, the Administrator stated they developed a Quality Improvement Plan dated 12/27/18 which was provided. This plan included: 1. review concerns with Resident #1 and Resident #2's families; 2. place resident (#1) on 30 minute monitor for location; 3. male resident (#1) moved to south neighborhood; 4. male resident (#1) placed on [MEDICATION NAME] (an antidepressant) for increased sexual behaviors. Review of Resident #1's medical record revealed on 12/28/18 the physician examined Resident #1 at the request of nursing staff regarding increasing sexual behaviors. The physician noted Resident #1 stated he did not physically touch anyone but admitted to attempting to enter the room of a female resident on more than one occasion and stated he shouldn't have done that. The physical exam noted :motor intact, sensory intact, speech fluent. Alert and oriented x 2 (person and place). The physician ordered [MEDICATION NAME] HCL (an antidepressant) 20 mg daily for sexual behaviors. Review of the computerized physician orders [REDACTED]. Review of documentation provided by the facility, 30 minute checks were initiated for Resident #1 and documented beginning 12/27/18 through 01/04/19. Documentation was noted for half hour increments ( i.e. 1:00 PM - 1:30 PM, 1:30 PM - 2:00 PM, etc.). The care plan for Resident #1 was updated on 12/28/18 with a goal that Resident #1 would not have nor vocalize delusions of a sexual nature. Interventions included the physician to evaluate the need of medication to decrease his sexual drive, visit with the resident and allow him to verbalize negative feelings, visit and remind him of the implications of false allegations and ensure he takes his medications. Review of the nursing notes dated 12/28/18 at 2:29 PM revealed Resident #1 was moved to the south unit on 12/28/18. Nursing notes dated 01/03/19 at 6:53 AM revealed during the shift, Resident #1 exhibited multiple behaviors including wandering in and out of other resident rooms, taking their belongings, removing ornaments from the Christmas tree in the south parlor, getting out of bed and self transferring to his wheelchair and sitting on the foot of his roommates bed using his telephone without permission. After being assisted back to bed, Resident #1 was again noted out of bed trying to give personal care to his roommate. It was noted Resident #1 needed constant redirecting. Resident #1 was seen by psychiatric services on 01/03/19. The note stated Resident #1's speech was at normal rate and volume although monotone and his affect was restricted but reactive. His thought process was simple at times and he seemed superficially connected. There was no auditory or visual hallucinations recently and no delusions. His insight and judgement were poor. His recent memory and remote memory were intact. Recommendations were to discontinue [MEDICATION NAME] (Quetiapine) and start [MEDICATION NAME] 125 mg twice a day. The Administrator was informed of Immediate Jeopardy on 01/10/19 at 4:40 PM. The facility provided an acceptable allegation of immediate jeopardy removal on 01/12/19 at 11:23 AM as follows: White Oak Manor -(NAME)will ensure the safety of residents from abuse. On 12/27/18, Resident # 1 reported to staff that he 'fingered' Resident # 2, and that Resident # 2 approached him and asked him to make love with her in her room. He could not get his penis to work but he indicated he used his finger and they enjoyed each other. Resident # 1 stated they were married and had children together. Resident # 1 was placed on 30-minute location monitoring checks. The 30-minute location monitoring was documented on a spreadsheet. Resident # 2 was immediately assessed by DON, Licensed Nurse and Social Services Director, which included a body audit that took 3 staff members due to the difficulty to examine the resident with her clenching of her thighs. There was no indication that resident was touched or harmed by another resident. Resident # 2 is non-verbal and is unable to say anything about Resident # 1's comments about her. Resident # 1 and # 2's Resident Representatives were notified. On 1/4/19, Resident # 1 was noted lying in bed of Resident # 3. Resident # 1 was lying on top, toward the left of Resident # 1 with his pants undone and his penis exposed. Resident # 3's brief was noted undone and disheveled on the right side of Resident # 3. Facility staff immediately removed Resident # 1 from Resident # 3's room, and Resident # 3 was assessed by the nursing staff. Police was notified, and reported to the State. Police and Crime Scene Investigator conducted their investigation, and then Resident # 3 was transferred to the hospital for further evaluation. Resident # 1 was immediately placed on one-on-one monitoring with a staff member at all times until his discharge from the facility on 1/9/19 at 5:30AM. On 12/27/18 and 1/4/19, Social Services Director checked by observation only on other residents that were in the proximity of Resident # 2 and # 3, and those residents were not interviewable due to mental capacity. On 1/10/19 and 1/11/19, Social Services Department conducted interviews with interviewable residents throughout the facility. The interview questions consisted of the following: has anyone touched you an inappropriate manner including sexual, has anyone talked to you in an inappropriate manner, including sexually, has anyone tried to climb in the bed with you, and did you see anything sexually inappropriate to anyone else. All questions were answered with a no. Non-interviewable residents were assessed by 3 Licensed Nursing staff to determine any distress or clothing disturbances or change from their normal demeanor. No variances were noted during the assessments. Re-education on the Abuse/Neglect Policy was started on 1/04/19 of all current staff in all departments, and completed on 1/11/19. Newly hired staff will be re-educated during their specific job orientation by the Staff Development Coordinator or Social Services Director. The Abuse/Neglect Policy will be reviewed annually with all staff and as needed throughout the calendar year. On 1/11/19, the 24-hour report and Quality Improvement (QI) documentation sheets were modified to document and address any observation or verbalization of sexual behavior reported by facility staff. On 1/11/19, a questionnaire was developed regarding sexual inappropriateness that included physical interaction and verbalizations, and will be implemented during care plan meetings and Resident Council meetings. The Social Services Department will randomly interview 5 residents per week for 8 weeks. The interview questions will address inappropriate sexual behaviors affecting themselves or that they may have observed. Another 5 random residents that are non-interviewable will be monitored for changes in behavior or demeanor that would possibly indicate any mistreatment or abuse, particularly for sexual interactions whether verbal or physical. The monitoring will identify any allegations of sexual abuse, and assure reporting and the investigation is complete thoroughly. The monitoring will be completed by the Director of Nursing (DON) and/or designee. All indications or suspicion of sexual abuse will be reported to the Administrator and DON by facility staff, and appropriately reported to the state agency and a thorough investigation will be completed. The Quality Improvement (QI) committee was informed on 12/27/19 with the situation involving Resident # 2 and on 1/4/19 regarding the incident involving Resident # 3. Results from the monitoring will be discussed Monday through Friday during Quality Improvement (QI) morning meetings and any identified issues or trends will be further discussed at the Quality Assurance meeting with the team and recommendation made as indicated. The QA committee was notified of credible allegation on 1/9/19, 1/10/19, and 1/11/19 respectively throughout the survey process as it was informed to the facility. The QA committee includes the Attending Physician, Administrator, DON, Social Services department, ADON, Nursing Supervisors, Dietary, Activities, SDC, Therapy Department, Restorative Nurse, and MDS Licensed Nurses. Alleged Compliance Date is 1/12/19 The DON is responsible for ongoing compliance of F600. The facility's credible allegation of IJ removal was verified on 01/14/19 at 6:04 PM and based on verification that Resident #1 was no longer in the building. Interviews with alert and oriented residents were conducted and no one expressed they had been abused and family members were interviewed and voiced no concerns. Administrative and nursing staff verified that training had been provided regarding the abuse policy and need to protect residents, investigate allegations and report to the state agency. This was verified as also being provided to all departments.

Based on record review and staff interviews, the facility failed to implement their abuse policy and procedure to protect residents from abuse and to investigate and report allegations of abuse for 1 of 2 residents reviewed for sexual abuse (Resident #2). Resident #1 informed staff that he put his finger in a cognitively impaired resident's vagina (Resident #2). The facility failed to thoroughly investigate this allegation of abuse or report it to the State agency. Subsequently, Resident #1 was found attempting to have intercourse with another cognitively impaired resident. Resident #2 was assessed by the facility's nursing staff and found to have no physical injuries. Immediate Jeopardy began on 12/27/18 when Resident #1 verbally told several direct care staff that he had stuck his finger up a cognitively impaired resident's (Resident #2) vagina and staff failed to conduct a thorough investigation of this allegation by not following their abuse policy. In addition, effective monitoring of Resident #1 was not implemented following the 12/27/18 incident to ensure he did not have the opportunity to abuse another resident. Immediate Jeopardy was removed on 01/14/19 when the facility provided and implemented a Credible Allegation of Immediate Jeopardy removal. The facility remains out of compliance at the lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. The findings included: Review of the facility's Neglect, abuse, Mistreatment, Threatened or Alleged Abuse of Residents policy, which was revised in (MONTH) of (YEAR) included the following in part: *under Section V Protection: A. Protection of the resident who has been a victim, the facility will take immediate measures to protect the resident from further harm including measures that might include more frequent monitoring. Under the section of Resident to Resident Abuse the facility was to monitor residents for aggressive/inappropriate behavior toward other residents. * under Section VI Investigation: A. Should an incident or suspected incident of resident abuse be reported, the Administrator, or his designee will investigate the alleged incident. B. The person in charge of the investigation will obtain a completed copy of the Incident report and any supporting documents relative to the allegation. C. The individual conducting the investigation will as a minimum: *Review the completed forms; *Interview the person(s) reporting the incident; *Interview any witnesses to the incident; *Interview staff members on all shifts who have had contact with the resident during the period of the alleged incident; *Interview the resident's roommate other residents, visitors as appropriate. E. Statements will be obtained from individuals identified as having potential involvement and/or knowledge of the alleged incident. Statements shall include but not limited to the time frame of contact and or observation of the alleged victim, interaction with the alleged victim and or act ivies at the time of the alleged incident, observation of other person's activities and/or interaction with the alleged victim (including staff, family or others). F. Following a complete and thorough investigation on the alleged abuse a written report will be finalized summarizing the investigation. H. Preliminary reporting requirements will be followed and the results of the final investigation will be reported to appropriate individuals and state agencies as required by law. *Under section VII Reporting and Response in the abuse policy and procedure included in part: B. Upon receipt of an allegation of abuse, The Administrator or designee will notify the State agency(s). C. The report of the initial investigation will be telephoned or faxed to the appropriate State agency. D. The facility will follow the investigation procedure as outlined. E. following the investigation, a five day report will be filed with the appropriate State agency summarizing the investigation, corrective action taken and outcome of the investigation. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. admission orders [REDACTED]. Occupational therapy (OT) notes dated 12/18/18 at 4:55 PM stated Resident #1 carried out activities of daily living skills demonstrating the ability to unlock/lock brakes appropriately. The OT aide used 12 percent verbal cues for safety awareness and proper hand placement and Resident #1 needed stand by assistance during ambulating in room with rolling walker. Resident #1 was able to manage door and maneuver rolling walker with stand by assistance. Resident #1's admission Minimum Data Set ((MDS) dated [DATE] coded him with being understood and understanding, having intact cognition, rejecting care 1 to 3 days during the previous 7 days, requiring extensive assistance with bed mobility, transfers, walking, dressing, and toileting, and limited assistance with locomotion and eating. A care plan was initiated on 12/20/18 in order to address the problem that the resident makes inappropriate comments of a sexual nature to female staff. The goal was that Resident #1 would have no increase in making inappropriate comments. Interventions included redirect the resident in a professional manner when he makes inappropriate comments, refer to psychiatric consult at needed and liaison with family as needed. The Care Area Assessment (CAA) for cognition dated 12/21/18 stated Resident #1 had dementia which affected his cognition. His mood state can also impact cognition. Over the look back period, nursing notes indicted times of disorientation and confusion. The OT notes dated 12/26/18 at 10:31 AM stated Resident #1 was improved standing tolerance allowing for improvements with toileting and lower body dressing. He was able to propel through the facility. The CAA for behaviors dated 12/27/18 stated the residents cognitive status problems may also contribute to his behavioral symptoms. He has a [DIAGNOSES REDACTED]. Although the resident displays behavioral symptoms that may impact himself or others, he was not an immediate threat to himself or others at this time. Review of the nursing notes for Resident #1 revealed on 12/27/18 at 1:11 PM the Director of Nursing wrote that Resident #1 was reported by staff to be saying he had used his fingers on another resident in their private area and that she liked it. The resident had been verbally inappropriate with staff but not with other residents. Family was contacted who reported that prior to admission when Resident #1 was diagnosed with [REDACTED]. The note continued stating Due to the limitations of the resident's physical body habitus, he would not be able to do anything to another resident. However, he is placed on q (every) 30 minute monitoring by staff. The resident also had delusions that the female resident is his new wife. The next nursing note dated 12/27/18 at 1:35 PM identified the female resident involved as Resident #2. a. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her cognition CAA dated 08/28/18 stated Resident #2 was alert and exhibited impaired ability to communicate. She was nonverbal during the interview with occasional smiles. Her communication was impaired as related to understanding and relating information. She received assistance in all phases of care with her participation involving staff cueing and hands on assistance. She could stand and ambulate with and without assistance and walked on and off the unit with assistance given as needed for redirection and safety. Her most recent MDS, a quarterly dated 10/30/18 coded her with unclear speech, sometimes understanding, sometimes being understood, not being able to assess her cognition, being ambulatory, and requiring limited assistance with most activities of daily living skills. In Resident #2's nursing notes was an entry dated 12/27/18 at 2:01 PM written by the Director of Nursing stated a male resident made statements that he had inappropriate physical contact with a female resident. The male resident stated he put his fingers in the resident's vagina. A body audit was conducted on the female resident and no signs or symptoms of redness, bruising or discharge were noted. The resident clamped her thighs together when assessed. It appeared that the male resident had fixated on the female resident. The male resident was placed on 30 minute checks. The next nursing note written by the Social Service Director dated 12/28/18 at 12:15 PM identified the male resident as Resident #1. Review of the facility's investigation of the alleged incident between Resident #1 and Resident #2, provided by the Director of Nursing on 01/09/19, did not include an occurrence report/incident report, did not include evidence of the state agency notification of the allegation or the report summary and findings. The facility provided their evidence of the investigation which included the following written statements and follow up interviews made by the surveyor: *A hand written statement dated 12/27/18 at 7:06 AM signed by Nurse Aide (NA) # 1 stated that at 7 AM he went to check on Resident #1 who stated last night he went into Resident #2's room and he tried to stick the head in and it wouldn't fit so he just used his finger. On 01/09/19 at 1:40 PM NA #1 was interviewed to confirm his written statement. He stated that when Resident #1 told the NA that he had fingered Resident #2, Resident 1 actually used her name. NA #1 stated that Resident #1 told him he tried to put his penis (referring to his head) inside Resident #2 but ended up using his finger. He further stated that he had not seen anything inappropriate between Resident #1 and Resident #2 previous to the allegation. He reported it to his supervisor. *A hand written statement dated 12/27/18 at 8:30 AM signed by NA #2 stated during breakfast, she noticed Resident #1 was in Resident #2's room. Resident #1 was immediately asked to leave and he said he was feeding Resident #2 and he said that's not all I did. He then stated to NA #2 in front of the nurse (Nurse #2) that he stuck his finger inside her vagina yesterday and that she wanted him to do it again. NA #2 was interviewed on 01/09/19 at 3:39 PM via phone to confirm the written statement. NA #2 stated she saw Resident #1 by Resident#2's bed the morning of 12/27/18. Resident #1 referred to Resident #2 as his wife and then stated he stuck his finger inside of her. NA #2 stated that he was bedridden the first couple of days following his admission but after the first few days he could transfer himself and walked by himself. She stated he had called out to female residents before to come here. She stated she, NA #1 and Nurse #2 all wrote statements. *A hand written note dated 12/27/18 at 8:30 AM signed by Nurse #2 stated while at the med cart NA called her to be a witness to what the resident was stating in that he stuck his middle finger inside Resident #2 and she liked it. Nurse #2 was interviewed on 01/09/19 at 1:31 PM to confirm the written statement. Nurse #2 stated Resident 2 did not verbalize anytime. She stated Resident #2 wandered independently around the halls and they try to watch her for elopement risk. Resident #1 became more vocal to staff, not residents in a flirtatious manner. Nurse #2 stated that on 12/27/18 a nurse aide called to her to witness what Resident #1 was saying which was that he stuck his finger and motioned to indicate inside the resident. She does not recall Resident #2 acting any differently following this accusation. *A hand written statement dated 12/27/18 at 9:00 PM by Nurse #1 who stated she caught Resident #1 trying to go into Resident #2's room and shut the door. Nurse #1 noted she removed Resident #1 and reported the incident to Nurse #3. At first Resident #1 did not answer the nurse's question as to why he tried to shut the door and later stated he wanted to put her to sleep. Nurse #1 was interviewed via phone on 01/10/19 at 1:50 PM to confirm her written statement. Nurse #1 stated that she caught Resident #1 going into Resident #2's room and he was trying to shut the door when he caught him. This occurred in the evening on 12/27/18. When she asked him what he was doing, Resident #1 said he was trying to put her to sleep then asked Nurse #1 if he was going to be going to jail and immediately said never mind. She stated she wrote her statement on her own and left it for the next shift after informing her supervisors. *A hand written note dated 12/27/18 at 12:45 PM signed by the Director of Nursing (DON) stated Resident #1's daughter stated Resident #2 was sitting on the bed in Resident #1's room his second Sunday at the facility. She reported this on 12/27/18. Resident #1's daughter reported this occurred twice. A second note, no date but noted at 10:45 AM, revealed Resident #1's daughter called and stated Resident #1 stated he was guilty of the offense of putting his fingers inside of the resident. He stated she was fully clothed, had a brief on and was unable to speak. The plans noted included that the social worker discussed concerns with Resident #1's representative, his wife and the physician; he was placed on 30 minute monitoring for location; he was moved to another unit; and he was placed on [MEDICATION NAME] (an antidepressant). *A hand written note, dated 12/27/18 at 12:45 PM by the DON, indicated a skin assessment was completed on Resident #2 by the DON, social Service Director and East supervisor noting her periarea/rectal area showed no bruising, bleeding or discharge was noted. The DON was interviewed on 01/09/19 at 2:00 PM. The DON stated Resident #1 did verbalize to her that he had his fingers inside Resident #2. She stated she talked to the supervisor and staff on the night shift and was unable to obtain proof to the allegations. She stated to be on the safe side, she placed him on 30 minute checks for location. She stated that there was no way this could have occurred so she did not report the allegation or follow the abuse policy because the event did not happen based on no physical evidence from Resident #2's body audit. The facility provided their developed quality improvement plan dated 12/27/18 which included discussing concerns with Resident #1 and Resident #2's family; placing Resident #1 on 30 minute monitoring for his location; moving Resident #1 to another unit; and placing Resident #1 on an antidepressant for increased sexual behaviors. An attempt to interview Resident #2 was made on 01/09/19 at 12:58 PM. She was nonverbal and did not follow directions to shake her head to yes and no questions. She started dancing. Resident #1 was no longer in the facility as he was discharged to the hospital for surgery on 01/09/19. No interview with Resident #1 could be conducted. On 01/09/19 at 1:52 PM Nurse #4 was interviewed. She stated she was the supervisor on 12/27/18 first shift on the East side. Once the nurse aide brought the allegations Resident #1 was making to her attention, she notified the DON and got written statements. She did not talk to Resident #1 nor did she hear him make the allegations. A follow up interview with Nurse #4 on 01/10/19 at 8:45 AM revealed she was not asked about interactions between Residents #1 and #2 previous to the morning of 12/27/18. On 01/09/19 at 4:09 PM the Administrator stated that Resident #1 was delusional and confused and she knew nothing occurred between Resident #1 and Resident #2 because Resident #2's body audit showed no trauma. She further stated that she placed Resident #1 on 30 minute monitoring on 12/27/18 (at 10:00 AM per the documentation) as a precaution and she felt this monitoring was effective. The DON was interviewed again on 01/10/19 at 12:30 PM and provided the names of the staff she interviewed that proved to her there was no way Resident #1 assaulted Resident #2. She named Nurse #6 and Nurse #4. Additionally she named NA #1 and Resident #1. Additional interviews were conducted with these staff as follows: *NA #1, who worked first shift, was interviewed on 01/10/19 at 8:37 AM. NA #1 stated no one questioned him about any interactions known to him regarding interactions between Residents #1 and #2 previous to Resident #1 reporting his sexual behavior the morning of 12/27/18. *Nurse #4, who worked first shift, was interviewed on 01/10/19 at 8:45 AM. She stated that no administrative staff had asked her about interactions between Resident #1 and Resident #2 over the previous day of 12/26/18. *Nurse #6, who worked third shift, was interviewed via phone on 01/10/19 at 11:49 PM. Nurse #6 denied that the DON questioned him about any interaction he knew of between Residents #1 and #2. He further stated he learned of the allegation 2 to 3 days later during supervisory report. An interview was conducted with the Social Service Director (SSD) on 01/10/19 at 12:31 PM. She stated that she heard that Resident #1 was bragging about what he allegedly did to Resident #2. She assisted in the body audit of Resident #2 and stated she would have checked with the residents who were cared for by the aide who had the same assignment as Resident #2. SSD stated during follow up interview on 01/10/19 at 3:53 PM that she eye balled those residents directly around Resident #2's room. She stated no resident was interviewable so she did not attempt to interview any other resident. She stated she knew her residents well and would have been able to tell if they were traumatized by observing them. She was unable to say how many or who she eye balled. She stated she did not eyeball or try to interview any resident surrounding Resident #1's room. She further stated she did not do any body audits on the residents surrounding either residents' rooms. Interview with the Administrator on 01/09/19 at 11:53 AM revealed that she did not believe that Resident #1 was capable of assaulting Resident #2 and that Resident #2 would have fought back if Resident #1 tried anything inappropriate. She stated abuse did not occur and there was no need to launch a formal investigation and report the incident to the health care personnel investigations per their policy based on Resident #2 having no signs or symptoms of sexual abuse. A phone interview with Resident #1's physician occurred on 01/09/19 at 3:12 PM. She stated that she saw him initially after admission and twice more, once after each incident relating to sexual behaviors. She described Resident #1 as alert and oriented but delusional with a [DIAGNOSES REDACTED].#3. Resident #1 had stated that he can ambulate to(NAME) drive a car and has had 2 children by 2 different women at the same time which the spouse denied. The physician stated she was unaware he could walk until talking with therapy last week. When asked if Resident #1 could have delusions of grandeur, meaning he does something but talks about it in more grandiose detail to make it sound like more occurred and she stated Resident #1 was incompetent. Interviews were conducted with staff who worked with Resident #1 and #2 on 12/26/18 on all three shifts as follows: *On 01/10/19 at 8:35 AM, NA #5 stated she worked day shift on 12/26/18 and stated no administrative staff asked her about any interaction between Resident #1 and Resident #2 during her shift on 12/26/18. *On 01/10/19 at 8:55 AM, NA #6 stated she worked 12/26/18 first shift and that she had known nothing about the accusations Resident #1 made about assaulting Resident #2 and that no one asked her questions about known interactions between the two residents. *On 01/10/19 at 9:06 AM a phone call was made to NA #7 who stated she worked second shift on 12/26/18. She stated no administrative staff asked her about known interactions between Residents #1 and #2 on 12/26/18. *On 01/10/19 at 9:43 AM a phone interview with NA #9 was conducted. NA #9 stated she worked the evening of 12/26/18 and that no administrative staff questioned her about any interaction observed between Residents #1 and #2 during her shift on 12/26/18. *On 1/10/19 at 9:46 AM, NA #10 stated she worked the day shift on 12/26/18 and recalled staff asking about behaviors of Resident #1. *On 01/10/19 at 1:27 PM Nurse #7 was interviewed via phone. She stated she was the charge nurse the night of 12/26/18 and stated that no administrative staff had asked her about any interactions she may have witnessed between Resident #1 and Resident #2 during her shift. *On 01/10/19 at 2:30 PM a phone interview with NA #11 revealed she worked with Resident #2 on 12/26/18 during the evening shift. She stated she was never asked by administration about any interaction observed between Residents #1 and #2 on 12/26/18. *On 01/10/19 at 7:00 PM, a phone interview with NA #12 revealed she worked the night of 12/26/18 and stated that no one had asked her about any interaction she observed between Resident #1 and Resident #2 that night. She further stated she knew no details about the allegation. *On 01/10/19 at 11:49 PM a phone interview with Nurse #6 revealed he worked the night shift of 12/26/18. He stated no one asked him questions about any observations he made of Resident #1 or Resident #2. *On 01/10/19 at 11:57 PM NA #14 stated during a phone interview that she worked the night of 12/26/18. She further stated no administrative staff asked her about any observations she saw between Residents #1 and #2 that night. b. Review of an occurrence report dated 01/04/19 at 12:08 AM revealed that Resident #1 was in cognitively impaired Resident #3's room with socially inappropriate behavior involving resident to resident altercation. This was witnessed by Nurse Aide (NA) #3 with NA #4 and Nurse #5 assigned to resident care. The investigation summary stated Resident #1 was noted lying on top of Resident #3 with his penis out. Resident #3's brief was open on the right side. The residents were separated and a body audit of Resident #3 revealed no redness or blood noted in the vaginal area. Interview with Nurse #5 on 01/09/19 at 7:15 PM revealed she was the charge nurse on south unit during the third shift beginning on 01/03/19 at 11:00 PM and ending on 01/04/19 at 7:00 AM. Nurse #5 stated that she was called to Resident #3's room on 01/04/19 at 12:08 AM where she saw Resident #1 lying on top of Resident #3 with his pants partially down and his penis in his hand as if he was trying to reposition himself to have intercourse. Resident #3's brief was open on one side. Interview with NA #4 on 01/09/19 at 3:51 PM revealed he had put resident #1 in bed wearing pajama pants and a brief between 11:15 PM and 11:30 PM on 01/03/19. Then he was called to Resident #3's room where he saw Resident #1 sitting on the edge of Resident #3's bed leaning over Resident #3, with his penis exposed. On a follow up phone interview on 01/11/19 at 9:33 AM, Nurse #5 stated she thought she had last seen Resident #1 for his 30 minute location check around 11:45 PM sitting at the nursing station. It was the nurse's responsibility to conduct the 30 minute checks on Resident #1. Interview via phone with NA #3 on 01/10/19 at 1:49 AM revealed that she was assigned to Resident #3 beginning 11:00 PM on 01/03/19 through 7:00 AM on 01/04/19. She stated that she began her normal rounds around midnight on 01/04/19 with Resident #3. NA #3 stated she entered the resident's room and when she pulled back the curtain she saw Resident #1 on top of Resident #3. Resident #3 was asking for help and pushing Resident #1's head away. NA #3 stated Resident #3's dress was up and her periarea was very much exposed. Resident #1 was also exposed and he had his penis in his hand positioning himself. NA #3 stated it was obvious to her he was trying to have intercourse with Resident #3. She immediately yelled for the nurse and started to separate the residents. At the time he did not say what he was doing, but afterwards Resident #1 was saying how good it was and how Resident #3 squealed with enjoyment. Resident #3 kept repeating 'Don't let me die this way .I don't want to die this way.' NA #3 stated she had not seen Resident #1 before this encounter during this shift and was not assigned to care for Resident #1. NA #3 stated that after this incident, Resident #3 was more fidgety and apprehensive during the provision of care than previously. Review of the facility's investigation revealed the Resident #1 was removed immediately, Resident #3 was checked for injuries, the police were called and health care personnel investigations was conducted. Resident #3 was then sent to the hospital for evaluation which revealed no evidence of sexual contact. The Administrator was informed of Immediate Jeopardy on 01/11/19 at 11:22 AM The facility provided an acceptable allegation of immediate jeopardy removal on 01/12/19 at 11:23 AM as follows: White Oak Manor -(NAME)will follow the facility's policies and procedures to report and thoroughly investigate abuse allegations. On 12/27/18, Resident # 1 reported to staff that he 'fingered' Resident # 2, and that Resident # 2 approached him and asked him to make love with her in her room. He could not get his penis to work but he indicated he used his finger and they enjoyed each other. Resident # 1 stated they were married and had children together. Resident # 1 was placed on 30-minute location monitoring checks. The 30-minute location monitoring was documented on a spreadsheet. Resident # 2 was immediately assessed by DON, Licensed Nurse and Social Services Director, which included a body audit that took 3 staff members due to the difficulty to examine the resident with her clenching of her thighs. There was no indication that resident was touched or harmed by another resident. Resident # 2 is non-verbal and is unable to say anything about Resident # 1's comments about her. Resident # 1 and # 2's Resident Representatives were notified. After further discussion with the corporate office and based on the initial assessment/investigation by the facility staff, it was determined an allegation of abuse did not occur and was not reported to the State (24-hour and 5-day reports were not completed). On 1/10/18, all staff involved (DON, Licensed Nurse and Social Services Director) were in-serviced by the Staff Development Coordinator on the Abuse Protocol which included investigating and reporting abuse. The 24 hour and 5 day investigation will be sent on 1/12/2019. On 12/27/18 and 1/4/19, Social Services Director (SSD) checked by observation only on other residents that were in the proximity of Resident # 2 and # 3, and those residents were not interviewable due to mental capacity. On 1/10/19 and 1/11/19, Social Services Department conducted interviews with interviewable residents throughout the facility. The interview questions consisted of the following: has anyone touched you an inappropriate manner including sexual, has anyone talked to you in an inappropriate manner, including sexually, has anyone tried to climb in the bed with you, and did you see anything sexually inappropriate to anyone else. All questions were answered with a no. Non-interviewable residents were assessed by 3 Licensed Nursing staff to determine any distress or clothing disturbances or change from their normal demeanor. No variances were noted during the assessments. Re-education on the Abuse/Neglect Policy, which included definitions, components of protecting residents, investigation, and reporting suspected or actual abuse, was started on 1/04/19 of all current staff in all departments, and completed on 1/11/19. Newly hired staff will be re-educated during their specific job orientation by the Staff Development Coordinator or Social Services Director. The Abuse/Neglect Policy will be reviewed annually with all staff and as needed throughout the calendar year. All facility staff are responsible to report all suspected or actual abuse to the Administrator, DON and/or SSD. The Administrator, DON and SSD are responsible for completing the investigations. Reports of suspected or actual abuse will always be reported to the Administrator and DON immediately by any facility staff. The reports will also be documented on the 24 hour report and monitored daily by the DON and/or ADON. Further monitoring of the thorough investigation will be conducted and monitored by the Quality Improvement committee which includes Administrator, DON, SSD, ADON, and/or Nursing Supervisors. This monitoring will conducted Monday through Friday during QI morning meetings. On 1/11/19, the 24-hour report and Quality Improvement (QI) documentation sheets were modified to document and address any observation or verbalization of sexual behavior reported by facility staff. On 1/11/19, a questionnaire was developed regarding sexual inappropriateness that included physical interaction and verbalizations, and will be implemented during care plan meetings and Resident Council meetings. The Social Services Department will randomly interview 5 residents per week for 8 weeks. The interview questions will address inappropriate sexual behaviors affecting themselves or that they may have observed. Another 5 random residents that are non-interviewable will be monitored for changes in behavior or demeanor that would possibly indicate any mistreatment or abuse, particularly for sexual interactions whether verbal or physical. The monitoring will identify any allegations of sexual abuse, and assure reporting and the investigation is complete thoroughly. The monitoring will be completed by the Administrator and/or designee. All indications or suspicion of sexual abuse, including verbalization of sexual behavior will be reported to the Administrator and DON by facility staff, and appropriately reported to the state agency to file a report of abuse by the Administrator, DON and/or SSD. A thorough investigation will be conducted by the Administrator, DON and/or SSD. The Quality Improvement (QI) committee was informed on 12/27/19 of the situation involving Resident # 2. Results from the monitoring will be discussed Monday through Friday during Quality Improvement (QI) morning meetings and any identified issues or trends will be further discussed at the Quality Assurance meeting with the team and recommendation made as indicated. The QA committee was notified of credible allegation on 1/9/19, 1/10/19, and 1/11/19 respectively throughout the survey process as it was informed to the facility. The QA committee includes the Attending Physician, Administrator, DON, Social Services department, ADON, Nursing Supervisors, Dietary, Activities, SDC, Therapy Department, Restorative Nurse, and MDS Licensed Nurses. Alleged date of Immediate Jeopardy removal is 1/12/19. The DON is responsible for ongoing compliance of F607. Immediate Jeopardy removal was verified on 01/14/19 at 6:04 PM and based on verification that Resident #1 was no longer in the building. Interviews with alert and oriented residents were conducted and no one expressed they had been abused and family members were interviewed and voiced no concerns. Administrative and nursing staff verified that training had been provided regardi

Based on observations, record reviews, resident interview, staff, and physician interviews, the facility failed to assess and administer effective pain medication for a resident who had shingles causing the resident to have unrelenting pain for 1 of 3 sampled residents reviewed for pain management (Resident #69). The findings included: 1) Review of a document titled Pain Management Program with a revised date of 12/08/10 read in part the following: · Pain - whether voiced, report, or observed - will be monitored to determine location, source, intensity, and duration. · Pain Data Collection Tool will determine if interventions are needed for uncontrolled pain, through: observation, verbalization, physician orders, and pain related diagnosis. · Residents with uncontrolled pain levels will have a pain management program implemented to include a pain flow sheet. · The plan will be adjusted as needed to assure adequate pain relief is obtained, while maintaining the resident's highest quality of life, both physically and psychosocially with the fewest side effects possible. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #69 had no short or long term memory problem, was cognitively intact for daily decision making, and required extensive assistance from staff for most of her activities of daily living. Further review of the MDS indicated Resident #69 had no behaviors exhibited and no rejection of care. A review of the physician's orders [REDACTED]. · On 06/24/16 at 3:10 PM: [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication) 800 milligrams (mg) by mouth (PO) 5 times every day for 7 days, Diagnosis: [REDACTED].>· On 07/05/16 at 2:15 PM: 1) [MEDICATION NAME] ([MEDICATION NAME]-pain-reliever) cream 0.025% apply twice daily as needed (PRN) for right arm pain for 1 week and 2) Daily dressing changes to right arm · On 07/11/16 at 12:50 PM: [MEDICATION NAME] (an [MEDICATION NAME]/pain medication) 50 mg PO every 8 hours PRN for pain · On 07/12/16 at 1:15 PM: [MEDICATION NAME] (a topical numbing medication/pain reliever) 2% jelly, apply to right arm every 6 hours PRN for pain A review of the electronic Medication Administration Record [REDACTED] 07/03/16 at 7:34 AM and 10:24 PM 07/05/16 at 5:46 PM 07/07/16 at 5:11 AM 07/08/16 at 10:12 AM and 10:13 PM 07/09/16 at 3:33 AM 07/10/16 at 5:43 AM and 6:00 PM 07/11/16 at 4:36 AM and 5:59 PM 07/13/16 at 12:12 AM Resident #69 had no Tylenol noted as being administered for pain from 07/11/16 at 5:59 PM until 07/13/16 at 12:12 AM (approximately 30 hours between doses). The MAR indicated [REDACTED] 07/12/16 at 2:23 AM, 12:54 PM, and 9:51 PM 07/13/16 at 5:35 PM Resident #69 had no [MEDICATION NAME] noted as being administered for pain from 07/12/16 at 9:51 PM until 07/13/16 at 5:35 PM (approximately 19 hours between doses). The MAR further revealed Resident #69 was administered a one-time dose of [MEDICATION NAME] 5 mg-325 mg (2 tablets) PO on 07/13/16 at 9:30 PM and was later administered 2 tablets of [MEDICATION NAME] for pain on 07/15/16 at 10:05 AM (approximately 36.5 hours between doses). A review of a document titled Individual Resident's Narcotics Record dated 07/11/16 through 07/13/16 with an affixed pharmacy label which read [MEDICATION NAME] 50 mg take 1 tablet PO every 8 hours PRN for pain. The document indicated Resident #69 was administered her first dose of [MEDICATION NAME] 50 mg (1 tablet) PO on 07/12/16 at 2:00 AM by Nurse #12, with subsequent doses as per the following entries: · 07/12/16 at 1:30 PM by Nurse #10, which was indicated on the MAR indicated [REDACTED] · 07/12/16 at 9:00 PM by Nurse #11, which was indicted on the MAR indicated [REDACTED] A review of a nurse's note dated 07/13/16 at 12:41 AM indicated Resident #69 had been administered a pain medication ([MEDICATION NAME] 50 mg tablet PO) on 07/12/16 at 9:51 PM and the pain medication, [MEDICATION NAME], was not effective. The nurse's notes were reviewed from 07/01/16 and this was the first entry in regards to Resident #69's pain or the administration of pain medication. A review of a nurse's note dated 07/13/16 at 1:14 AM indicated Resident #69 was administered 2 tablets of Tylenol 325 mg PO on 07/13/16 at 12:12 AM due to pain medication, [MEDICATION NAME], not being effective. Further review of the Narcotics Record indicated the following entries: · 07/13/16 at 6:00 AM, the nurse's initials, which could not be identified, this dose of [MEDICATION NAME] was not indicated on the MAR indicated [REDACTED] · 07/13/16 at 12:00 PM by Nurse #10, this dose of [MEDICATION NAME] was not indicated on the MAR indicated [REDACTED] Resident #69 was observed on 07/13/16 at 12:45 PM in the dining room clinching her right arm and rocking back and forth. Resident #69 was asked if she was enjoying the music and she replied No, my arm is hurting really bad. When asked if she needed her nurse Resident #69 stated Yes! During this time Resident #69 was observed not eating her meal, grimacing, and continued to rock back and forth with her head down, the resident appeared to be in great pain. Within approximately 2 minutes a nurse was observed to take the resident out of the dining room. On 07/13/16 at 1:56 PM, Nurse #10 was observed to do a dressing change to Resident #69's right arm. Resident #69 was observed to grimace with pain at the time her right arm was raised off of the bed to remove the old dressing. Resident #69 was asked if she would like for the nurse to stop and administer a pain medication and she replied No, just get it over with! Oh, lord, my arm hurts. Nurse #10 was observed to remove the old dressing and Resident #69's right arm was observed to have numerous scabbed areas on the underside of the arm, up past the elbow, on the forearm, and on the posterior part of her hand. Nurse #10 applied the [MEDICATION NAME] cream 0.025% liberally to the resident's right arm and wrapped the arm with a gauze type dressing (kerlix) and applied an arm sleeve over the kerlix dressing. Resident #69 was observed to still grimace and complained of pain during the time the arm sleeve was being applied. Nurse #10 indicated she had administered [MEDICATION NAME] 50 mg (1 tablet) PO to Resident #69 at 12:00 PM prior to doing the dressing change, however this dose of [MEDICATION NAME] was not indicated on the MAR indicated [REDACTED] A review of a document titled Pain Flow Sheet this was the first pain flow sheet that had been started for Resident #69 with the first entry dated 07/13/16 at 4:00 PM through 07/15/16 at 9:30 AM read in part the following: columns which indicated the date, time, signature of the nurse, the location of the pain, the pain scale (from 0 to 10, with 0 = no pain and 10 = unbearable pain), medication/dose administered, follow-up (F/U) pain scale (0 to 10), and time. Throughout the Pain Flow Sheet the location of the pain was incorrectly identified as the Left Arm when it should have been the Right Arm. The following entries were noted: · 07/13/16 at 4:00 PM Nurse #11, Left Arm 0 No medication administered (admin.) with no follow-up (F/U) needed. · 07/13/16 at 6:00 PM Nurse #11, Left Arm 9 [MEDICATION NAME] 50 mg (1 tablet) admin. F/U 4 at 6:25 PM · 07/13/16 at 9:00 PM Nurse #11, Left Arm 4 [MEDICATION NAME] 5mg-325mg (1 tablet) admin. F/U 0 at 9:45 PM On 07/13/16 at 6:00 PM, an interview was conducted with Resident #69. She was observed to hold her right arm, grimacing with pain, and rocking back in forth while sitting in her bed. Resident #69 stated her pain was an 8 on a scale of 1 to 10. The resident further reflected her pain had been a 10 out of 10 when observed in the dining room at 12:45 PM. Resident #69 stated her pain had not been controlled for a while and was unable to recall the last time she was not in pain. On 07/13/16 at 7:22 PM, Resident #69 was observed grimacing and stated what is wrong with my arm, it is killing me, please do something Nurse #11 was asked to assess the resident. A continuous observation in Resident #69's room was done on 07/13/16 from 7:25 PM to 8:15 PM. Nurse #11 asked the resident What is your pain, now? Resident #69 advised Nurse #11 that her pain was an 8 out of 10. The nurse stated you had pain medicine at 6:00 PM. The resident stated I don't remember getting any pain medicine at 6:00 PM and this pain is so bad I am going to die. Nurse #11 was observed to start the removal of the gauze dressing from the resident's right arm and Resident #69 was observed during this time to grimace, moan, shake involuntarily, and yell out Oh lord, ouch, ouch. Nurse #11 was observed to ask the resident do you want me to stop? and the resident replied, No, go ahead but hurry and the nurse continued to remove the old dressing and she applied the topical jelly [MEDICATION NAME] and another kerlix gauze dressing. Nurse #11 asked the resident how are you feeling now, better? Resident #69 was observed to shake her head in an up and down motion as to indicate Yes. Further review of a nurse's note dated 07/13/16 at 10:15 PM indicated Resident #69 continued to have severe pain to the right arm (approximately 21 hours, 07/13/16 at 12:41 AM to 07/13/16 at 9:10 PM). The physician was notified and a one-time order was obtained to administer [MEDICATION NAME] 5 mg-325mg 2 tablets PO. Further review of the nurse's entry indicated the resident was medicated on 07/13/16 at 9:10 PM and the pain medication, [MEDICATION NAME], was effective. Further review of the nurse's notes indicated an entry dated 07/14/16 at 5:59 AM, Resident #69 was resting quietly and the pain medication, [MEDICATION NAME], was effective. On 07/14/16 at 9:23 AM, Resident #69 was observed sitting up in her bed and eating her breakfast. The resident indicated her arm was hurting and the resident was unable to voice a number on a scale of 0 to 10 as to indicate her pain score/level. The dressing on the resident's right arm was observed to be the same dressing which was applied on 07/13/16 at approximately 8:00 PM. On 07/14/16 at 3:15 PM, an interview was conducted with the Nurse Practitioner (NP). The NP stated she was made aware of Resident #69's uncontrolled pain on 07/13/16 at around 8:45 PM. The NP further stated prior to that she was unaware of the resident's uncontrolled pain. On 07/15/16 at 9:00 AM, Resident #69 was observed grimacing, rocking back and forth, and stated Oh god, my arm is killing me! She further stated it is awful and I can't take it anymore, please go and get me a nurse? The resident's call bell was observed to be in a chair, approximately 2 arm lengths away from the resident's bed, and out of the resident's reach, which caused Resident #69 to be unable to call or inform the nurse that she needed assistance. Nurse #10 confirmed she was the nurse responsible for the care of Resident #69 and was informed of the resident's request. She stated she had not assessed or been in the resident's room and was unaware of the resident's pain. The nurse further stated she had obtained from the 3rd shift nurse that the resident had been administered Tylenol around 6:00 AM. On 07/15/16 at 9:25 AM, Nurse #10 was observed to go into Resident #69's room and asked her what's going on? Resident #69 stated my arm is killing me! The nurse stated so it's hurting? Nurse #11 asked the resident how bad is your pain on a scale of 1 to 10? Resident #69 voiced an 8 or 9 and the nurse stated which is it an 8 or a 9? The resident then stated it's a 9. Nurse #10 was observed to leave the resident's room and return after approximately 5 minutes with 2 tablets of [MEDICATION NAME] 5mg-325mg and administered the pain medication to Resident #69. On 07/15/16 at 10:00 AM, an interview was conducted with Nurse #10. She confirmed she was the nurse responsible for Resident #69 on 1st shift (7:00 AM through 3:00 PM). She confirmed she was aware of the resident's uncontrolled pain and she indicated she had administered Resident #69's pain medication as ordered by the physician. Nurse #10 confirmed that the electronic MAR indicated [REDACTED]. Nurse #10 stated she was unable to recall if she had actually administered Resident #69's pain medication on 07/13/16. Nurse #10 further confirmed she had applied the wrong topical pain medication on 07/13/16. A telephone interview was conducted on 07/15/16 at 3:30 PM with Nurse #9. She confirmed she was responsible for the care of Resident #69 on 07/13/16 from 11:00 PM until 7:00 AM (3rd shift). Nurse #9 stated Resident #69 had complained of right arm pain being that of a 10 on a scale of 1 to 10 during her shift on 07/13/16. Nurse #9 further stated she did not notify the physician or the NP of Resident #69's uncontrolled pain. Nurse #9 indicated she had reported the resident's pain to the third shift supervisor and was advised to administer the pain medications which was already ordered and it would be okay. Nurse #9 further indicated she completed a concern/communication form for the physician or NP. She also indicated she had reported the resident's uncontrolled pain to the on-coming first shift nurse and to the first shift unit supervisor prior to leaving her shift the morning of 07/14/16. The 3rd shift supervisor was unable to be contacted for an interview. An interview was conducted on 07/15/16 at 3:52 PM with the 1st shift unit nurse supervisor (Nurse #6). She stated she did recall Nurse #9 completing the concern/communication form for the physician or NP and also recalled obtaining a verbal report from Nurse #9 in regards to Resident #69's uncontrolled pain the night of 07/13/16. Nurse #6 reviewed the concern/communication notebook and was unable to find or provide the form/report completed by Nurse #9. Nurse #6 stated she had not contacted the physician or the NP on 07/14/16 but was aware the second shift nurse had contacted the NP and had obtained a one-time order for [MEDICATION NAME]. Nurse #6 further stated she was unable to recall why she had not contacted the physician or NP on 07/14/16. An interview was conducted on 07/15/16 at 4:08 PM with the Assistant Director of Nursing (ADON). She stated she would have expected the 3rd shift nurse or the 3rd shift supervisor to have contacted the physician or NP in regards to Resident #69's uncontrolled pain. The ADON further stated she would have expected the nurses to have been more attentive to Resident #69's pain and the management of getting her pain under control. An interview was conducted on 07/15/16 at 4:45 PM with the Director of Nursing (DON). She stated they would notify the NP or the physician should there be a significant change in a resident outside of what could be done within the facility protocol. The DON further stated the Pain Assessment Flow Sheets were not routinely started on all residents but was started on resident's who had been identified as having problems with pain. The DON indicated Resident #69's pain assessment flow sheet was started on 07/13/16 after Resident #69's uncontrolled pain was discussed and the physician was contacted and the one-time dose of [MEDICATION NAME] was ordered. 2. The facility's Physician Standing Orders, undated, recorded in part: Run the No BM (bowel movement) report daily. Residents who have not had a charted bowel movement in 3 days will trigger in this report. Check for impaction for resident who was triggered. If the resident was not impacted, give 30 millimeter (ml) of milk of Magnesia suspension by mouth for one time. If no results after 12 hours, proceed with [MEDICATION NAME] 10 milligram (mg) suppository rectally for one time. If no results after one hour, may give Fleets enema per rectum. Notify physician if no results. Resident #125 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] coded Resident #125 with having severely impaired cognition, requiring extensive assistance with one person physical assist for toileting, and occasionally incontinent of bladder. Review of care plan dated 03/25/16 revealed that Resident #125 was at risk of constipation due to decreased mobility. The goal was for Resident #125 to have more than 2 bowel movements weekly. Intervention included reviewing current drug regimen for drugs that may have constipation as a side effect, administering medication as ordered by physician, and documenting Resident's bowel evacuation status at least daily and report any abnormal findings to the Charge Nurse for implementation of standing orders for constipation. Review of medical record revealed Resident #125 had physician's orders [REDACTED]. Review of the July 2016 Medication Administration Record [REDACTED]. Review of physician's orders [REDACTED]. [MEDICATION NAME] 125 mg, 2 tablets by mouth in the morning, 1 tablet at noon and 1 tablet before bed time for dementia with behaviors causing significant distress to self. [MEDICATION NAME] 0.5 mg, one tablet by mouth every 8 hours as needed for dementia with behaviors causing significant distress to self. [MEDICATION NAME] 50 mg, one-half tablet by mouth three times daily as needed for pain related to age- related [MEDICAL CONDITION] without current pathological fracture. Review of Bowel Movement Details Roster from 06/12/16 to 07/12/16 and subsequent interviews with Nurse Aide (NA) #3 on 07/14/16 at 11:08 AM, NA #2 on 07/15/16 at 11:00 AM, and Nurse #4 on 07/15/16 at 3:03 PM confirmed that Resident #125 did not have bowel movements from 07/04/16 to 07/07/16, 4 consecutive days. Resident #125 had a bowel movement on his own on 07/08/16 at 1:44 AM. There was no documentation in the Resident #125's medical record or the July 2016 MAR indicated [REDACTED]. An interview on 07/14/16 at 11:08 AM with NA #3 revealed that he worked routinely on the 7 AM to 3 PM shift and he was providing care for Resident #125 from 07/04/16 to 07/07/16. NA #3 stated he was responsible for checking on resident's bowel movement for his shift and documenting the information in the facility's Bowel Movement Details Roster. NA #3 confirmed that Resident #125 did not have bowel movements from 07/04/16 to 07/07/16. He normally would update the nurse at the shift transition for resident's bowel-related issues. In an interview on 07/15/16 at 11:00 AM with NA #2, she stated that Resident #125 was on a mechanically altered diet, able to feed himself, and usually had a poor appetite. She worked on the 3 PM to 11 PM shift and she was providing care for Resident #125 from 07/04/16 to 07/07/16. NA #2 confirmed Resident #125 did not have bowel movements for all the shifts she worked for the above 4 days. An interview on 07/15/16 at 3:03 PM with Nurse #4 revealed that Resident #125 was constipated and was on 2 scheduled constipation medications. Nurse #4 stated that she was the nurse providing care for Resident #125 during the second shift on 07/04/16, first shift on 07/05/16, second shift on 07/06/16, and first shift on 07/07/16. She confirmed that Resident #125 did not have any bowel movements during all her shifts. Nurse #4 stated that the nurse supervisor would typically bring her the No BM report at the beginning of the shift regarding residents who had not had a bowel movement after 3 consecutive days for implementation of the standing orders for constipation. Nurse #4 could not recall if she had received the No BM report on 07/06/16 from the nurse supervisor. She did not know that Resident #125 did not have a bowel movement for more than 3 days and therefore she did not implement the bowel protocol for him. Review of the facility's No BM reports from 07/04/16 to 07/07/16 revealed that Resident #125 was included in the report on 07/07/16. An interview on 07/15/16 at 3:31 PM with Nurse #6 confirmed that as a nurse supervisor, she used to generate the No BM report for the nurses at the beginning of the shift. However, she could not recall whether she had done it on the 07/07/16 morning. She added that the nurses had been trained on how to generate this report and she expected them to generate and review the report if she did not provide it to them. In an interview on 07/15/16 at 4:23 PM with Director of Nursing (DON), she stated it was her expectation for all the nurses to generate and review the No BM report at the beginning of their shift and implement the bowel protocol for constipation accordingly. She agreed that the nurse should have implemented the bowel protocol for constipation for Resident #125 on 07/07/16 morning per physician's standing orders.