Every finding on record at White Oak Manor - Tryon

Based on observations, record review, manufacturer recommendations, North Carolina Governor's Executive Order, and staff, Family Member, Medical Director, Civilian, Emergency Medical Services (EMS), and Assistant Fire Chief interviews, the facility failed to supervise a cognitively impaired resident, who had a diagnosis of dementia and wore an elopement alarm device due to exit-seeking behavior, from exiting the facility without staff knowledge for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On Saturday 01/24/26, Resident #1 exited the facility with her walker, wearing thin, capri pants and a loose-fitting shirt with no jacket in 36-degree Fahrenheit weather. Resident #1 walked through the parking lot and down the hill on a public two-lane road with a posted speed limit of 25 miles per hour approximately 300 to 400 feet toward the stop sign, turned right and continued walking along another public two lane road with no sidewalks approximately 500 to 600 feet where she fell down a 17-foot embankment. At approximately 10:00 AM, a Civilian found Resident #1 down the embankment holding onto a tree limb just above a riverbed and contacted EMS. Fire and EMS personnel used a stokes basket (a rigid, basket-shaped stretcher with raised sides that is designed to fully contain and protect an individual and used by rescue teams to remove individuals from steep inclines and across uneven ground) to lift Resident #1 out of the embankment. Resident #1 was transported to the hospital where she was assessed to have a right frontal forehead contusion (bruise on the upper right side of the head caused by a blunt impact that breaks small blood vessels under the skin typically causing pain, swelling and bruising). This deficient practice had a high likelihood of causing serious injury, serious bodily harm such as hypothermia (abnormally low body temperature caused by being exposed to extremely cold temperatures for a long period of time), or death. Immediate jeopardy began on 01/24/26 when Resident #1 exited the facility without staff knowledge, walked along public roadways and fell down an embankment. Immediate Jeopardy was removed on 01/31/26 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Findings included:Review of the undated manufacturer's recommendations, provided by the Administrator, specified in part, The Secure Care 135DE Door Guardian wander management system uses active, waterproof transmitters (elopement alarm bracelets) that can be worn on either the ankle or the wrist according to manufacturer specifications. Proper placement is critical for ensuring continuous monitoring with recommended placement and attachment guidelines for location: transmitters may be placed on either the ankle or the wrist.Resident #1 was admitted to the facility from home on [DATE] with diagnoses that included dementia-mild without behavioral disturbance, mood disturbance and anxiety.A Resident Brief Interview of Mental Status (BIMS, a 15-point screening tool used in long-term care settings to assess a resident's cognitive function) assessment dated [DATE] revealed Resident #1 had a BIMS score of ten out of fifteen (score of 8 to 12 indicates moderate cognitive impairment).An elopement risk assessment dated [DATE] that was completed by the Social Worker revealed Resident #1 was resistive to nursing home placement, verbally expressed a desire to leave the facility or go home, had poor decision-making skills, and had a diagnosis of dementia. The risk assessment score indicated Resident #1 was at risk for elopement. A nurse progress note dated 01/22/26 at 7:41 PM written by Nurse #2 revealed Resident #1's roommate reported Resident #1 was packing her clothes and talking about leaving this afternoon. Medical Director was at the facility and gave an order for an elopement alarm device. An elopement alarm bracelet was applied to Resident #1's walker and cane. Review of Resident #1's physician orders dated 01/22/26 revealed no order for the elopement alarm device. A skilled nursing note dated 01/23/26 at 4:20 PM written by the Weekend Registered Nurse (RN) Supervisor revealed Resident #1 required supervision or touching assistance with transfers, sit-to-stand and walking. A nurse progress note dated 01/24/26 at 3:15 PM written by the Director of Nursing (DON) revealed in part, Resident #1's Family Member was visiting at the facility when the Family Member was contacted by EMS. Resident #1's Family Member reported EMS stated Resident #1 was found outside on facility grounds lying near her walker and was transported to the hospital. During an interview conducted on 01/28/26 at 3:06 PM, the DON revealed that on 01/24/26 at approximately 10:30 AM, she was working on the 100 Hall medication cart when the Weekend Registered Nurse (RN) Supervisor asked if she had seen Resident #1 as her family was at the facility for a visit, but they could not locate Resident #1. The DON told the Weekend RN Supervisor that she last observed Resident #1 standing by the nurses' station approximately 15 to 20 minutes earlier. The DON stated at that point, she went into Code [NAME] (facility's missing person protocol) mode. She had everyone drop what they were doing and start a search to find Resident #1. She recalled while searching for Resident #1, staff mentioned Resident #1 was last seen looking for the turtles in the facility courtyard, though it was cold outside. The DON explained that staff completed several sweeps of the inside and outside of the facility, including the lobby and courtyards, and one staff member drove around the facility property but Resident #1 was not located. The DON stated around 11:00 AM she was at the nurses' station with Resident #1's family when Resident #1's Family Member received a call from EMS stating Resident #1 was being transported to the hospital. The DON indicated she was unsure how Resident #1 exited the building and explained it was a busy and hectic weekend with visitors coming and going all day due to the impending winter storm. She suggested that it was possible a visitor held the door open, allowing Resident #1 to leave. The DON confirmed Resident #1 had an elopement alarm bracelet which should have caused the alarm to sound when she walked through the exit door. However, the DON stated she did not recall hearing the alarm sound at any point that morning. A witness statement written by the Weekend RN Supervisor and dated 01/24/26 revealed in part, Resident #1 was seen frequently by the Weekend RN Supervisor between 7:30 AM and 9:30 AM. Resident #1 was confused, asking about leaving and going outside. Resident #1 was walking in the halls looking for an exit and attempting to open the doors at the nurses' station and on 200 Hall, but they would not open for Resident #1. The Weekend RN Supervisor indicated she redirected Resident #1 multiple times and got Resident #1 to sit down in a chair near the 200 Hall medication cart. A few minutes later around 9:30 AM, Resident #1 got up, started walking toward 100 Hall and that was the last time Resident #1 was seen by the Weekend RN Supervisor.During a telephone interview conducted on 01/28/26 at 4:22 PM, the Weekend RN Supervisor confirmed she worked on the 200 Hall medication cart during the hours of 7:00 AM to 7:00 PM on 01/24/26 but was not Resident #1's assigned nurse that day. The Weekend RN Supervisor recalled Resident #1 got up early that morning and was restless, confused and wandering around the facility wanting to find a way out. She did not recall actually seeing the elopement alarm bracelet on Resident #1 but did recall the exit doors and doors by the nurses' station leading out to the lobby locked and wouldn't open when Resident #1 went up to the doors. The Weekend RN Supervisor stated sometime between 9:00 AM and 9:30 AM, Resident #1 was sitting in a chair out in the hall while she was at the medication cart and Resident #1 got up stating she needed to find the room to get paid for the work she had done. The Weekend RN Supervisor stated she redirected Resident #1 back to her chair and then a few minutes later, saw her walking toward the 100 Hall and she did not see Resident #1 again after that. She stated when Code [NAME] was called, all staff members immediately started searching for Resident #1 until the facility was informed Resident #1 was found and at the hospital. The Weekend RN Supervisor did not know how Resident #1 exited the building and explained when a resident with an elopement alarm bracelet went through an alarmed door, you could hear the alarm out at the nurses' desk or out on the hall, but she did not recall hearing the alarm sound that morning. A witness statement obtained via phone from Nurse Aide (NA) #1 on 01/24/26 revealed NA #1 reported that between 8:30 AM and 9:30 AM, she noticed Resident #1 had not eaten her breakfast tray. Resident #1 was walking around and when NA #1 asked Resident #1 if she was going to eat, Resident #1 replied no. NA #1 stated she removed Resident #1's meal tray and she did not see Resident #1 again that morning.During a telephone interview on 02/03/26 at 12:48 PM, NA #1 confirmed she was assigned to provide care to Resident #1 on 01/24/26 during the hours of 7:00 AM to 7:00 PM and it was the first time she had worked with Resident #1. NA #1 revealed Resident #1 had been walking around the facility all morning, but she had not observed Resident #1 going up to exit doors or verbalizing that she wanted to leave. NA #1 stated sometime between 8:30 AM and 9:00 AM she noticed Resident #1 had not eaten her breakfast and was walking around the hall. NA #1 stated when she asked Resident #1 if she was going to eat her breakfast, Resident #1 replied no and NA #1 removed the breakfast tray from Resident #1's room. NA #1 stated she did not see Resident #1 again after that encounter. NA #1 stated she did not notice if Resident #1's elopement alarm bracelet was in place when she observed her walking around that morning. She stated that at one point, a Code [NAME] was called, and all the NAs had to go check their assigned residents to make sure the residents with elopement alarm bracelets had them in place. NA #1 did not recall hearing an alarm sound nor did she know when or how Resident #1 exited the facility. A witness statement written by Nurse #1 and dated 01/24/26 revealed at 9:40 AM, Resident #1 was observed wandering around the 400 Hall looking for the turtles. Nurse #1 told Resident #1 she was in the wrong place and the turtles were outside. Nurse #1 advised Resident #1 not to go outside because of the cold weather. Resident #1 replied ok, I'll take a look and then walked toward the nurses' station.During a telephone interview conducted on 02/04/26 at 3:43 PM, Nurse #1 recalled on 01/24/26 at approximately 9:40 AM, he was standing at the 400 Hall medication cart that was placed near the nurses' desk and adjacent to 300 Hall. Nurse #1 recalled observing Resident #1 wandering around the 400 hall, asking about the location of the turtles. Nurse #1 stated he walked with Resident #1 to the courtyard door on 300 Hall to show her where the turtles were located. He recalled Resident #1 voicing that it was too cold outside, and she then proceeded to walk back down the 300 hall toward the nurses' station near the front lobby. Nurse #1 stated that was the only time he observed Resident #1 and could not recall for certain if the alarm sounded that morning (01/24/26). During a telephone interview conducted on 01/29/26 at 8:57 AM, the Civilian (former Fire Department employee who found Resident #1) recalled sometime after 9:00 AM on 01/24/26 he was driving toward town and observed Resident #1 walking along a public road with her walker. He stated this appeared strange because the road was narrow and lacked sidewalks, which made it dangerous for someone to walk along. He stated he stopped to ask Resident #1 if she was ok, and Resident #1 replied that she was fine and was just out getting some fresh air. The Civilian stated he proceeded into town and when he returned approximately 15 to 20 minutes later, he saw Resident #1's walker on the side of the road. He immediately stopped, blocked the road with his vehicle and began searching for Resident #1. He stated as he walked down the side of the road, he heard Resident #1 yelling for help. She had fallen approximately 17 feet down a steep embankment near the riverbed and was holding on to a tree limb. After calling 911, the Civilian stated he climbed down the embankment to Resident #1 and upon initial assessment, Resident #1 did not appear to have any life-threatening injuries. He explained Resident #1 was alert but not fully oriented, she was aware of her circumstances, her pupils were reactive to light, and she had no signs or symptoms of brain injury. The Civilian stated when Fire and EMS personnel arrived, he assisted them with slowly moving Resident #1 up the embankment to the stokes basket and ladder for them to pull her the rest of the way up and then she was placed into the ambulance for transport to the hospital. The Civilian stated when he first reached Resident #1, she was wearing one shoe, thin beige capris and a loose fitting, long-sleeve shirt. He stated Resident #1's hands were still warm; however, due to the cold weather, a warming blanket was placed on her midway through the process of moving her up the embankment. The Civilian estimated Resident #1 had walked approximately one fifth of a mile from the facility before her fall.EMS records dated 01/24/26 revealed medics arrived at the embankment adjacent to the public road where Resident #1 was located at 10:00 AM and observed Resident #1 standing at the bottom of the embankment with first responders. EMS records noted that Resident #1 reported she was walking when she tripped and fell down a 17-foot embankment. Resident #1 had a minor hematoma (type of bruise that happens when an injury causes blood to collect and pool under the skin) on her forehead with no other injuries noted. Resident #1 was removed from the embankment via a stokes basket, placed on a stretcher with rails in upright position and transported to the hospital by EMS at 10:28 AM. During a telephone interview conducted on 01/28/26 at 12:14 PM, EMS Personnel #1 stated that between 9:30 AM and 10:00 AM on 01/24/26, EMS received a call reporting that an elderly female had fallen down a 17-foot embankment. EMS Personnel #1 stated they had to use a ladder and stokes basket to get Resident #1 safely back up the embankment. She stated the outside temperature was 30 degrees at the time Resident #1 was found and she was wearing thin pajamas without a jacket or shoes. EMS Personnel #1 also stated there was no elopement alarm bracelet observed on Resident #1. Upon initial assessment, EMS Personnel #1 stated the only injury noted was a hematoma to the right side of Resident #1's forehead. EMS Personnel #1 stated she was very surprised that Resident #1 had not been seriously injured considering she had fallen down a 17-foot embankment. EMS Personnel #1 stated once they arrived at the hospital, she had Resident #1 call her family and then using Resident #1's cellphone, EMS Personnel #1 spoke directly with the Family Member to explain what had happened.During telephone interviews conducted on 01/28/26 at 12:22 PM and 01/29/26 at 8:54 AM, the Assistant Fire Chief revealed on 01/24/26 both EMS and the Fire Department were already on scene when he arrived to the location where Resident #1 was found. He stated the Civilian who contacted EMS on 01/24/26 was a former Fire Department employee and had first noticed Resident #1 walking with her walker along the road as he drove by into town. The Assistant Fire Chief did not know how much time had passed when the Civilian returned and observed Resident #1's walker on the side of the road. He stated the Civilian had pulled over, got out of his vehicle and as he looked around for Resident #1, he heard her yelling for help. The Assistant Fire Chief stated Resident #1 fell approximately 17 feet down a steep and wooded ravine (deep, narrow valley featuring a winding bottom that might host a stream and be filled with trees, rocks and varied vegetation, creating a rugged and sometimes, hidden landscape) and they had to set up a ladder and use a stokes basket in order to pull her out. The Assistant Fire Chief stated it was roughly 20 minutes from the time the Fire Department arrived on scene and Resident #1 was in EMS care.During a telephone interview conducted on 01/29/26 at 12:10 PM, Resident #1's Family Member recalled on 01/24/26 at approximately 10:30 AM, she and her husband arrived at the facility for a visit with Resident #1. She stated Resident #1 wasn't in her room when they arrived and staff reported Resident #1 had been walking around the facility all morning. The Family Member stated she and her husband walked around the facility for approximately 30 minutes but were unable to find Resident #1. She stated at one point, the DON joined them and shortly thereafter, the entire facility staff started looking for Resident #1. The Family Member stated a little after 11:00 AM, she received a call from Resident #1's cellphone and when she answered, it was EMS. She stated EMS informed her that Resident #1 was found outside the facility, she had fallen down a 10-foot embankment and was at the hospital. The Family Member stated prior to their arrival at the facility, no one at the facility knew that Resident #1 was missing. The Family Member stated based on the time it took to get to the hospital, Resident #1 had to have already left the facility before they arrived at 10:30 AM. Hospital records dated 01/24/26 revealed Resident #1 presented to the Emergency Department (ED) for evaluation following a fall from a 17-foot embankment. The ED note revealed in part that Resident #1 reported she was looking for a place to walk for exercise and ended up in a parking lot near her workplace. She attempted to find a residential street with sidewalks but was unsuccessful and while walking, she tripped over thick vines on the ground, leading to a fall. Resident #1 reported that her forehead hurt when she wrinkled it but denied neck pain or any other symptoms. A computed tomography (CT) scan revealed no acute intracranial abnormality. A physical exam revealed Resident #1 was in no acute distress, had full range of motion in all extremities and her head was normocephalic (normal shape and size) with no injury other than a right frontal forehead contusion. Resident #1 was discharged from the hospital in stable condition 01/24/26. During a telephone interview on 01/29/26 at 12:30 PM, the Medical Director stated the facility informed the on-call provider of Resident #1's elopement on 01/24/26 and he was made aware of the incident on 01/26/26. When asked his medical opinion regarding the potential harm of Resident #1 being outside unsupervised, the Medical Director stated he felt that the facility acted proactively by implementing an elopement alarm device for Resident #1 upon her admission and facility staff did everything appropriately following the incident. He described Resident #1's elopement as an unfortunate incident and stated he did not believe there was any negligence on the part of facility staff as Resident #1 was definitely on a mission that day, she may not have known where she was going but she was determined to leave. The Medical Director stated since starting at the facility in August 2025, there had been no concerns of elopement issues and as a result of this incident, the facility would definitely become more vigilant going forward.An observation and interview were conducted with Resident #1 on 01/28/26 at 10:40 AM. Resident #1 was sitting in a recliner in her room with a one-to-one sitter present. Resident #1's walker was placed directly in front of her and an elopement alarm bracelet was attached to the front bar of the walker. Resident #1 was not observed to have an elopement alarm bracelet on her person. On the right side of Resident #1's forehead was a small abrasion and purple bruising the size of a golf-ball that extended partially into the hairline. Resident #1 revealed there was a knot on her forehead that had gone away and her forehead only hurt when she raised her eyebrows. Resident #1 recalled leaving the facility and stated she felt like going for a walk and just wanted out of the building. Resident #1 stated she walked down a sidewalk to the road and then fell down a ravine. She stated someone came to help her and took her to the hospital but could not recall any further details. When asked, Resident #1 was unable to state which door she used to exit the facility, how long she was outside, where along the road she fell, or how she fell. An observation was conducted on 01/29/26 at 2:15 PM of the location where Resident #1 was found on 01/24/26. The distance from the facility's front parking lot to the stop sign at the bottom of the hill was approximately 300 to 400 feet. The distance from the stop sign to the approximate location along the public road where Resident #1 fell down the embankment was an additional 500 to 600 feet. The public road is a two-lane road with no sidewalks on either side with a posted speed limit of 25 miles per hour. The embankment adjacent to the road was steep and densely covered with branches and vines, which limited the view of the riverbed located at the bottom of the embankment. An online website named Weather Underground was used to obtain the outside weather in [NAME], North Carolina on 01/24/26 which revealed the following data for [NAME], North Carolina at 9:53 AM: cloudy conditions, temperature of 36 degrees Fahrenheit (F) with no precipitation and Northeast wind speed of 9 miles per hour. Further review revealed that at 11:53 PM on the evening of 01/24/26, the temperature dropped to 23 degrees F with a wintry mix (snow, sleet and freezing rain) that continued throughout the day and evening of 01/25/26. During interviews on 01/28/26 at 2:10 PM and 02/04/26 at 3:30 PM, the Administrator revealed that on 01/24/26 she received a text message from the DON around 10:40 AM notifying her that a Code [NAME] had been initiated for a missing resident and she immediately went into the facility. The Administrator stated that Resident #1's family had been walking around the facility looking for Resident #1 after they had arrived around 10:30 AM for a visit but were unable to locate her. She explained while staff were searching inside and outside the facility, Resident #1's family also went outside to look for Resident #1. The Administrator recalled that at approximately 11:10 AM, she was present when Resident #1's family returned to the building and received a call from Resident #1's cellphone. When the Family Member returned the call, EMS answered and reported that Resident #1 had fallen down an embankment and was transported by ambulance to the hospital. After Resident #1's family left to go to the hospital, the Administrator stated she and staff inspected the property and observed an area on facility grounds with tire tracks and numerous broken tree limbs and branches, which they initially believed to be the location where EMS had found Resident #1. The Administrator stated that interviews with staff confirmed that Resident #1 had been observed throughout the facility between 6:45 AM and 9:40 AM. She verified that Resident #1 was last seen at 9:40 AM by Nurse #1 when Resident #1 was looking for the turtles. The Administrator confirmed that Resident #1's whereabouts were unaccounted for from 9:40 AM until 11:10 AM, when EMS notified Resident #1's Family Member that she had been transported to the hospital.A continuation of the Administrator interview revealed she was unable to definitively determine how Resident #1 exited the facility. The Administrator recalled it was a busy weekend with families visiting residents prior to the anticipated winter storm and the most plausible way Resident #1 could have exited the building was through the front entrance. She reported that on 01/22/26, an elopement alarm bracelet was initially placed on Resident #1's wrist that had to be reapplied when she kept removing the device, so staff applied additional elopement alarm bracelets to Resident #1's walker and cane that same day. She indicated that on 01/24/26, Resident #1 had an elopement alarm bracelet attached to the lower right leg of the walker and another on her person; however, staff reported they did not hear the alarm sound when Resident #1 exited the building. The Administrator confirmed that when Resident #1 returned to the facility, the elopement alarm bracelet was still attached to her walker but Resident #1 did not have an elopement alarm bracelet on her person. She stated on 01/24/26, she had Maintenance come to the facility to check all the alarm doors and nothing faulty was identified with the alarm system. The Administrator indicated she could not determine whether the alarm sounded and was turned off by staff when they didn't notice a resident near the door or if the alarm failed to trigger due to the position of the elopement alarm bracelet on Resident #1's walker when she quickly walked through the door. The Administrator revealed on 01/24/26 at 12:39 PM she spoke with Resident #1's Family Member who reported that Resident #1 stated she went for a walk and ran out of road. The Administrator stated shortly after Resident #1 returned from the hospital, Resident #1 told the Administrator that she had watched someone open the front door, followed them out and she would do it again because they could not stop her. The Administrator stated Resident #1 was placed on one-to-one monitoring until alternate placement could be arranged at a facility with a secured memory care unit. The State of North Carolina Executive Order No. 31 revealed the Governor declared a state of emergency, effective 01/21/26, due to the projected winter storm.The Administrator was notified of Immediate Jeopardy on 01/29/26 at 1:43 PM.The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility believes Resident #1 exited the facility from the main entrance on Saturday, 01/24/26 at around 9:40 am without the facility's knowledge, because the other entrances are locked down and require a code with or without an wander alarm bracelet. No cameras are available to determine time of exit. Resident #1 was seen by staff between 7:30 am to 9:30 am. According to the licensed nurse interview, Resident #1 was asking to leave and wanted to go outside around 7:30 am and was redirected. Breakfast tray was removed from the resident at around 8:30 am. Staff interviews revealed they did not hear the alarm sounding or observe Resident #1 leaving from the door by the nurse's station. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Certified Dietary Manager (CDM) conducted the staff interviews with nursing, dietary and housekeeping staff that were present and working on 01/24/26 during the time of the elopement. Resident #1 had an wander alarm bracelet on their person and on their rollator walker placed by Medication Aide on 01/22/26 at 2:30 pm. Resident #1 reported to the licensed nurses that she was taking a walk and looking for turtles on 01/24/26 around 9:40 am. Family visited around 10:30 am and alerted the staff that she was not in her room and were wondering where she was. When Resident #1 could not be located, then Code [NAME] was started. A Code [NAME] was initiated by the facility at 10:40 am on 01/24/26 by Director of Nursing (DON). The on-call physician was contacted on 01/24/26 by the DON and Administrator, an on-call report and the practice notified the Medical Director on Monday, 01/26/26. The Administrator and the DON completed the head count on 01/24/26 of all current residents and indicated on the census that current residents were present and accounted for. Emergency Medical Services (EMS) used Resident #1's personal cell phone around 11:10 am to call Resident #1's family and notified them that Resident #1 was outside and found on the ground down a 10-foot embankment from the phone call that the family was having with EMS and witnessed by the Administrator and the DON, but the hospital records report it being a 17-foot embankment. Resident #1 was then transported to the hospital by EMS who found the resident on the ground. Family left the facility, went home and then traveled to the hospital to meet the resident there. The Maintenance Assistant on 01/29/26 at 4:45 pm measured the embankment distance from the facility's northeast entrance by miles .1 miles which converts to approximately 528 feet. This was determined by the Administrator after investigating the facility surroundings where tire tracks were noted on the ground and freshly cut tree branches were noted on 1/24/26.The Administrator, on 01/24/26 at around 6:00 pm attempted to get details from EMS personnel or director of where Resident #1 was found exactly with no success. Resident #1 was readmitted to the facility the same day (01/24/26) at 4:30 pm. When Resident #1 returned to the facility, she was noted to not have her wander alarm bracelet on her person, but it was found in the resident's purse. Full skin assessment was completed and Resident #1 was noted with soiled feet from being outside by Licensed Nurse and DON. Resident #1 was also noted to have right forehead discoloration and abrasion, no dressing in place, large right lateral upper back discoloration, no swelling or fluid, and left lower arm with small abrasions. Wander Alarm bracelet was still noted on the resident's rollator walker. The wander alarm bracelet was intact, tested by the Administrator with Resident #1's rollator walker passing through the door and it activated the door alarm and was functioning. It was determined that the only door Resident #1 was able to leave the facility through was the front door. The other doors were always locked and required a code and the front door was unlocked for visitors to come and go. Resident #1 reported to the Administrator on 01/24/26 that she waited for the door to be opened and as people left she followed them out the door at the front entrance. Elopement Observation is an assessment that is used to assess the residents and determine if they are at risk for elopement. Resident #1's Elopement Observation dated 01/22/26 and completed by the Social Services Director (SSD) indicated Resident #1 was at risk for elopement and an alarm bracelet was applied that day by the Medication Aide at 2:30 pm, but Resident #1 was able to remove the bracelet from her person multiple times and additional alarm bracelets were applied on the resident's rollator walker and cane on 01/22/26 by the Medication Aide. When Resident #1 returned from the hospital on [DATE] at 4:30 pm, an alarm bracelet was reapplied on Resident #1's left arm by the Licensed Nurse but Resident #1 kept on stretching it out and removing it and replacing on each hand and then refused to keep the alarm bracelet on but a wander alarm continued to be on the rollator walker. Resident #1's rollator walker still had the alarm bracelet intact, activated and sounded the alarm at the front door. The Manufacturer's instructions for the alarm bracelet recommends not to directly attach the device to the resident's equipment. When Resident #1 was readmitted from the hospital on [DATE], her plan of care for being at risk for elopement continued and was updated by the SSD, ensured the physician order for the wander alarm bracelet was in the electronic medical record, and the elopement board/binders updated with resident's picture and room number. Resident #1's picture was not updated on the board/binders when the wander alarm bracelet was applied on 01/22/26. Resident #1 was placed on 1-on-1 supervision with licensed nurses, nursing assistants and dietary staff on 01/24/26 and upgraded to 15-minute checks as a trial on 01/27/26 and the resident has had no further incidents. The Administrator [TRUNCATED]

Based on observations and staff interviews the facility failed to protect residents' healthcare information by leaving confidential medication information unattended, visible, and accessible to others on the computer screen for 1 of 4 medication carts observed (Medication cart for hall 300).A continuous observation of 300 hall medication cart occurred on 7/21/25 from 1:50pm to 1:52pm. The medication cart was in the hallway unattended, and it was observed to have the computer screen showing resident information such as medications, date of birth , room number, and diagnosis. The medication cart was observed for 2 minutes and during that time 2 staff members and 2 residents walked past the medication cart.Medication Aide (MA) #2 was interviewed at 1:53pm. MA #2 explained the computer screen containing resident information should be placed on the privacy setting when the medication cart was unattended. MA #2 confirmed she had left the computer screen open to resident information when she walked away to care for another resident. She stated she was in a hurry and just forgot. A continuous observation of 300 hall medication cart occurred on 7/22/25 from 3:18pm to 3:26pm. The medication cart was unattended in the hallway, and it was observed to have the computer screen open to resident information such as date of birth , allergies, and diagnosis. The medication cart was observed for 8 minutes and during that time several residents, visitors, and staff walked past the medication cart.During an interview with MA #2 on 7/22/25 at 3:26pm, MA #2 confirmed the computer screen had been opened to resident information and stated she thought she had locked the screen prior to walking away from the medication cart. MA #2 explained she was nervous and should have made sure the computer screen was locked prior to walking away from the medication cart.Nurse #2 was interviewed on 7/22/25 at 3:12pm. The nurse explained that anyone working on a medication cart should fold the computer lid down or have the privacy screen showing prior to walking away from the medication cart. Nurse #2 discussed that all staff received resident privacy training yearly and that MA #2 should have had her privacy screen showing prior to walking away from her medication cart.The Director of Nursing (DON) was interviewed on 7/21/25 at 2:17pm. The DON explained the process for the nurses or Medication Aides was to make sure their computer screens were locked to the privacy window prior to leaving the medication cart. She stated MA #2 had yearly training on the medication cart which included keeping the computer screen locked on the privacy window. The DON discussed MA #2 being aware of the requirements and should have locked her computer screen on the privacy window prior to stepping away from her medication cart.The Administrator was interviewed by telephone on 7/24/25 at 2:00pm. The Administrator discussed that computer screens should show the privacy screen whenever the medication cart was unattended. She stated she did not know why MA #2 had left the computer screens showing resident information when she was not at her medication cart. The Administrator stated MA #2 should have placed the computer screen to the privacy screen prior to walking away from her medication cart.

Based on observations, record review, staff and resident interviews, the facility failed to assess a resident's ability to self-administer medications for 1 of 1 resident reviewed for self-administration (Resident #40).The findings included:Resident #40 was admitted to the facility on [DATE] with multiple diagnoses that included dry eye syndrome and dry mouth.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact and was independent with eating, oral hygiene, and personal hygiene.Review of Resident #40's current and active care plan dated 7/21/25 revealed no goals or interventions for self-administering medications.A review of Resident #40's medical record revealed there was no self-administration assessment or a Physician order for Resident #40 to self-administer her medications. During an interview and observation with Resident #40 on 7/21/25 at 10:51am, the resident was observed sitting up in her recliner next to her bed fully clothed. On the bed next to Resident #40 there was a bottle of Systane (for dry eyes) eyedrops with the direction label faded and partially removed, a bottle of Olopatadine (eye drops to treat itchy eyes) eyedrops with directions to administer 1 drop each eye daily, and a bottle of Biotene (mouth spray for dry mouth) mouth moistening spray with directions to spray in the mouth twice a day. Resident #40 explained the nurse gave her these medications this morning (7/21/25) to self-administer. The resident was unable to state what the medications were for other than they were for her eyes and mouth or how often she needed to administer them. Resident #40 stated the nurse left the medications with her every morning and then would come back and pick them up. Resident #40 stated she had already administered her eyedrops and mouth spray by herself.A second observation was made of Resident #40's room on 7/21/25 at 2:42pm. The observation showed the Systane eyedrops, Olopatadine eye drops and the Biotene were still present on Resident #40's bed.On 7/22/25 at 9:30am, a third observation was made of Resident #40's room which showed the Systane eyedrops, Olopatadine eyedrops and the Biotene were present on Resident #40's bed.Resident #40 was interviewed on 7/22/25 at 11:35am. Resident #40 confirmed the nurse had left her eyedrops and mouth spray for her this morning (7/22/25) but stated she must have come and got them because they are no longer on my bed.During an interview with Medication Aide (MA) #2 on 7/22/25 at 1:29pm, the MA explained there were no residents on the skilled unit who self-administered medication. She stated she was unaware of the policy for self-administration of medication because there were no residents who self-administered their medication. MA #2 confirmed there was no order for Resident #40 to self-administer her own medication and explained Resident #40 liked to put her own eyedrops in so she would stand next to Resident #40 while the resident administered her own eyedrops. She explained on 7/21/25 and this morning (7/22/25) were very stressful and she left the medication in Resident #40's room for her to administer herself when she was ready and then forgot to pick up the medication on 7/21/25.Nurse #2 was interviewed on 7/22/25 at 3:06pm. The nurse explained if a resident wanted to self-administer their medication a Physician order was needed, and an assessment of the resident, and a care plan completed. She stated Resident #40 was not a resident who could self-administer her own medication and MA #2 should have informed nursing that Resident #40 wanted to self-administer her own medication so proper steps could be taken. Nurse #2 stated medications should not be left with a resident who was not approved to self-administer their medication.The Director of Nursing (DON) was interviewed on 7/22/25 at 1:36pm. The DON discussed the policy for self-administration of medication including an assessment, the resident's representative would need to agree, the Doctor would need to be notified, and a care plan completed. She stated she did not know if there were any residents on the skilled units who self-administered their own medication. The DON discussed not being aware if Resident #40 had an order to self-administer her own medication and that MA #2 should not have left the medication in Resident #40's room.The Administrator was interviewed by telephone on 7/24/25 at 2:00pm. The Administrator discussed that there was a procedure for residents to self-administer their medication. She explained she did not know if Resident #40 could self-administer her medication but stated if there was not an order, an assessment, and/or care plan then the medication should not have been left in Resident #40's room.

Based on observations, record review, staff, and law enforcement officer interviews, the facility failed to protect the resident's right to be free of misappropriation of medication for 1 of 3 residents reviewed for misappropriation (Resident #53).The findings included:Resident #53 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included hypertension.A physician order dated [DATE] read; Lisinopril 20 milligrams (mg) by mouth every day. Hold for systolic blood pressure less than 100. The order was discontinued on [DATE].A physician order dated [DATE] read; Lisinopril 10 mg by mouth every day. Hold for systolic blood pressure less than 100. The order was discontinued on [DATE].A physician order dated [DATE] read; Lisinopril 5 mg by mouth every day. Hold for systolic blood pressure less than 110. The order was discontinued on [DATE].A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #53 was severely cognitively impaired.An interview with the local Law Enforcement Officer was conducted in person on [DATE] at 1:30 PM. The Law Enforcement Officer stated that on [DATE] Medication Aide (MA) #1 called the police station and requested a wellness check on her significant other because she had been unable to reach him. When the responding officer responded to the address, MA #1's significant other was found deceased . Law Enforcement Officer stated that there was nothing suspicious with the death and the death certificate was signed off immediately. However, on [DATE] the significant others family came to the police station to turn in a bottle of medication that was prescribed for Resident #53. Law Enforcement Officer stated that he took the information and started an investigation. He contacted MA #1 several times and asked her to give a statement and on [DATE] or [DATE] he reached out to the former Director of Nursing (DON) at the facility and did not get a return call. On [DATE] Law Enforcement Officer stated he sent an email to the former DON asking for assistance with the investigation and was met with great resistance. Law Enforcement Officer stated the former DON would not confirm or deny that MA #1 worked at the facility and kept saying via text message that the medication for Resident #53 was not a controlled substance. Law Enforcement Officer stated that he conveyed via text message to the former DON that it did not matter that it was still larceny (unlawful taking and carrying away of personal property with the intent to deprive the rightful owner of it permanently) and that he was going to press charges against MA #1. Law Enforcement Officer stated that on [DATE] he visited Resident #53 who was unaware that her medication had been stolen. Law Enforcement Officer stated that on [DATE] MA #1 returned his call and was informed that she was being charged with larceny, and she stated she would turn herself in which she ultimately did. MA #1 admitted to Law Enforcement Officer that she had taken the medication but stated she was not the only one that took medications from the facility. Law Enforcement Officer concluded by saying that MA #1 had an upcoming court date on [DATE].An attempt to speak to MA #1 via phone and email were attempted on [DATE] at 11:16 AM and were unsuccessful.A picture provided by Law Enforcement Officer was reviewed on [DATE]. The picture revealed a bottle of medication labelled with Resident #53's name and contained the medication name Lisinopril 20 mg and direction to take one by mouth every morning. The bottle contained a previous address that belonged to the Independent Living Apartments located next to the skilled facility. The name of the pharmacy (mail order pharmacy not the facility pharmacy) that filled the prescription was noted on the bottle along with a phone number. In the picture you could see pills in the bottom of the bottle that were visible around the large white medication label that was on the bottle.Review of an evidence log provided by the local Law Enforcement Officer revealed that they had a bottle of Lisinopril 20 mg that contained 103 pills prescribed for Resident #53. The pills were verified by the Law Enforcement officer using a pill identifier application and confirmed that they were the labeled medication.An observation and interview were conducted with Resident #53 on [DATE] at 3:41 PM. Resident #53 was sitting in a wheelchair in the doorway of her room. She was pleasantly confused and could not recall anyone stealing her medications.An attempt to speak to Resident #53's responsible party was conducted on [DATE] at 8:14 PM to confirm Resident #53's previous address and was unsuccessful.An interview was conducted via phone on [DATE] at 8:24 AM with the pharmacy that had filled the Lisinopril 20 mg for Resident #53. The pharmacy staff indicated that they were a mail order pharmacy and confirmed the name and date of birth for Resident #53 and indicated that they had last fill the prescription in [DATE] and sent it to the member via mail. An interview conducted with Human Resources Manager on [DATE] at 11:26 AM revealed that MA #1 was a former employee who had worked at the facility for well over 12 years. She stated that one evening MA #1 could not reach her significant other and called law enforcement for a wellness check and when they arrived at his address he was found deceased . The officer that responded noted pill bottles that had the facility name (the bottle for Resident #53 did not contain the nursing home name) on them and reached out to the former Administration and wanted them to press charges for stealing medication. The Human Resources Manager stated that the former Administrator investigated, and MA #1 was suspended and then terminated. She stated at first MA #1 stated she did not know anything about the medication and then stated that she used to take empty pill bottles home to store things in. The Human Resources Manager stated that it could not be proven that MA #1 stole any actual medication and the resident did not miss any medication, so they proceeded with termination and to her knowledge no charges were ever filed.An attempt to speak to the former DON was conducted on [DATE] at 4:24 PM and was unsuccessful.The former Administrator was interviewed via phone on [DATE] at 4:05 PM. The former Administrator stated the local LEO contacted the former DON to notify her that they responded to a death in the community and had found bottles of medication with the facility information on it and the deceased 's significant other worked at the facility. The former Administrator did not recall the medications involved or the residents involved but stated that the facility did not use medication bottles, they use unit dose packs. The former Administrator stated that when the former DON notified him, he suspended MA #1 and contacted the Nurse Consultant for advice on how to proceed and the former DON ensured the residents had no missing medications. We spoke with MA #1 who stated she would take empty pill bottles home to store things in and eventually the decision was made to separate employment with her.The Nurse Consultant was interviewed via phone on [DATE] at 4:27 PM and reported that she was contacted by the former Administrator who had been contacted by local Law Enforcement Office who reported that MA #1's significant other had passed away and there was bottles of medication with the facility information on them found at his residence. At the time Law Enforcement Officer would not send anything or come to the facility to discuss the issue it was basically a cold call to the former DON. There were bottles that had resident names on them and some of the bottles had no names on them. The Nurse Consultant recalled that the one bottle had a pharmacy name on it that filled prescriptions to their assisted living residents but through the investigation they realized that they had no missing medications. MA #1 was interviewed and stated she used to take empty pill bottles home to store things in, so the facility considered it a privacy issue and terminated MA #1.The current DON was interviewed on [DATE] at 3:16 PM who stated she started her employment in February 2025 and had no knowledge of the investigation and was not involved with the investigation.

Based on record review, observations, and staff interviews, the facility failed to secure medications on an unattended medication cart that was unlocked and a drawer partially opened for 1 of 4 medication carts (hall 300).A continuous observation occurred on 7/21/25 from 11:58am to 12:00pm of the medication cart on hall 300. The medication cart was in the hallway unattended, unlocked, and with a drawer partially opened that contained resident medications. The observation occurred for 2 minutes with the staff member returning to the cart at 12:00pm. During the 2-minute observation 2 staff members were observed to walk past the medication cart. No residents were near or passed by the cart during the observation.Medication Aide (MA) #2 was interviewed on 7/21/25 at 1:53pm. The MA discussed that when she was not present at her medication cart the cart should be locked with all the drawers closed. She confirmed right before 12:00pm she had walked away from her medication cart leaving a drawer open containing resident medication and that her cart was unlocked. MA #2 stated she was in a hurry and just forgot to close the drawer and lock her cart.During an interview with Nurse #2 on 7/22/25 at 3:16pm, Nurse #2 explained that medication carts should be locked with all the drawers closed if they were unattended. She stated MA #2 had yearly training on the importance of keeping the medication cart locked for safety. Nurse #2 discussed that MA #2 became distracted and forgot to lock her medication cart, but that MA #2 should have ensured all the drawers were closed and the medication cart was locked.The Director of Nursing (DON) was interviewed on 7/21/25 at 2:17pm. The DON explained when a nurse or Medication Aide was not at their medication cart the cart should be locked and all the drawers closed. She further explained that anyone assigned to a medication cart had yearly training which included ensuring unattended medication carts were locked and all the drawers closed. The DON discussed that MA #2 had the training and did not know why she would have left her cart unlocked or a drawer open.The Administrator was interviewed by telephone on 7/24/25 at 2:00pm. The Administrator discussed that all medication carts were to be locked, and drawers closed when unattended. She discussed not knowing why MA #2 had not locked her medication cart or left a drawer open but stated MA #2 should have ensured the drawers were closed and the medication cart was locked prior to walking away.

Based on record review, staff, and Law Enforcement Officer interviews, the facility failed to implement their abuse policy and procedures by failing to thoroughly investigate an allegation of misappropriation of resident medication and report to the State Survey Agency and Adult Protective Services for 1 of 3 residents reviewed for misappropriation (Resident #53).The findings included:Review of a facility policy titled, Plan for the Prevention of Elder Abuse with no date noted read in part, Investigation-all reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Reporting- it is the responsibility of our employees, workforce, facility consultants, physicians, family members, etc to promptly report any incident or suspected incident of neglect or resident abuse including injuries of unknown course, theft, or misappropriation of resident property to facility management. Upon receipt of an allegation of abuse or neglect, the Administrator or designee will notify the appropriate State agency immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury.An interview with Nurse Consultant #1 on [DATE] at 2:23 PM revealed that their policy titled Plan for the Prevention of Elder Abuse had been updated most recently [DATE] and was the only policy they had and used. Nurse Consultant #1 stated that the policy was used for Abuse, neglect, and misappropriation for each allegation that was brought to the attention of management for a thorough investigation to be completed.An interview with the local Law Enforcement Officer was conducted in person on [DATE] at 1:30 PM. The Law Enforcement Officer stated that on [DATE] Medication Aide (MA) #1 called the police station and requested a wellness check on her significant other because she had been unable to reach him. When the responding officer responded to the address, MA #1's significant other was found deceased . Law Enforcement Officer stated that there was nothing suspicious with the death and the death certificate was signed off immediately. However, on [DATE] the significant others family came to the police station to turn in a bottle of medication that was prescribed for Resident #53. Law Enforcement Officer stated that he took the information and started an investigation. On [DATE] or [DATE] he reached out to the former Director of Nursing (DON) at the facility and did not get a return call. On [DATE] Law Enforcement Officer stated he sent an email to the former DON asking for assistance with the investigation and was met with great resistance. Law Enforcement Officer stated the former DON would not confirm or deny that MA #1 worked at the facility and kept saying via text message that the medication for Resident #53 was not a controlled substance. Law Enforcement Officer stated that he conveyed via text message to the former DON that it did not matter that it was still larceny (unlawful taking and carrying away of personal property with the intent to deprive the rightful owner of it permanently) and that he was going to press charges against MA #1.An interview conducted with Human Resources Manager on [DATE] at 11:26 AM revealed that MA #1 was a former employee who had worked at the facility for well over 12 years. She stated that one evening MA #1 could not reach her significant other and called law enforcement for a wellness check and when they arrived at his address he was found deceased . The officer that responded noted pill bottles that had the facility name (the bottle for Resident #53 did not contain the nursing home name) on them and reached out to the former Administration and wanted them to press charges for stealing medication. The Human Resources Manager stated that the former Administrator investigated, and MA #1 was suspended and then terminated.An attempt to speak to the former DON was conducted on [DATE] at 4:24 PM and was unsuccessful.The former Administrator was interviewed via phone on [DATE] at 4:05 PM. The former Administrator stated the local LEO contacted the former DON to notify her that they responded to a death in the community and had found bottles of medication with the facility information on it and the deceased 's significant other worked at the facility. The former Administrator stated that when the former DON notified him, he suspended MA #1 and contacted the Nurse Consultant for advice on how to proceed and the former DON ensured the residents had no missing medications. The former Administrator indicated they spoke with MA #1 who stated she would take empty pill bottles home to store things in and eventually the decision was made to separate employment with her. The former Administrator stated that there should be an investigation file in the facility or with the current Administrator but could not recall what was in the investigation file. The Administrator also stated that after discussion with the Nurse Consultant the decision was made that this did not need to be reported to the State Survey Agency or Adult Protective Services and so no report was made.The Nurse Consultant was interviewed via phone on [DATE] at 4:27 PM and reported that she was contacted by the former Administrator who had been contacted by local Law Enforcement Officer who reported that MA #1's significant other had passed away and there were bottles of medication with the facility information on them found at his residence. At the time Law Enforcement Officer would not send anything or come to the facility to discuss the issue it was basically a cold call to the former DON. There were bottles that had resident names on them and some of the bottles had no names on them. The Nurse Consultant recalled that the one bottle had a pharmacy name on it that filled prescriptions to their assisted living residents but through the investigation they realized that they had no missing medications. The Nurse Consultant indicated MA #1 was interviewed and stated she used to take empty pill bottles home to store things in, so the facility considered it a privacy issue and terminated MA #1. The Nurse Consultant stated that they discussed reporting the issue to the State Survey Agency to Adult Protective Services, but they had no information that was connected to our residents, so no report was made. The Nurse Consultant added that the investigation file was with the former Administrator but could not say where it landed since he no longer works at the facility.The current DON was interviewed on [DATE] at 3:16 PM who stated she started her employment in February 2025 and had no knowledge of the investigation and was not involved with the investigation.The current Administrator was interviewed on [DATE] at 4:27 PM who stated she could not locate any investigation file or report to the State Survey agency on the incident. The Administrator was shown the investigation provided by Law Enforcement Officer and the investigation he had conducted. The Administrator stated if she had all the information she would have started an investigation into the missing medications and reported the occurrence to the appropriate entities.

Based on observations, record review, and resident and staff interviews, the facility failed to administer oxygen via nasal canula as prescribed for 1 of 1 resident reviewed for respiratory care (Resident #66).The findings included:Resident #66 was admitted to the facility on [DATE] with diagnoses that included pneumonia, heart failure, sleep apnea, and acute/chronic respiratory failure.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #66 was cognitively intact and used oxygen. The MDS also revealed that during the assessment reference period Resident #66 experienced shortness of breath with exertion and when lying flat.A physician order dated 07/14/25 read: oxygen at 4 liters via nasal canula while walking and oxygen at 1 liter via nasal canula while sitting/resting. An observation and interview with Resident #66 were conducted on 07/21/25 at 1:51 PM. Resident #66 was resting in bed watching television. He had oxygen via nasal canula being administered via oxygen concentrator that was set at 3 liters per minute. Resident #66 denied any shortness of breath at the moment and stated that the nurses kept a close eye on his oxygen and oxygen levels, and he did not touch his concentrator and let the nurses do what was necessary. An observation of Resident #66 was conducted on 07/23/25 at 9:19 AM. Resident #66 was resting in bed in no acute distress with oxygen via nasal canula being administered via oxygen concentrator at 3 liters per minute.Nurse #1 was interviewed on 07/23/25 at 1:58 PM and confirmed that she cared Resident #66 on 07/21/25 and 07/23/25. Nurse #1 stated that when Resident #66 was resting in bed he was on 2 liters of oxygen via nasal canula, but if he walked or with exertion, they could increase it to 4 liters of oxygen via nasal canula. Nurse #1 explained that over the last week therapy had been titrating his oxygen during therapy but currently remained on 2 liters at rest and 4 liters with exertion. Nurse #1 added Resident #66 was very complaint with his continuous oxygen and never bothered his oxygen concentrator.An observation of Resident #66 was made on 07/23/25 at 3:40 PM. Resident #66 was resting in bed with his eyes closed on his right side. He had oxygen via nasal canula that was being administered via oxygen concentrator set to deliver 2 liters per minute.A follow up interview with Nurse #1 was conducted on 07/23/25 at 4:56 PM. Nurse #1 was asked to review Resident #66's oxygen orders for accuracy. When she came to the oxygen order she stated, 1 liter when did they change that, it was 2 liters. Nurse #1 stated she wanted to get confirmation that was correct but that it appeared that Resident #66 should be on 1 liter of oxygen via nasal canula when at rest.An interview with Nurse #1 was conducted on 07/23/25 at 4:59 PM. Nurse #1 stated she had verified with the medical provider that Resident #66 should be at 1 liter per minute via nasal cannula when at rest.An interview with the Director of Nursing (DON) was conducted on 07/24/25 at 11:36 AM. The DON stated that the nurse on the hall was responsible for ensuring the correct dose of oxygen was being delivered after reviewing the residents' orders each shift.

Based on record review and staff interviews, the facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours for 1 of 82 days reviewed for staffing (7/20/25).The findings included:The July 2025 daily posted nurse staffing sheets revealed there was no RN coverage for 7/20/25.The Director of Nursing (DON) was interviewed on 7/23/25 at 5:15pm. The DON explained she was responsible for checking the daily posted staffing sheets everyday Monday through Friday. She discussed checking the weekend daily posted staffing sheets on Monday. The DON stated either the nightshift (11:00pm to 7:00am) nurse or the dayshift (7:00am to 3:00pm) nurse would fill out the posted daily staffing sheets and she would look at it as she entered the building. She stated she was unaware the RN time needed to be 8 consecutive hours. The 7/20/25 daily posted staffing sheets were reviewed. The DON explained the facility had a regular RN that worked the weekends but that she was on vacation 7/19/25 and 7/20/25. She further explained 7/19/25 was covered and thought 7/20/25 was covered but when the DON looked at the schedule, she realized the RN scheduled would not have come to work on 7/20/25. The DON stated there was no RN coverage on 7/20/25.During an interview with the Scheduler on 7/24/25 at 10:35am, the Scheduler stated she had only been in her position for a couple of months. She explained she was informed that an RN needed to be in the facility for at least 8 consecutive hours. The Scheduler discussed the facility using contract staff when there was no RN in house to fill the need. The Scheduler explained for the weekend of 7/19/25 she was able to find RN coverage for 7/19/25 but on 7/20/25 she could not find an RN to work. She stated she had informed the DON.A follow-up interview with the DON occurred on 7/24/25 at 10:45am. The DON stated the Scheduler may have told her there was no RN coverage for 7/20/25 but she was not sure. She explained it was rare for the facility not to have an RN but if she had known there was not an RN available, she would have assisted in finding one for 7/20/25.A telephone interview occurred with the Administrator on 7/24/25 at 2:00pm. The Administrator discussed DON being responsible for checking the daily posted staffing sheets for accuracy and coverage. She also discussed being aware that an RN needed to be present in the building for at least 8 consecutive hours. The Administrator stated she was unaware there was not an RN in the building on 7/20/25 and did not know why there was not an RN present.

Based on record review and staff interviews, the facility failed to ensure daily posted nurse staffing sheets were filled out completely and everyday for 6 of 61 days reviewed for daily posted nurse staffing (5/5/25, 5/6/25, 5/8/25, 5/23/25, 6/16/25, and 6/23/25).The findings included:Review of the facility's daily posted nurse staffing sheets from 5/1/25 through 6/30/25 revealed the following:-On 5/5/25, 5/6/25, and 5/8/25 the daily posted staffing sheets revealed no number of hours worked for the Nurse Aides or the Nurses.-The daily posted nurse staffing sheet for 5/23/25 was not present.-The 6/16/25 daily posted nurse staffing sheet showed no hours were documented for the Nurse Aides or the Nurses.-On 6/23/25 the daily posted nurse staffing sheets revealed RN hours as 4 for the 7:00am to 3:00pm shift.During an interview with the Director of Nursing (DON) on 7/23/25 at 5:15pm, the DON discussed being responsible for making sure the daily posted nurse staffing sheets were present and correct. She explained either the nightshift (11:00pm to 7:00am) nurse or the dayshift (7:00am to 3:00pm) nurse filled out the daily posted nurse staffing sheets and she checked them for accuracy each morning when she entered the building. The DON stated she had not noticed on 5/5/25, 5/6/25, or 5/8/25 that there were no hours entered. She explained she attempted to find the daily posted nurse staffing sheet for 5/23/25 but was unable to locate the sheet. The DON discussed being unaware that the RN hours needed to show 8 consecutive hours. She stated she was not aware that on 6/16/25 the daily posted nurse staffing sheets did not contain any hours for the Nurse Aides or Nurses. The DON discussed on 6/23/25 the daily posted nurse staffing sheets were written incorrectly. She stated there were four (4) RNs on duty not that one (1) RN worked 4 hours. She stated the nurses on the nightshift and the nurses on the dayshift were educated on how to fill out the daily posted nurse staffing sheet but that it was her responsibility to make sure they were accurate.The Administrator was interviewed by telephone on 7/24/25 at 2:00pm. The Administrator discussed the DON being responsible for the daily posted nurse staffing sheets and did not know why there were errors. She stated something went wrong but would expect the daily posted nurse staffing sheets to be correct.

Based on record review and staff interviews the facility failed to submit a request for a re-evaluation for Preadmission Screening and Resident Review (PASRR) determination for a resident who was diagnosed with a new mental health disorder and received a change in treatment (Resident #6) for 1 of 1 resident reviewed for PASRR. The findings included: Record review of the North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document dated 05/08/21 revealed Resident #6 had a Level I PASRR effective 05/03/16. There were no requests for a Level II PASRR evaluation submitted or completed since 05/03/16. Resident #6 was admitted to the facility on [DATE] with a diagnosis that included mood disorder due to known psychological condition. Review of the annual minimum data set (MDS) dated [DATE] revealed Resident #6 had not been evaluated by Level II PASRR and determined to have a serious mental illness, intellectual disability or other related condition. Resident #6 received antianxiety, antidepressant medication on a routine. Review of Resident #6 cumulative medical diagnosis list revealed a new diagnosis of delusional disorder on 6/19/24. Record review of the physicians' orders for Resident #6 revealed in part an order dated 06/19/24 for Risperidone 0.25 milligram (MG) tablet (antipsychotic medication) for delusional disorder. Record review of the medication administration records (MAR) from June 2024 to July 2024 revealed it was documented that Resident #6 was administered Risperidone 0.25 milligram (MG) tablet per the physician's order. An interview with the Social Service Director on 07/10/24 at 1:39 PM revealed that she was trained the focus was on schizophrenia and Huntington's only for a level 2 PASARR evaluation. She stated that she was not aware that any new mental health diagnosis needed a request for level 2 PASARR. She stated that the only PASARR they had for Resident #6 was the one dated 05/03/2016. An interview with the Administrator on 07/10/24 at 2:16 PM revealed that his expectation was that all residents have a current PASARR and at the level that was appropriate for their current diagnosis and condition.

Based on record review, observations and staff interviews, the facility failed to treat residents in a dignified manner by standing over them while assisting with eating and/or referring to residents as feeders. This practice affected 5 of 5 residents reviewed for dignity (Residents #206, #21, #31, #16, and #42). The reasonable person concept was applied to this deficiency as individuals have the expectation of being treated with dignity while dining. The findings included: 1. Resident #206 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #206 was moderately cognitively impaired and required extensive assistance with eating. During a lunch observation in the resident dining room on 3/13/23 at 12:05 PM, the Quality Improvement Manager was observed standing over Resident #206 while providing feeding assistance for the duration of the meal from 12:05 PM to 12:26 PM. There were empty chairs in the dining room that were available for use. An interview was conducted with the Quality Improvement Manager on 3/14/23 at 11:04 AM. The Quality Improvement Manager stated that she usually assisted with meals whenever asked. She explained that she normally asked staff about which residents needed assistance with eating. The Quality Improvement Manager stated that she watched a training video on feeding assistance and that it did not include whether to sit or stand while providing assistance. She stated that whether to stand or sit beside the resident depended on whatever the staff assisting with the meal preferred. The Quality Improvement Manager stated she was supposed to sit beside the resident but that there was not enough room at the table on 3/13/23. She revealed that she typically assisted residents while standing over them. An interview with the Director of Nursing (DON) was conducted on 3/16/23 at 4:26 PM. The DON stated that the Quality Improvement Manager was new and that she had already spoken to her regarding feeding assistance. 2. During a dinner meal observation on the 200 hall on 3/15/23 at 6:07 PM, Nurse Aide (NA) #3 was observed telling the other nurse aides on the 200 hall that the rest are feeders, as he was assisting with passing out dinner trays. The doors to residents' rooms were open to the hallway and Residents #206, #21, #42, and #31 were all in their rooms and within hearing distance of NA #3. An interview with NA #3 on 3/15/23 at 6:08 PM revealed he did not typically call the residents feeders and that he only meant to say it to the other nurse aides. An interview with the Director of Nursing (DON) was conducted on 3/16/23 at 4:26 PM. The DON stated that it was inappropriate to refer to residents as feeders and that they should be referred to as residents who require feeding assistance. An interview was conducted with the Administrator on 3/17/23 at 4:15 PM. The Administrator stated that he never wanted to hear the word feeder used to describe residents. He stated he talked to some staff individually and that an in-service email had been sent out to all staff. 47695 3a. Resident #16 was admitted to the facility on [DATE]. The most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had severe cognitive impairment and required supervision with eating. 3b. Resident #42 was admitted to the facility on [DATE]. The most recent quarterly MDS dated [DATE] showed that Resident #42 had severe cognitive impairment and required extensive assistance with eating. During an observation of lunch in the facility dining room on 03/13/23 from 12:18 PM to 12:25 PM, Nurse Aide (NA) #2 was observed standing at a table assisting Resident #16 and Resident #42 with eating while standing over them for about 5 minutes. There were empty chairs in the dining room that were available for use. During a phone interview on 03/13/23 at 4:13 PM with NA #2, she described how a resident who needed assistance should be helped with meals. NA #2 said she would position herself seated, in a chair to assist and would face the resident while feeding. She said she was standing next to Resident #16 and Resident #42 to assist with feeding during lunch because there were too many residents at the table. NA #2 further stated the nurse aides typically sat between two residents and did not stand when assisting with feeding. If the table was too crowded with residents needing assistance and there was no room to put a chair between two residents, NA #2 said she would normally move a resident to a separate table to assist. During an interview on 03/16/23 at 4:26 PM with the Director of Nursing (DON), she stated that staff had been educated to sit next to the residents while assisting them to eat and not stand over them. The DON reported that she had spoken with staff about feeding assistance. The DON stated that standing over a resident when assisting with eating was not appropriate. During an interview on 03/17/23 at 4:22 PM with the Administrator, he reported standing over residents while assisting them to eat was not acceptable.

Based on medical record review and staff interviews the facility failed to accurately code the Minimum Data Set assessments for 2 of 4 sampled residents reviewed for falls (Residents #6 and #58) and 3 of 5 sampled residents reviewed for medications (Residents #1, #22 and #27.) The findings included: 1. Resident #1 was admitted to the facility 10/07/13 and readmitted to the facility 8/27/17 with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. An annual Minimum Data Set ((MDS) dated [DATE] for Resident #1 did not code Resident #1 on a diuretic. On 07/20/18 at 4:40 PM MDS Nurse #2 stated the HCTZ should have been coded as a diuretic on the 07/12/18 annual MDS for Resident #1 and it was an oversight that it was not coded correctly. On 07/20/18 at 8:00 PM the Director of Nursing stated she expected the MDS to be coded accurately and noted the HCTZ should have been coded as a diuretic on the 07/12/18 MDS for Resident #1. On 07/20/18 at 8:05 PM the administrator stated he expected the MDS to be coded accurately,. 2. Resident #27 was admitted to the facility 08/30/12 with [DIAGNOSES REDACTED]. Review of the (MONTH) Medication Administration Record [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] did not code Resident #27 on an anti-anxiety or antibiotic medication. On 07/20/18 at 4:40 PM MDS Nurse #1 reviewed the 06/05/18 quarterly MDS for Resident #27 and stated the [MEDICATION NAME] should have been coded as an antibiotic and the [MEDICATION NAME] should have been coded as an anti-anxiety medication. MDS Nurse #1 stated it was an oversight that the two medications were not coded correctly on the 06/05/18 MDS for Resident #27. On 07/20/18 at 8:00 PM the Director of Nursing stated she expected the MDS to be coded accurately. The Director of Nursing stated the 06/05/18 quarterly MDS for Resident #27 should have coded the resident was taking an anti-anxiety and antibiotic at the time of the assessment. On 07/20/18 at 8:05 PM the administrator stated he expected the MDS to be coded accurately. 3. Resident #58 was admitted to the facility 01/10/12 with [DIAGNOSES REDACTED]. Review of the medical record of Resident #58 noted 2 falls with details as follows: 5/6/18 6:30 AM-Resident #58 was sitting on her walker in the bathroom and slipped off the walker onto the floor. No complaints of pain were noted. She had on polyester pants which were slick and most likely reason she slipped. 6/11/18 3:35 PM-Resident #58 fell over her walker. Resident #58 was found on the floor, lying on her back, with her head next to the dresser. Resident #58 complained of severe head pain and had a lump on the back of the right side of her head as well as complaints of lower back pain. The quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #58 coded Resident #58 had no falls since the prior assessment (which was dated 04/19/18.) On 07/19/18 at 3:50 PM MDS Nurse #1 stated she kept a hand logged book in her office of resident falls to utilize when an MDS was completed. MDS Nurse #1 looked at the book and stated it did not include the 05/06/18 and 06/11/18 falls for Resident #58 which resulted in an error when the quarterly MDS was coded for Resident #58. MDS Nurse #1 stated not coding the 2 falls on the 07/10/18 quarterly MDS for Resident #58 was an oversight. On 07/20/18 at 8:00 PM the Director of Nursing stated she expected the MDS to be coded accurately and the 07/10/18 quarterly MDS for Resident #58 should have noted the 2 falls since the prior assessment. On 7/20/18 at 8:05 PM the administrator stated he expected the MDS to be coded accurately. 4. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's medical record revealed she had an unwitnessed fall on 04/01/18 at 2:15 PM while in the courtyard of the facility. Further review revealed Resident #6 sustained a skin tear to her right hand as a result of the fall. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #6 had no falls since the prior MDS assessment which was dated 02/03/18. During an interview on 07/19/18 at 5:45 PM MDS Nurse #1 revealed she reviewed the fall occurrence reports and manually logged them into a fall book that she referenced when completing a MDS. MDS Nurse #1 confirmed Resident #6 had a fall on 04/01/18 and the MDS dated [DATE] was coded incorrectly. MDS Nurse #1 added not coding the fall on 04/01/18 was an oversight and a corrected MDS would be submitted to accurately reflect Resident #6 had a fall. During an interview on 07/20/18 at 7:40 PM the Director of Nursing stated she would expect for the MDS to be accurately coded. 5. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. depression. Review of Resident #22's physician orders [REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #22 received an anticoagulant and diuretic daily during the 7-day assessment period. During an interview on 07/19/18 MDS Nurse #1 revealed she referenced the MAR indicated [REDACTED]. MDS Nurse #1 stated it was possible she had reviewed another resident's MAR by mistake which caused the incorrect coding of medications on Resident #22's MDS dated [DATE]. MDS Nurse #1 added a corrected MDS would be submitted to accurately reflect Resident #22 did not receive anticoagulants or diuretics. During an interview on 07/20/18 at 7:40 PM the Director of Nursing stated she would expect for the MDS to be accurately coded.

Based on observations and interviews with staff the facility failed to ensure the reach in freezer containing single serve ice cream/sandwiches maintained food in a frozen state, failed to store buckets of ice cream off the floor of the walk in freezer, failed to refrigerate individual servings of salad dressing consistent with manufacturer recommendations and failed to ensure cottage cheese, fresh mozzarella cheese and single service cartons of milk were not stored beyond expiration. The findings included: 1. During the initial tour of the facility kitchen on [DATE] from 10:55 AM-11:20 AM the following concerns were identified: -The temperature of food stored in a box reach in freezer was noted to be 24 degrees Fahrenheit when tested by the Assistant Food Service Director (AFSD). Stored inside the box reach in freezer at the time the temperature was taken was a box of single serve vanilla sandwiches which were completely melted and five boxes of single serve ice cream cups. All the boxes were stored directly on the bottom of the freezer and when the lid of several of the single serve ice cream cups was lightly touched the product inside pooled out over the cup. The AFSD was present at the time of the observation and noted the box reach in freezer was new and had recently been moved within the kitchen because of problems with maintaining temperature. The AFSD explained the reach in freezer had been located close to the warming unit and they thought the heat from the warming unit might have been the problem with maintaining the freezer temperature. The AFSD stated she did not think staff had opened the reach in freezer box that morning and the product inside had not been from a recent delivery. The AFSD stated she was not aware the products inside the reach in freezer were not frozen. The AFSD reviewed the daily temperature log and noted staff had not checked the temperature of the reach in freezer that morning. -Two, 5 quart plastic buckets of ice cream were observed stored under shelving, on the floor of the walk in freezer. The AFSD was present at the time of the observation and stated no food products were supposed to be stored on the floor of the walk in freezer. The AFSD stated the 5 quart plastic buckets belonged to the activity department and they stored them in the kitchen walk in freezer for resident use at activities. The AFSD stated she was not sure who placed the 5 quart buckets of ice cream under shelving in the walk in freezer. -One, 5 pound unopened container of lowfat cottage cheese with a manufacturer stamped expiration date of [DATE] was stored, ready for use on shelving in the walk in refrigerator. The AFSD was present at the time of the observation and stated the coolers were checked on stock days (Tuesday/Friday) for any outdated items and were supposed to be checked all other days by all staff for any outdated items. The AFSD could not explain why the 5 pound container of lowfat cottage cheese with a [DATE] expiration date remained ready for use on shelving in the walk in refrigerator. -One, 3 pound unopened container of fresh mozzarella cheese with a manufacturer stamped best by date of (MONTH) 15th was stored, ready for use on shelving in the walk in refrigerator. The AFSD was present at the time of the observation and stated the coolers were checked on stock days (Tuesday/Friday) for any outdated items and were supposed to be checked all other days by all staff for any outdated items. The AFSD could not explain why the 3 pound container of fresh mozzarella cheese with a (MONTH) 15th expiration date remained ready for use on shelving in the walk in refrigerator. On [DATE] at 11:40 AM the Food Service Director (FSD) stated she expected frozen food items to be stored frozen. The FSD stated even at the highest setting the reach in box freezer was still not working and they were not going to use it again until it was serviced. The FSD stated staff should be checking the walk in refrigerator five days a week for any items out of date and couldn't explain why the expired cottage cheese and fresh mozzarella had not been removed prior to [DATE] by dietary staff. The FSD stated the activity staff brought the buckets of ice cream to the kitchen the week prior and asked if they could be stored in the walk in freezer. The FSD stated she was not sure who placed the buckets of ice cream in the freezer but expected all food to be stored on shelving, not on the floor of the walk in freezer. 2. On [DATE] at 12:00 PM 5, ,[DATE] pints of whole milk with a manufacturer expiration date of [DATE] were stored inside a pantry refrigerator which was located adjacent to the 400 hall. On [DATE] at 9:42 AM 5, ,[DATE] pints of whole milk remained in the pantry refrigerator located adjacent to the 400 hall. In addition, there were also 2, ,[DATE] pint containers of lowfat milk with a manufacturer expiration date of [DATE]. On [DATE] at 11:00 AM a dietary aide stated someone from the dietary department checked each nourishment pantry every day to replenish stock and remove any outdated items. The dietary aide stated the 5, ,[DATE] pints of whole milk with an expiration date of ,[DATE] should have been discarded two days prior and the 2, ,[DATE] pints of lowfat milk with an expiration date of ,[DATE] should have been discarded the day prior. The dietary aide stated she was not sure who checked the nourishment pantries [DATE] and [DATE]. On [DATE] at 11:40 AM the Food Service Director stated dietary staff should remove any outdated food items from the pantry refrigerators when they were stocked each day. 3. On [DATE] at 11:15 AM a wicker basket housing individual servings of salad dressing was observed in the Benson dining room. A dietary aide present at the time of the observation stated the individual servings of salad dressing were stored in the wicker basket for resident use when a salad was served to residents. Inside the basket were five, 1.5 ounce servings of honey mustard salad dressing which had marked on the label by the manufacturer keep refrigerated. The five, 1.5 ounce servings of honey mustard salad dressing all felt at room temperature. On [DATE] at 11:20 AM observations were made of the tray line for the lunch meal. Included on the pre-planned lunch menu was salad and a large container of salad was observed on the tray line. Also on the tray line was a container of assorted individual salad dressings. The FSD was present at the time of the observation and stated the individual assorted salad dressings were for resident use when a salad was on the menu. Inside the container were 5, 1.5 ounce servings of honey mustard salad dressing which had marked on the label by the manufacturer keep refrigerated. The 5, 1.5 ounce servings of salad dressing all felt at room temperature. The FSD stated the single serve honey mustard salad dressing was pulled from a box stored in dry storage. The FSD obtained the box containing 18 singe serve honey mustard salad dressings off shelving in dry storage and noted the manufacturer instructions outside the box must be refrigerated. The FSD stated she wasn't aware the single serve honey mustard dressing needed to be refrigerated. The FSD stated she thought the Assistant Food Service Director (AFSD) only bought shelf stable salad dressings. The AFSD was present at the time of the interview and stated she was not aware the honey mustard salad dressing needed to be refrigerated. On [DATE] at 8:00 PM the Administrator stated he expected frozen foods to be stored frozen, food that required refrigeration to be refrigerated and food not stored beyond the manufacturer expiration date.

Based on observations and staff interviews the facility failed to repair scratched doors in resident bathrooms (#201 and #213) failed to repair a scratched closet in resident room (#203), failed to repair torn laminate on closet in resident room (#213) and failed to repair holes in bathroom doors in resident rooms (#204 and #213) on 1 of 4 resident hallways. The findings included: 1. Observation on 07/17/18 at 12:32 PM of the private bathroom of resident room [ROOM NUMBER] revealed both sides of the lower half of the bathroom door had multiple scratches. Subsequent observations on 07/19/18 at 8:56 AM and 07/20/18 at 5:06 PM revealed the condition of the door remained unchanged. 2. Observation on 07/17/18 at 11:53 AM of the shared bathroom of resident room [ROOM NUMBER] revealed the lower half of the inside bathroom door of room [ROOM NUMBER] had multiple scratches. Subsequent observations on 07/18/18 at 9:31 AM and 07/19/18 at 8:35 AM revealed the condition remained unchanged. Observation on 07/17/18 at 11:53 AM in resident room [ROOM NUMBER] revealed an approximately 11 inch X 5.5 inch area on the bottom of the right side of the closet door had torn laminate. Subsequent observations on 07/18/18 at 9:31 AM and 07/19/18 at 8:35 AM revealed the condition remained unchanged. Observation on 07/17/18 at 11:53 AM of resident room [ROOM NUMBER] revealed an approximately 6 centimeter (cm) hole in the room side of bathroom door. Subsequent observations on 07/18/18 at 9:31 AM and 07/19/18 at 8:35 AM revealed the condition remained unchanged. 3. Observation on 07/17/18 at 12:38 PM in resident room [ROOM NUMBER] revealed the right side of the closet wall had multiple scratches. Subsequent observations on 07/19/18 at 8:58 AM and 07/20/18 5:03 PM revealed the condition remained unchanged. 4. Observation on 07/17/18 at 2:01 PM in resident room [ROOM NUMBER] revealed an approximately 6 cm hole in the room side of the bathroom door. Subsequent observations on 07/18/18 at 10:52 AM and 07/19/18 at 8:35 AM revealed the condition remained unchanged. An interview with the Maintenance Assistant (MA) (the Maintenance Supervisor (MS) was on vacation) on 07/20/18 at 4:41 PM was conducted. The MA stated the work order system the facility currently utilized was that the aides and the nurses wrote a note and put it in the box that was mounted on the wall on the way out of the front of the building by the Administrator's office. The MA explained he checked the box twice a day and prioritized the work orders in the order they came in. The MA further stated the Administrator, MS and he made walking rounds about every other day and he would document the repairs that needed to be made. During an environmental tour with the MA on 07/20/18 at 4:55 PM he explained they (Administrator, MS and he) talked about the holes in the doors a couple of weeks ago and hopefully when he (MS) returned from vacation they could change them. The MA stated the bathroom doors could be sanded to remove the scratches and he was not sure what the Administrator and MS had decided what to do about the scratched and torn closets. An interview was conducted with the Administrator on 07/20/18 at 8:15 PM who confirmed there were no definite plans for the facility to go through renovations. The Administrator stated he expected his Maintenance Department to conduct rounds through the resident rooms and make repairs as needed. The Administrator further stated he expected the residents' living quarters to be homelike.

Based on observation, record review, and staff interviews, the facility failed to use proper infection control practices by failing to apply personal protective equipment and wash hands prior to entering a room and failing to wash hands prior to exiting a room that was identified as having contact precaution isolation for 1 of 1 residents on contact isolation (Resident # 20). Findings included: Review of the facility's policy and procedure for [MEDICATION NAME] Contact Precautions dated 4/18/17 revealed: · Gown and gloves to be utilized upon entering room. · Perform hand hygiene prior to entering room. Wash hands with soap and water after removing gloves and before leaving room. A lab dated 6/15/17 revealed Resident # 20 positive for clostridium difficile (c-diff). Medical record review for Resident # 20 revealed a doctor's order dated 6/15/17 indicated [MEDICATION NAME] contact precautions until treatment completed. The medical record further revealed a doctor's order dated 6/16/17 for isolation precaution,[DIAGNOSES REDACTED] positive. Observation of the Dietary Manager (DM) on 6/18/17 at 12:31 PM revealed she went into an [MEDICATION NAME] contact isolation room with two drinks and did not perform hand hygiene or don gloves prior to entering room. There was a sign posted on the door of Resident # 20's room that read [MEDICATION NAME] Contact Precaution. The DM adjusted Resident # 20's blinds on his window. The DM exited the contact isolation room with the two drinks without washing her hands. An interview with the DM on 6/18/17 at 12:58 PM stated she had entered Resident # 20 room and adjusted his window blinds. The DM indicated she did not wash her hands prior to entering or leaving the room. The DM stated she did not don any gloves prior to entering the room. The DM indicated she was not aware that Resident # 20 was on precautions because she did not see the precaution bag on the door. An interview with the Director of Nursing on 6/18/17 at 2:40 PM indicated her expectations were for all facility staff to follow the policy and instructions on the door as they are written for contact precautions, and if they had any questions they would be expected to ask her or the nurse. An interview with the Administrator on 6/19/17 at 3:11 PM indicated his expectations were for the staff to follow the guidelines, policy and procedures that were in place for contact precautions.

Based on observations, staff interviews, resident interviews and record reviews the facility failed to provide one (1) of thirteen (13) sampled residents with assistance to maintain their ability to eat. (Resident #8). The findings are: Resident #8 has [DIAGNOSES REDACTED]. The resident was included on the facility's listing of interviewable residents. Review of Resident #8's most recent Minimum Data Set (MDS) assessment of 07/15/11 revealed she required supervision and one person physical assistance with eating. Resident #8's current plan of care, which was initiated on 06/17/11, contained a "Problem/Need" which addressed a need for assistance with Activities of Daily Living (ADLs) related to her weakness and shortness of breath. The care plan's goal specified that Resident #8 would continue to feed herself. An approach specified that staff were to encourage Resident #8 to be as independent as able and to monitor for a decline in her ability to participate with ADLs. On 08/03/11 at 9:22 a.m. Resident #8 was observed in bed as staff served her breakfast meal. Staff provided the resident with set up assistance with her meal tray and encouraged her to eat her breakfast. At 9:25 a.m. staff was observed to leave the resident's room. Observations of Resident #8 from 9:25 a.m. to 9:47 a.m. revealed that she became easily fatigued as she attempted to feed herself and drink milk from a regular sized cup. As she attempted to feed herself independently Resident #8 was observed to have difficulty getting foods and fluids from her meal tray to her mouth due to her hands shaking. The resident was observed to spill foods and milk onto herself while feeding herself. During this observation staff was observed to enter the resident's room at 9:37 a.m. and 9:47 a.m. to encourage her to eat, but offered no physical assistance. At 9:48 a.m. staff was observed to remove Resident #8's breakfast meal tray from her room and to leave her milk on her over bed table which was positioned to the resident's left side. Observations of the resident's finished breakfast tray revealed that she ate less than twenty-five (25) percent of the meal. On 08/03/11 at 9:50 a.m. Resident #8 stated that she becomes very tired when feeding herself and that it is difficult to eat very much. The resident also stated that she did not consume very much of the milk that was served on her breakfast tray because she became weak and that it was difficult for her to drink from a regular sized cup. The resident stated that she now needed to use smaller cups to be able to drink fluids with spillage. The resident explained that she had previously made staff aware of this need, but continued to be served fluids in regular sized cups. The resident specified that she did not want to be fed, but in order for her to be as independent as possible with eating she now required beverages to be served in smaller cups and more staff assistance. On 08/03/11 at 10:05 a.m. a staff member was observed to enter Resident #8's room and provided her with a four (4) ounce yogurt. Staff set the unopened yogurt on the resident's over bed table and exited the room. Staff did not provide Resident #8 with a eating utensil or open the container prior to leaving the resident's room. On 08/03/11 at 10:50 a.m. Resident #8 was observed in bed with the unopened four ounce yogurt still on her over bed table. The resident stated that she would like to try the yogurt, but needed assistance. The resident specified that she needed someone to open the container of yogurt and needed a spoon to be able to eat the yogurt. On 08/03/11 at 11:15 a.m. Nursing Assistant (NA) #2 was observed to enter Resident #8's room. The resident stated that she had not eaten her yogurt because she could not open it and was not provided with a spoon. Resident #8 said she did not want to eat the yogurt now because it was too warm. Interview with NA #2, at this time, revealed that Resident #8 required assistance with eating and that her fluids needed be served in small cups to allow her to drink beverages without difficulty. NA #2 provided Resident #8 with a small cup that contained thickened water and the resident consumed it without difficulty. Interview with administrative staff on 08/03/11 at 11:25 a.m. revealed that Resident #8 should be assisted by staff to eat her meals and snacks. Staff also stated that Resident #8's beverages should be served in small cups and that all of her foods needed to be opened to allow her to be as independent as possible with eating.

Based on observations, staff interviews and record review, the facility failed to keep fingernails clean for one (1) of nine (9) sampled residents who were dependent on staff to maintain their personal hygiene.(Resident #9). The findings are: Resident # 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed the resident required extensive assistance from staff for activities of daily living (ADL) including personal hygiene. A review of the Care Area Assessment (CAA) Summary dated 04/01/11 revealed ADL to be addressed in a care plan due to nutritional problems, mental errors: sequencing problems, incomplete performance, anxiety limitations, and physical limitations such as weakness, limited range of motion, poor coordination, poor balance, visual impairment and pain. Resident #9's current care plan, dated 06/07/11, specified that that she required extensive to total assist with ADLs due to [MEDICAL CONDITION] with limited range of motion. An approach included: provide assist with all ADLs as needed. On 08/02/11 at 10:25 a.m. Resident #9 was observed in his room lying in bed. His fingernails on both hands were long and had brown debris underneath them. The resident was asked when he gets his nails cut and he said he did not want his nails cut because he opens soda cans with them. On 08/02/11 at 4:15 p.m., 08/03/11 at 9:30 a.m., 08/04/11 at 12 noon and on 08/04/11 at 2:40 p.m. Resident #9's nails were observed with brown debris underneath the nails on both hands. On 08/04/11 at 2:40 p.m. Nursing Assistant (NA) #1 who was caring for Resident #9 was interviewed. NA #1 stated that NAs usually trim and clean nails during shower days. The NA said Resident #9 is bed bound and he has to keep an eye on his nails to make sure they are cleaned during his bed baths or as needed. The NA observed the resident's nails and confirmed they should have been cleaned. On 08/04/11 at 3:00 p.m. The Director of Nursing (DON) was interviewed. The DON stated resident's nails should be cleaned daily. She said NAs need to check resident's nails for length on bath days and trim them if needed and if the resident chooses to have them trimmed.

Based on observations and staff interviews the facility failed to ensure one(1) of one(1) nourishment freezer units worked properly. The findings are: During an initial tour of the facility on 7/26/10 at 9:15 a.m. the facility's nourishment refrigerator freezer was observed. The freezer's internal thermometer registered 10 degrees Fahrenheit. The freezer contained individual ice cream cups that were soft to touch. The nourishment freezer was observed for a second time on 7/26/10 at 3:00 p.m. that revealed the ice cream was soft to touch. On 7/27/10 at 8:45 a.m. the nourishment freezer was observed in use with 28 individual ice cream cups soft to touch stored ready for use. A subsequent observation that occurred on 7/27/10 at 1:50 p.m. revealed 25 individual ice cream cups soft to touch stored ready for use. During this observation Nurse Aide (NA) #1 was interviewed and confirmed individual ice cream cups stored in the nourishment freezer were for residents. She reported the ice cream was available upon request. On 7/28/10 at 10:00 a.m. the facility's Regional Registered Dietitian (RD) was interviewed and reported the second shift cook is responsible for checking the temperature of nourishment refrigerator freezer. The temperature log for 7/10 was reviewed and revealed no concerns were documented with the freezer's temperature. The RD confirmed the ice cream was soft and removed all cartons of ice cream from the freezer unit. On 7/29/10 at 11:00 a.m. the Maintenance Director was interviewed and reported he did not monitor the nourishment freezer. He confirmed he would expect to receive a work request order if the unit was not working properly. He added the nourishment refrigeration unit was not cooling properly and the freezer unit needed to be defrosted. He was unaware of when the unit was last defrosted and confirmed this should be done routinely.

Based on observations, staff interviews, and medical record review, the facility failed to keep fingernails clean for one (1) of ten (10) residents (Resident # 9). The findings are: Resident # 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The latest Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory problems and was moderately impaired in cognitive skills for daily decision making. The MDS further revealed the resident required extensive assistance with most activities of daily living including grooming. A review of the resident's care plan revised 07/14/10 revealed the resident required assistance with activities of daily living. One intervention instructed staff to provide nail care as needed and keep nails clean and trimmed. On 07/27/10 at 10:51 a.m. Resident # 9 was observed dressed and up in her wheelchair at a group activity. She had black matter beneath the fingernails of both her hands. At 3:23 p.m. she was again observed in her wheelchair with black matter beneath the fingernails of both her hands. On 07/28/10 at 9:25 a.m. Resident # 9 was observed dressed and up in her wheelchair. She was observed to have black matter beneath the fingernails of both her hands. At 2:20 p.m. she was again observed in her wheelchair with black matter beneath the fingernails of both her hands. On 07/28/10 at 2:24 p.m. the nursing assistant assigned to care for Resident # 9 was interviewed. She stated all residents received two showers a week during which a head to toe skin checks were performed which included checking for long and dirty fingernails. She stated nursing assistants were responsible for cleaning resident's fingernails. On 07/28/10 at 2:30 p.m. the licensed nurse assigned to care for Resident # 9 was interviewed. She stated that nursing assistants are responsible for cleaning resident fingernails as needed. She also stated that Resident # 9 does not refuse grooming or bathing care. On 07/28/10 at 4:21 p.m. the Director of Nursing (DON) was interviewed. She stated that she expected nail care to be done whenever it was needed. She stated that facility policy is for nursing assistants to check residents' fingernails daily and clean and trim them as needed. The DON observed the fingernails of Resident # 9 and stated that they were dirty and needed cleaning. She asked the resident if she would allow her to clean her nails and the resident answered yes.

Based on observations and staff interview, the facility failed to ensure water temperatures in resident living areas did not exceed 118 degrees Fahrenheit on one (1) of three (3) halls (C hall), and failed to ensure two people assisted a resident during a lift transfer for one (1) of five(5) residents. (Resident # 28) The findings are: 1. On 7/26/10 between 9:45 and 10:00 a.m., a tour was made of all facility halls to spot check water temperatures in resident hand sinks. Hand sinks were checked in two resident bathrooms on opposite sides of each hall. The sinks were chosen for their proximity to water heaters and the kitchen. The following water temperatures were recorded using a digital thermometer in hand sinks in bathrooms adjacent to resident rooms on the C hall: Room 5 123.9 degrees Fahrenheit Room 1 123.3 degrees Fahrenheit On 7/26/10 at 10:00a.m. the Maintenance Director was contacted and interviewed. He stated he randomly checks water temperatures in resident hand sinks weekly and documents them. He stated his goal is to keep the temperatures below 116 degrees Fahrenheit. He reported that on 7/23/10 he received a concern from the nursing staff of water temperatures being too hot. He confirmed the water temperature in resident's hand sink measured 117 degrees Fahrenheit and an adjustment was made to the metering device (a device used to meter the amount of hot and cold water being mixed together). A review of his log for the year revealed the highest temperature to be 117 degrees Fahrenheit, recorded on 7/23/10. The Maintenance Director confirmed he had not monitored the water temperature to residents' rooms since making the adjustment to the metering device on 7/23/10. On 7/26/10 at 11:00 a.m. the Maintenance Director reported digital and dial thermometers are used to record water temperatures. He confirmed his dial thermometer was last calibrated approximately six (6) months ago. The Maintenance Director then spot checked resident hand sink temperatures using his dial thermometer that recorded: Room 5 120 degrees Fahrenheit During this time the Maintenance Director confirmed the water temperature was "too hot" and left to adjust the mixing valve. On 7/29/10 at 2:00 p.m. the Maintenance Director was interviewed and reported the metering device on the mixing value was faulty and had to be replaced. He confirmed this was the likley cause of the water temperature being too hot. 2. Resident # 28 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessed the resident as needing extensive assistance with transfers and use of a mechanical lift. Review of Resident # 28's record revealed a care plan dated 11/12/09 and review date 07/16/10 entitled high risk for recurrent falls secondary to history of falls and weakness related to anemia, recurrent UTI's and pneumonia and increased confusion, and indicates resident is on a fall management program(12/01/09). Resident required low bed and fall mat. Record review further revealed a transfer assessment performed by physical therapy dated 04/27/10 which indicated fall precautions. A physical therapy department assessment dated [DATE] indicated the resident was to be transferred by total lift with the assistance of two persons. Record review revealed a document entitled "Safe Resident Handling Assessment Form" dated 04/30/10 which indicated Resident # 28 required a total lift with the assistance of two people. An additional Safe Resident Handling Assessment Form dated 05/19/10 indicated Resident #28 required a sit to stand lift with two person assist. A nurses note dated 06/09/10 indicated that at approximately 9:15 am a nurse assistant reported resident was lowered to the floor with total lift. Upon arrival resident was on the floor on left side, skin tear on forearm underneath watch, with no apparent head injury noted. Record further revealed the resident complained of hip pain and was x-rayed and found to have no hip injury. During an observation of Resident # 28 on 07/28/10 at 1:15 pm she was transferred using a sit to stand lift assisted by Nurse assistant(NA) #1 and NA # 2. Resident # 28 stated that while she was being weighed, the NA dropped her from a total lift and she had a skin tear on her left forearm. A sign on the doorway to Resident #28's room indicated " SS2" which was interpreted by NA #1 as meaning the resident required a sit to stand lift with two person assist. Nurse Assistant (NA) # 1 and NA # 2 were interviewed on 07/28/10 at 1:30 pm and indicated each resident who requires lift assistance has a sticker/sign on the door indicating the type of lift and how many people were to assist. They further stated that any person who is unable to stand is weighed by total lift and usually another NA is able to help the NA assigned to weigh residents. NA #3 was interviewed on 07/29/10 at 1:40 pm and stated she was the NA assigned to do weights. She further stated that the number of people needed for lift transfer is on the resident's door and in the Patient Care Book. She indicated she was assigned to weigh Resident # 28 on 06/09/10 and was going to transfer her to the shower chair to be taken to the shower afterwards. She indicated she removed the fall mat in order to position the lift. She stated she was the only staff person transferring Resident #28 and when she pulled the lift back Resident #28 turned sideways in the lift. NA #3 said she lowered her to the floor. Na # 3 stated she was unaware that Resident # 28 required two people to assist during transfer. She further indicated another NA was in the room with her prior to the transfer and was called out to do something else, so she continued to transfer the resident by herself. An interview with the Director of Nurses on 07/29/10 at 10:15 am revealed her expectation was that the resident could have been weighed by only one person, however, with transfers the resident record indicated the need for two persons to assist with a sit to stand lift at the time of the incident.