Hibriten Mountain Nursing And Rehabilitation

Based on manufacturer guidelines, observations and staff interviews, the facility failed to label DuoNeb solution (inhalation breathing solution) with an open date for 1 of 3 medication carts (C and D medication cart) reviewed for medication storage.The findings included:Review of the manufacturer's guidelines for DuoNeb solution indicated: After opening the foil pouch individual vials of DuoNeb should be used within 14 days. On 02/17/26 at 2:30 PM an observation was made of the C and D medication cart accompanied by Nurse #1. The observation yielded an open and undated box of Duoneb solutions in the drawer of the medication cart and available for use. The delivery date on the box was 12/23/25.An interview was conducted with Nurse #1 on 02/17/25 at 2:30 PM who explained that the box of DuoNeb should be dated when opened because if the vials were not used within 7 days, then they should have been discarded. During an interview with the Director of Nursing (DON) on 02/19/26 at 10:30 AM the DON explained that the medication carts should be checked every day by the Nurse on the cart and making sure the DuoNeb solutions were dated was a part of the daily checks. The DON stated her expectation was that the Nurse who opened the box of DuoNeb solution should be the one who dated the box.

Based on observations, record review, and staff interviews, the facility failed to follow their Infection Control policy and Hand Hygiene policy when Nurse Aide #1 did not perform hand hygiene before applying clean gloves and Nurse Aide #1 nor the Unit Manager applied gowns while providing suprapubic catheter care on Resident #26. This deficient practice occurred for 2 of 7 staff members observed for infection control practices (Nurse Aide #1 and Nurse #4).The findings included:Review of the facility's policy and procedure entitled Hand Hygiene revised June 2025 read in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.Review of the facility's Enhanced Barrier Precautions policy last revised June 2025 read in part as follows: Enhanced barrier precaution (EBP) are utilized to reduce the transmission of multidrug resistant organisms (MDROs) to residents. EBP's employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gowns and gloves for EBPs include dressing, providing hygiene, and changing briefs. EBPs are indicated for residents with indwelling medical devices regardless of MDRO colonization. Indwelling medical devices include urinary catheters. EBPs remain in place for the duration of the resident's stay or until resolution or discontinuation of the indwelling medical device (catheter) that places them at risk.An observation of suprapubic catheter care was conducted on Resident #26 on 02/18/26 at 2:00 PM by Nurse Aide (NA) #1 and Nurse #4. Upon entering the Resident's room both staff removed gloves from the personal protective equipment (PPE) tower that was mounted on the Resident's door and applied the gloves but did not apply a gown. An enhanced barrier precaution sign that indicated the specific PPE required which was a gown and gloves was posted on the door. NA #1 removed the dirty dressing from the Resident's suprapubic site then removed her dirty gloves and applied clean gloves without sanitizing her hands. The NA cleaned the suprapubic site and catheter tubing then removed her dirty gloves and without utilizing hand sanitizer she applied clean gloves. Nurse #4 then applied a dressing to the suprapubic site and removed her gloves and washed her hands.An interview was conducted with Nurse Aide #1 on 02/18/2026 at 2:20 PM. The NA was asked what precautions Resident #26 was currently on and the NA explained that it was enhanced barrier precautions and that she should have worn a gown while providing care to Resident #26. The NA continued to explain that she realized that she did not wash her hands between gloves changes which she should have. She stated she was nervous and forgot. On 02/18/2026 at 2:40 PM during an interview with Nurse #4 the Nurse explained that she did not know what type of precautions Resident #26 was on until she pulled his information up on the computer during the interview. The Nurse continued to explain that the Resident was on enhanced barrier precautions, and she should have worn a gown. She stated she did not pay attention to the enhanced barrier precaution sign posted on the Resident's door and that she did not do anything to Resident #26 that would warrant wearing a gown.An interview was conducted with the Director of Nursing (DON) on 10/19/26 at 10:06 AM. The DON explained that NA and the Nurse should have worn a gown for enhanced barrier precautions and that NA #1 should have washed or sanitized her hands between glove changes. She indicated both staff needed to be reeducated on enhanced barrier precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff and resident interviews, the facility failed to assess Resident #62 for the ability to self-administer medications for 1 of 1 resident reviewed for self-administering medications.The findings included:Resident #62 was admitted to the facility on [DATE].Resident #62's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact.Review of Resident #62's physician orders revealed there were no orders for a calcium carbonate (Tums) medication.Review of Resident #62's medical record revealed there was no self-administer assessment. On 02/16/2026 at 10:19 AM an observation was made of Resident #62's room where there was a bottle of calcium carbonate (Tums) tablets on her bed which was approximately 1/4 full. Resident #62 was not in the room. On 02/16/2026 at 3:18 PM an observation of the bottle of calcium carbonate (Tums) tablets was sitting on the Resident's over bed table which was approximately 1/4 full. Resident #62 was not in the room. On 02/17/2026 at 10:30 AM an observation and interview were conducted with Resident #62. The Resident stated her family brought the bottle of Tums to her because she needed them when she had heartburn. She stated she did not take them often, but she wanted to be able to take them when she needed them. Resident #62 could not say when the last time was that she took the tablets. On 02/18/2026 at 11:13 AM an interview and observation were made in Resident #62's room with Nurse #4. The Nurse stated she did not know that Resident #62 kept the Tums tablets in her room. The Nurse explained that Resident #62 did not have an order to self-administer medications and that she believed Resident #62 would not be safe to self-administer because some days she could be lethargic because of her medications. Nurse #4 removed the bottle of medication from the Resident's room.An interview was conducted with the Director of Nursing (DON) on 02/19/26 at 10:40 AM. The DON explained that Resident #62 did not have an order to self-administer and that they would get an order for an antacid for her heartburn.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, family, and staff interviews, the facility failed to complete a Do Not Resuscitate (DNR) form (a DNR form is a legal document signed by the physician) for a resident with a DNR physician order (Resident #11) at admission. The facility also failed to ensure resident advanced directive information was consistent throughout the medical record (Resident #31 and Resident #62). This deficient practice occurred for 3 of 6 residents reviewed for advanced directives.Findings included:
1. Resident #11 was admitted to the facility on [DATE].
A review of Resident #11's physician orders revealed an order for advanced directive of do not resuscitate (DNR) dated [DATE].
An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #11 was severely cognitively impaired.
A review of Resident #11's electronic medical record (EMR) revealed the advanced directive banner at the top of Resident #11's EMR page documented that his advance directive was DNR.
Review of the advanced directives notebook kept at the nurse's station revealed there were no advanced directives on file for Resident #11.
On [DATE] at 3:28 PM an interview was conducted with Nurse #3 who was assigned to Resident #11 that day ([DATE]). Nurse #3 explained that if she had to immediately determine a resident's advanced directives, she would look at the resident's medical record on the computer and she would look in the advanced directives notebook kept at the nurse's station. Nurse #3 looked in the advanced directives notebook for Resident #11's DNR form and acknowledged the form was not in the book. Nurse #3 stated that she was unsure who completed the code forms when a resident was admitted . Nurse #3 indicated that the Assistant Director of Nursing (ADON) and Director of Nursing (DON) would be responsible for ensuring the code forms were in the notebook stored at the nurse's station.
An interview was conducted with the DON on [DATE] at 3:43 PM. The DON explained that if a resident was a DNR then there should be a DNR form in the advanced directive notebook at the nurse's station in case of an emergency. The DON verbalized that Resident #11 was a DNR and verified on the EMR. The DON stated that the Social Worker was responsible for completing the advanced directive forms upon admission. The Social Worker was also responsible for audits of the advanced directive notebook to ensure the correct forms were in place. The DON explained that the previous Social Worker worked [DATE] through last week but was no longer employed at the facility. The new Social Worker began work today and would have no knowledge of Resident #11's advanced directive information. The DON verbalized she was unaware if the former Social Worker discussed advanced directives with Resident #11's family when he was admitted . The DON indicated Resident #11 was admitted from the hospital with an order for DNR, but she was unsure if the former Social Worker had a completed DNR form.
An interview with the Administrator was conducted on [DATE] at 12:11 PM. The Administrator stated that the DNR forms should be available for facility and emergency staff in case a resident had an emergency. The Administrator verbalized that she would expect the staff to follow the physician's orders and all advanced directive information should match and completed accurately. The Administrator stated that the ADON and DON would be responsible for ensuring accurate code forms were placed in the advanced directive folder if there was no Social Worker available.
2. Resident #62 was admitted to the facility on [DATE].
Review of Resident #62's electronic health record revealed a physician's order dated [DATE] for Do Not Resituate (DNR).
Review of Resident #62's care plan revised [DATE] revealed a Full Code status. The interventions included honoring the Resident's wishes and reviewing the (code status) with the Resident and/or family during quarterly care conferences.
Review of Resident #62's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact.
Review of Resident #62's physician progress note dated [DATE] revealed the advanced directive status was Full Code Blue.
Review of the code status notebook kept at the nursing desk revealed there was no advanced directive information in the notebook for Resident #62.
On [DATE] at 12:11 PM during an interview with the Administrator, she explained that it was her expectation that the staff follow the advanced directives and the advanced directive information should be the same throughout the medical record.
An interview was conducted with the Director of Nursing (DON) on [DATE] at 12:36 PM. The DON explained that the advanced directive paperwork was initiated at admission and periodically audited by the Social Worker (SW) which included making sure the advanced directives were in place and matched in the medical records and in the code status notebook at the desk, but the SW resigned last week. The DON stated it was possible that the discrepancies happened during one of the Resident's admissions to the hospital. Regardless, the DON indicated the advanced directives should match throughout the medical record.
During an interview with Nurse #3 on [DATE] at 9:10 AM the Nurse explained that if she had to determine what a resident's code status was, she would either look on the residents' profile page in their medical record (the profile page displays the residents' picture with their advanced directive listed underneath) or look in the code status notebook at the nursing desk. She indicated that if nothing was in the code status notebook then she would refer to the profile page in the medical record.
An interview was conducted with the Unit Manager (UM) on [DATE] at 11:46 AM. The UM explained that if she had to determine a residents' code status in a hurry it would depend on if her computer was booted up and if so, she would look at the profile page where the advanced directive was listed under their picture. She continued to explain that if she was closer to the nursing desk she would look in the code status notebook. The UM stated the two areas should match.
3. Review of the hospital Discharge summary dated [DATE] revealed Resident #31's code status was No Cardiopulmonary Resuscitation (CPR) (DNR).
Resident #31 was admitted to the facility on [DATE].
Resident #31's physician orders revealed an order dated [DATE] which indicated a Do Not Resuscitate (DNR) status in the event he had no pulse and was not breathing.
Review of the code book (a binder that contained paper copies of residents' advanced directives and code status) revealed Resident #31's paper medical record indicated the Medical Orders for Scope of Treatment (MOST) form dated [DATE] stated a preference for Attempt Cardiopulmonary Resuscitate (CPR) in the event Resident #31 had no pulse and was not breathing. The form was signed by Resident #31's Responsible Party (RP) on [DATE]. The MOST form did not have a physician's signature.
Review of the Advanced Directive Discussion Document located in the code book and completed by the Director of Sales and Marketing/admission Coordinator dated [DATE] revealed to provide Cardiopulmonary Resuscitation in the event Resident #31 had no pulse and was not breathing. The form was signed by Resident #31's RP on [DATE].
Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had moderately impaired cognition.
Further review of Resident #31's electronic medical record (EMR) revealed a physician's progress note dated [DATE] that read in part: Code Status: Do Not Attempt Resuscitation (DNR/no CPR).
An interview was conducted on [DATE] at 3:38 PM with Nurse #3 who stated that she does not check the code book unless there was an emergency. She explained that if there was an emergency, she would check the code book and the resident's EMR for the resident's code status. Nurse #3 revealed that she did not know who completed the advance directive information and code status when residents were admitted to the facility. Nurse #3 further explained that the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were responsible for checking the code book.
An interview was conducted with Resident #31 on [DATE] at 9:10 AM. Resident #31 stated that he had an advanced directive in place and that he and his RP had made the decision that he would not want any type of CPR.
Multiple unsuccessful attempts to contact Resident #31's RP were made.
An interview was conducted with the Director of Sales and Marketing/admission Coordinator on [DATE] 2:34 PM who stated that she had been completing the advanced directive discussions and paperwork with newly admitted residents and/or their RP since the facility did not have a current Social Worker (SW). She explained that she met with Resident #31's RP on [DATE] and Resident #31's RP completed the Advanced Directive Discussion Form and the MOST form. She further explained that Resident #31's RP indicated that she wanted Resident #31 to receive CPR on both documents. The Director of Sales and Marketing/admission Coordinator stated that she placed Resident #31's completed Advanced Directive Discussion Form and the MOST form in the code notebook (a binder that contained paper copies of residents' advanced directives and code status) at the nursing station.
An interview was conducted on [DATE] 3:43 PM with the Director of Nursing (DON) who stated Resident #31's had not been deemed incompetent, and his RP had signed all of his admission paperwork including his Advanced Directive Discussion Form and his MOST form. The DON verified Resident #31's physician order in the EMR for a DNR did not match the Advanced Directive Discussion Form and the MOST form which indicated to provide CPR. The DON also verified that Resident #31's MOST form had not been signed by the physician. The Director of Nursing (DON) revealed the admission Coordinator completed the advanced directive forms because the facility did not have a current SW. The DON explained that the admission Coordinator placed the forms in the code notebook at the nursing station when she should have placed the forms in the physician's folder for review and signature.
An interview was conducted on [DATE] 4:11 PM with the Administrator who stated she expected the staff to follow the advanced directive orders and that all advanced directive information should match and be correct in all locations including in the EMR and the code notebook at the nursing station. The Administrator further stated that if the advanced directive information did not match, she expected the staff to clarify the information with the resident and the RP to ensure the resident's wishes were honored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of resident narcotic medications for 1 of 4 resident reviewed for misappropriation of resident property (Resident #62).Findings included:Resident #62 was admitted to the facility on [DATE].Review of Resident #62's physician orders revealed an order for 5 milligram (mg) oxycodone HCl oral tablet (an opioid pain medication) with one tablet to be administered by mouth every 12 hours for pain. This order was dated 06/06/25. Additionally, Resident #62 had another order for 5mg oxycodone HCl oral tablet with one tablet to be administered by mouth every 6 hours as needed for breakthrough pain. This order was dated 06/06/25 and discontinued on 09/04/25.Review of the facility's record of a pharmacy delivery notification revealed Resident #62 had a pharmacy order that included 2 cards of 30 tablets each of 5mg oxycodone immediate release tablets that were delivered by the pharmacy on 09/04/25. Additional review of the pharmacy delivery notification revealed it was signed as received by Nurse #3 at 10:38 PM.An interview with Nurse #3 on 02/18/2026 at 2:46 PM revealed she worked 2nd shift most of the time. Nurse #3 stated when the pharmacy made a delivery of opioid or narcotic medications, the medications came in a sealed purple bag, and they were handed off to one of the nurses that was working at the time of the delivery. She continued, stating that the nurse who received the delivery would be responsible for verifying the medication and the amount delivered and would then sign off as having received the mediation. Nurse #3 verified that she was the nurse who signed for the pharmacy delivery of Resident #62's Oxycodone HCL medication on 09/04/25. Per Nurse #3, she distinctly remembered there were two, thirty pill count cards for Resident #62 that were delivered on 09/04/25 and that she verified the count and medication before signing off on the pharmacy's delivery sheet. Nurse #3 stated after she signed for the medication delivery, she delivered Resident #62's medication to the nurse (Nurse #4) who was assigned to Resident #62 that evening as she would need to complete two separate Controlled Drug Count Sheets one for each card of medication delivered. Nurse #3 stated she had no idea what happened to Resident #62's Oxycodone but stated it never made it to the medication cart as only one Controlled Drug Count Sheet was completed.Review of Resident #62's controlled drug count sheet dated from 08/31/25 through 09/06/25 revealed there were 41 cards of medications at shift change at 3:00 PM on 09/04/25 on the medication cart belonging to the hall where Resident #62 resided. Per the controlled drug count sheet, Nurse #4 was the oncoming nurse and verified that there were 41 cards of medications at that shift change. Additional review of the controlled drug count sheet revealed Nurse #4 signed off at 11:00 PM that there continued to be 41 cards of medication on the medication cart. There did not appear to be any addition or subtraction of medication cards while Nurse #4 was working. The 2 cards of Oxycodone that were delivered to the facility for Resident #62 on 09/04/25 were not added to the controlled drug count sheet by Nurse #4.Multiple attempts to reach Nurse #4 via telephone on 02/18/26 and 02/19/26 were unsuccessful. Nurse #4 was no longer an employee at the facility.An interview with the Director of Nursing (DON) on 02/19/26 at 5:11 PM revealed she was aware of Resident #62's 30 missing oxycodone tablets and indicated that she had assisted in the investigation. She reported she was initially informed of a discrepancy when a first shift nurse requested a refill for Resident #62's Oxycodone medication due to Resident #62 only having a few pills left on one card that was delivered on 09/04/25 and the pharmacy informed them they could not fill the prescription due to their records indicating that Resident #62 had 60 opioid (oxycodone) medications delivered 09/04/25 and it was too soon for the medication to be refilled as there should be at least 30 pills of the opioid medication still available. The Director of Nursing stated they searched the medication cart for the additional card of medication but were unsuccessful in locating it. The DON stated at that time, she reported the concern to the Former Administrator and the Regional Nurse Consultant. She was directed to count all the cards on all the facility's medication carts which was completed and reportedly found no discrepancies. The Director of Nursing also reported she reviewed 30 days of pharmacy deliveries with no discrepancies found. The Director of Nursing reported she interviewed Nurse #3 who had signed for the delivery and was reportedly told that Nurse #3 did not count or verify the medications and just signed the delivery paperwork and could not verify if 30 or 60 oxycodone tablets were delivered from the pharmacy. The Director of Nursing reported she spoke with multiple other staff members who were present at the time of the delivery but was unable to locate a staff member who could verify 2 cards (60 pills) of Oxycodone were delivered for Resident #62 on 09/04/25. The Director of Nursing reported she had no idea whether the pharmacy failed to bring both cards (60 tablets) of Oxycodone medications for Resident #62 or if one of the two Oxycodone medication cards went missing between delivery by the pharmacy and delivery to the medication cart.An interview with the Former Administrator, who was the Administrator at the time of the incident on 09/04/25, was completed via telephone on 02/19/26 at 6:31 PM. The Former Administrator stated it was hard to remember this incident as he believed it occurred shortly after he started. He stated he believed the Director of Nursing reported to him that there was some missing medication and when they began investigating, it seemed to had been going on for a couple weeks before it was discovered. The Former Administrator reported he recalled that the situation was discovered when a nurse went to try and reorder an Oxycodone medication for Resident #62 and the pharmacy reported it was too early to refill. He stated he remembered this investigation centered around Nurse #4 as she was the nurse assigned to the medication cart the Oxycodone medication went to after delivery. However, he stated they were ultimately unable to determine what actually happened to the missing card of medication and that they ordered another card of opioid medication at the facility's expense. He reported he had no further knowledge of the investigation due to him not being at the facility any longer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident and staff interviews, and Psychiatric Nurse Practitioner (NP) the facility failed to refer one resident with a new mental health diagnosis for Preadmission Screening and Resident Review (PASRR) level II for 1 of 1 resident for PASRR (Resident #31).The findings included:A PASRR level I was completed on 10/29/2025 prior to Resident #31's admission to the facility with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition.Review of the hospital Discharge summary dated [DATE] revealed Resident #31 experienced hallucinations and was talking to the ceiling. Resident #31 received haloperidol (antipsychotic used to treat schizophrenia) 1 milligram (mg) twice a day for agitation and quetiapine (atypical antipsychotic used to treat schizophrenia) 50 mg twice a day and 100 mg at bedtime with no indication for use documented. Resident #31 was evaluated by the hospital psychiatrist, and the quetiapine was discontinued and loxapine (antipsychotic mainly used to treat schizophrenia) 10 mg twice a day was initiated. Resident #31's discharge orders included follow up with the facility psychiatrist and continue haloperidol 1 mg twice a day for agitation, loxapine 10 mg twice a day, and buspirone (medication used to treat anxiety) 15 mg three times a day. The hospital discharge did not reveal that Resident #31 had a diagnosis of schizophrenia. Review of Resident #31's electronic medical record (EMR) revealed Resident #31 was admitted to the facility on [DATE]. Resident #31 had no mental health diagnoses when he was admitted to the facility.A psychiatry visit note dated 01/09/2026 revealed Resident #31 served in the military and then later served with the Central Intelligence Agency (CIA). Resident #31's military history was confirmed by his family member. During the visit Resident #31 stated that I lost it at the hospital, and I started seeing things that were not there, became delusional and blacked out. Resident #31's family member reported that he had hallucinations and paranoia while in the hospital which resulted in a nurse in the hospital being physically injured by Resident #31. Resident #31 denied any signs or symptoms of anger or anxiety during the visit. No emotional or behavioral outburst have occurred since Resident #31 arrived at the facility.Review of the electronic medical record (EMR) revealed Resident #31 was diagnosed with paranoid schizophrenia on 01/13/2026. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had moderately impaired cognition and the MDS coding indicated he had a level I PASRR. The MDS revealed Resident #31 had schizophrenia and he had received antipsychotics, anti-anxiety medications, and anticonvulsants during the 7 day look back period.An interview was conducted with Resident #31 on 2/17/2026 at 9:04 AM. Resident #31 stated that he had served in the military for 13 years and was stationed in Bosnia and Afghanistan. He further explained that he had suffered with mental illness since his return from active military duty and had night terrors related to his war experiences. Resident #31 further explained that he has received psychiatry counseling for many years. Resident #31 could not recall when he was first diagnosed with paranoid schizophrenia. A telephone interview was conducted on 02/18/2026 10:51 AM with the Psychiatric NP who cared for Resident #31. The Psychiatric NP stated that during his initial visit with Resident #31 on 01/09/2026, Resident #31 stated that he was a veteran and suffered from paranoid schizophrenia and had a long standing history of mental illness related to his military experiences. The Psychiatric NP stated that Resident #31's history was verified with his family member and further stated that Resident #31 was managing very well on his current medication regimen. The Psychiatric NP stated that Resident #31 should have been evaluated for a level II PASRR due to his mental health history.An interview was conducted with the MDS Coordinator on 02/17/2026 at 12:57 PM. The MDS Coordinator stated that she identified Resident #31's diagnosis of paranoid schizophrenia on a psychiatric note dated 01/09/2026. The MDS Coordinator stated that Resident #31 did not have a diagnosis of paranoid schizophrenia on his hospital Discharge summary dated [DATE]. The MDS Coordinator explained that she did not have access to request Level II PASRR evaluations, but she passed the information along to the previous Social Worker (SW) who was no longer employed with the facility. The MDS Coordinator could not recall when she passed the information to the previous SW. The MDS Coordinator further revealed that the previous SW did not have access to request Level II PASRR evaluations and the only person in the facility who had access was the Assistant Business Office Manager. The MDS Coordinator stated that she thought the SW passed the information along to the Assistant Business Office Manager. Multiple unsuccessful attempts to contact the previous SW were made.An interview was conducted with the Assistant Business Office Manager on 02/17/2026 at 1:27 PM. The Assistant Business Office Manager stated that she had not received any information or request to submit a request for a Level II PASRR evaluation for Resident #31. The Assistant Business Office Manager stated that she usually received that information during the morning clinical meetings.During an interview on 02/18/26 at 1:08 PM with the Administrator, she communicated her understanding that PASRR level II evaluations should be completed in a timely manner upon the admission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis. The Administrator stated that Resident #31 should have had a PASRR level II evaluation submitted when the diagnosis of paranoid schizophrenia was added to his diagnoses. The Administrator further stated that she did not know why the referral for a level II PASRR was not submitted for Resident #31.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop an individualized person-centered comprehensive care plan for 1 of 6 residents whose comprehensive care plans were reviewed (Resident #63).The findings included:Resident #63 was admitted to the facility on [DATE] with diagnoses which included dementia, Parkinson's disease, and diabetes mellitus (DM).Review of Resident #63's admission Minimum Data Set (MDS) assessment dated [DATE] revealed moderately impaired cognition. Resident #63 required supervision with eating and bed mobility, moderate assistance with oral hygiene, toileting, and transfers, and required maximum assistance with bathing and dressing. The MDS also revealed Resident #63 was incontinent of bowel and bladder. Resident #63's MDS was coded for Parkinson's Disease, dementia, hypertension, diabetes, and arthritis. The MDS also indicated Resident #63 had no pain and no weight loss but received a therapeutic diet. She was at risk for pressure ulcer development and had no wounds. She had received anti-psychotic, anti-anxiety, and hypoglycemic medications during the 7 day look back period. The MDS also revealed Resident #63 was planning to discharge back to the community.Review of Resident #63's comprehensive care plan dated 12/10/2025 revealed one care plan entry was developed by the Registered Dietician (RD) related to the potential for nutritional problems. There were no other care areas addressed in Resident #63's comprehensive care plan.Review of the Care Area Assessments (CAA) (a tool used to identify relevant causes, risk factors and complications in order to develop a person-centered plan of care) completed by the MDS Coordinator on 12/12/2025 revealed Resident #63 triggered for the following CAAs: 1. Cognitive loss/Dementia2. Functional Abilities for Self-Care and Mobility3. Urinary Incontinence4. Psychosocial Well-being5. Activities6. Falls7. Nutritional Status8. Pressure Ulcer Injury9. Psychotropic Drug UseA review of Resident #63's care plan was completed on 02/18/2026 at 7:40 AM with the MDS Coordinator who verified the only care plan entry for Resident #63 was for nutrition which was completed by the RD. She further stated that she remembered completing Resident #63's comprehensive care plan and does not know what happened to her care plan. The MDS Coordinator also stated that she was aware that a comprehensive care plan should be developed within 21 days of the resident's admission to the facility. The MDS Coordinator further explained that the facility had two recent computer upgrades, and she thought something happened to Resident #63's care plan when the computer updates occurred. An interview was conducted on 2/18/2026 at 9:02 AM with the Administrator who stated that she expected all residents to have an accurate and complete comprehensive care plan and the care plan should reflect the resident's clinical condition, medications, and care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop a care plan in the area of urinary catheter for 1 of 3 residents reviewed for care plans (Resident #99). The findings included:Resident #99 was admitted to the facility on [DATE] with diagnoses that included urinary retention. The Resident was discharged on 07/22/25.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #99 had an indwelling urinary catheter.Review of Resident #99's medical record revealed orders dated 06/23/25 for urinary catheter, change catheter as needed, change catheter bag as needed, catheter care every shift and as needed, place stat lock to secure catheter and to check placement every shift.Review of Resident #99's Treatment Administrator Record for June and July 2025 revealed the Resident had a urinary catheter and received daily care for the urinary catheter.Review of Resident #99's comprehensive care plan dated 07/03/25 revealed there was no mention of a urinary catheter on the care plan.During an interview with the MDS Coordinator on 02/26/26 at 5:15 PM the MDS Coordinator reviewed Resident #99's care plan and acknowledged the urinary catheter was not on the care plan. She continued to explain that during the time of Resident #99's admission to the facility the facility was undergoing a change in companies which included an electronic medical record upgrade, and it was possible that when she was completing the care plan the system did not accept her input of the care plan.An interview was conducted on 02/26/26 at 5:40 PM with the Administrator who stated that she expected all residents to have an accurate and complete comprehensive care plan and the care plan should reflect the resident's clinical condition, medications, and care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, family member, and staff interviews, the facility failed to ensure a resident's toenails were trimmed and podiatry services were arranged for 1 of 1 resident reviewed for foot care (Resident #63).The findings included:Resident #63 was admitted to the facility on [DATE] with diagnoses which included dementia, Parkinson's disease, and diabetes mellitus (DM).Review of the admission nursing assessment dated [DATE] did not reveal any issues with Resident #63's toenails.Review of Resident #63's admission Minimum Data Set (MDS) assessment dated [DATE] revealed moderately impaired cognition. Resident #63 required moderate assistant with bed mobility, toileting and transfers and required maximum assistant with bathing and dressing. The MDS also revealed Resident #63 had Parkinson's Disease, dementia, DM, and arthritis. The MDS indicated Resident #63 had no rejections of care and was at risk for pressure ulcer development. Review of Resident #63's care plan dated 12/10/2025 revealed one care plan was developed by the registered dietician (RD) related to the potential for nutritional problems. There were no other care areas addressed in Resident #63's care plan. Review of Resident #63's weekly nursing assessments from 12/03/2025 through 02/17/2026 revealed no notation that her toenails were long and thick and needed trimmed.Review of the facility's podiatry clinic schedule for 12/29/2025, revealed Resident #63 was not seen by the podiatrist. There were no consultation reports or notations in Resident #63's Electronic Medical Record (EMR) that she was scheduled to see the podiatrist or that she had been seen by a podiatrist since admission to the facility.An observation and interview were conducted on 02/16/2026 1:19 PM. Resident #63's toes revealed thick, long, jagged toenails on both feet. Resident #63's left great toenail had a brownish coloring at the base of the nailbed which had started to extend upward to the middle of the toenail. Resident #63 stated that her toenails looked nasty and she would like to have them trimmed. She explained that she had not been able to bend down and take care of her toenails and feet for a long time. She further explained that her daughter trimmed her toenails before she came to the facility. An observation and interview were conducted on 02/17/2026 11:24 AM with the wound nurse and the Assistant Director of Nursing (ADON). The wound nurse stated that she usually noticed resident's toenails when she provided wound care to their feet, but she did not notice Resident #63's toenails and she did not request for her to be added to the podiatry list. The ADON stated that Resident #63 would need to be seen by the podiatrist because she was diabetic and it would be best for the podiatrist to take care of her toenails. The ADON also stated that the facility's Social Worker usually added residents to the podiatry list, but the facility did not currently have a Social Worker. The ADON stated that she was responsible for adding residents to the podiatry schedule but added she had not referred Resident #63 to the podiatrist since her admission.An additional interview with Resident #63 and her family member was conducted on02/17/2026 2:28 PM. The family member stated Resident #63 had not been able to care for her feet and toenails in a long time. The family member explained that she used to keep Resident #63's toenails trimmed and groomed because Resident #63 was a diabetic and she knew how important it was too watch her feet for diabetic complications. Resident #63 stated that her toes did not hurt but she would like to have her toenails trimmed because they looked so bad.An interview was conducted with Nurse Aide (NA) #2 on 02/19/2026 8:19 AM who stated that she often gave Resident #63 her showers. NA #2 stated she had noticed Resident #63's toenails were very long and needed to be trimmed. NA #2 stated but to be honest, I don't remember if I told anyone about Resident #63's toenails. NA #2 further explained that she usually reported any concerns or issues to the resident's assigned nurse. An interview was conducted on 02/19/2026 4:36 PM with the DON & Administrator. The Administrator stated that she understood the concerns with Resident #63's toenails and explained that the nursing staff should observe resident's toenails when they completed their skin assessments and showers. She stated that she expected all residents to be referred to Podiatry services if needed, especially residents with diabetes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and Consultant Pharmacist interviews, the facility failed to have a system in place to ensure an accurate account of 1 of 1 resident's controlled medications (Resident #98), failed to have effective systems in place to ensure 2 of 2 residents (Resident #53 and Resident #74) had their physician prescribed narcotic pain medication available for administration, and the facility also failed to have a system to maintain an accurate receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled drugs for 5 of 5 months. The deficient practice occurred for 3 of 4 residents reviewed for misappropriation of medications.The findings included:
Resident #98 was admitted to the facility on [DATE]. Resident #98 discharged on 01/15/26.
A physician order dated 08/29/25 read; Oxycodone HCl oral tablet 30 milligrams (mg) – Give one tablet by mouth every 4 hours as needed for chronic pain.
Review of the Initial Allegation Report submitted to the state agency on 12/23/25 indicated there was possible misappropriation of Resident #98's medication after noticing a discrepancy in Resident #98's oxycodone medication.
Review of the Investigation Report dated 12/30/25 revealed Resident #98 was discharged from the facility to the hospital and while he was out of the facility, two doses of Resident #98's 30 milligram(mg) Oxycodone (a opioid pain medication) was signed out as being given to Resident #98. The facility's investigation found that one of the oxycodone tablets was signed out by Nurse #4 but were unable to determine who signed out the 2nd oxycodone tablet. Nurse #4 was reportedly uncooperative with the investigation and was terminated and the facility reported Nurse #4 to the Board of Nursing. Per the facility's report, due to Nurse #4's lack of cooperation and being unable to determine the 2nd signature, they could not unsubstantiate or substantiate the allegation.
Review of Resident #98's progress notes in his electronic health record revealed a note dated 12/17/25 that read: [Patient] is unresponsive and hypotensive and hypoxic. [Emergency Medical Services] called. Patient's [family] notified. The note was time-stamped 5:40 PM and was written by Nurse #4.
Additional review of Resident #98's progress notes revealed a note dated 12/17/25 at 8:33 PM that was a medication administration note for a single 30 mg oxycodone tablet. This note was written by Nurse #4.
Review of Resident #98's Medication Administration Record from December 2025 revealed the last dose of Oxycodone 30 mg tablet was signed as being provided to Resident #98 at 2:49 PM on 12/17/25 by Nurse #4.
Review of Resident #98's Controlled Medication Utilization Record for Resident #98's 30 mg Oxycodone tablets dated 12/17/25 revealed 2 doses of Oxycodone 30 mg tablets were signed out after Resident #98 was sent out to the hospital. One dose was signed out by Nurse #4 on 12/17/25 at 6:00 PM and another dose was signed out on the same date with an unreadable time with an unreadable signature.
Multiple attempts to reach Nurse #4 via telephone call on 02/18/26 and 02/19/26 were unsuccessful.
An interview with the Director of Nursing on 02/19/26 at 4:55 PM revealed she was familiar with the incident and reported she had investigated this potential diversion of Resident #98's medication. The Director of Nursing reported Resident #98 was sent out to the hospital on [DATE] and after he was discharged , she requested after Resident #98 left (time unknown) that his medications be pulled from the medication cart so they could be sent back to the pharmacy. She stated she could not recall who brought her Resident #98's medication but reported while she was reviewing the medications and the controlled medication utilization records, she noted there appeared to be 2 doses of Resident #98's 30 mg Oxycodone that were dispensed after Resident #98 discharged from the facility. She stated at that time she notified the Former Administrator. She reported she and the former Administrator attempted to reach Nurse #4 multiple times, but Nurse #4 continued to have reasons she could not talk or come to the facility. The Director of Nursing stated she did receive a text from Nurse #4 which was a statement of what led to Resident #98 being discharged to the hospital, but nothing was said about why she appeared to have signed out at least one dose of Resident #98's 30 mg Oxycodone after he discharged to the hospital. When the Director of Nursing reached out for an explanation, Nurse #4 never responded. The Director of Nursing reported Nurse #4 was ultimately terminated due to what appeared to be her dispensing medications for a resident who was not in the building at the time they were dispensed and for failure to respond to the investigation inquiries. The Director of Nursing stated she was confident that Nurse #4 had, at least, signed out one of the doses of Resident #98's 30 mg Oxycodone.
An interview with the Former Administrator on 02/19/26 at 6:27 PM revealed he remembered there was an issue with Nurse #4 and they believed she had diverted some opioid medications from a resident at the facility. He reported he did recall Nurse #4 not being very cooperative with the investigation and was ultimately terminated. He reported that he believed that the incident and Nurse #4 were reported to the Board of Nursing and apologized but stated he could not recall much else regarding the investigation.
2. Resident #53 was initially admitted to the facility on [DATE] with a readmission date of 01/15/26.
A physician order for Resident #53 dated 11/21/25 read: oxycodone (an opioid pain medication) 15 milligrams (mg), one (1) tablet by mouth every 6 hours, scheduled for pain.
A review of Resident #53's medication administration record (MAR) from December 2025 revealed oxycodone 15 mg, one (1) tablet by mouth, was administered as ordered from 12/05/25 through 12/10/25. The times of administration were: 6:00 PM, 12:00 AM, 6:00 AM, and 12:00 PM
Resident #102 was admitted to the facility on [DATE] with diagnoses which included chronic pain and opioid dependence.
A review of Resident #102's physician's orders revealed an order dated 11/04/25 for oxycodone 15 mg one (1) tablet by mouth twice daily scheduled.
A review of the completed controlled substance accountability record for Resident #102 dated 11/30/25 for oxycodone 15 mg immediate release tablets, revealed that Resident #53 was administered oxycodone 15 mg per the physician order using Resident #102's supply of oxycodone 15 mg from 12/05/25 at 6:00 PM through 12/10/25 at 12:00 PM by multiple nurses. Nurses documented that medication was borrowed for Resident #53. During the time frame 12/05/25 to 12/10/25 the following nurses documented that they borrowed oxycodone 15 milligrams from Resident #102 for Resident #53: Nurse #9, Nurse #7, Nurse #5, Nurse #11, and the Unit Manager. A total of 20 tablets were borrowed from Resident #102's medication supply for Resident #53.
A telephone interview with Nurse #7 who was no longer employed at the facility was conducted on 2/20/26 at 2:18 PM. Nurse #7 had documented borrowing oxycodone from Resident #102 for Resident #53 on 12/06/25 at 12:00 AM and 5:00 AM. Nurse #7 stated she could not recall those incidents when oxycodone had to be borrowed. She verbalized that it was common for controlled medications not to be available and to have to be borrowed from another resident. Nurse #7 indicated that nurses were supposed to notify the Director of Nursing (DON) when they borrowed medication, but she did not know how the controlled substances borrowed were replaced or reimbursed. Nurse #7 stated she had not notified the DON before she borrowed the oxycodone from Resident #102 for Resident #53.
An interview with the Unit Manager was conducted on 2/24/26 at 9:39 AM. The Unit Manager stated that she remembered signing out several doses of oxycodone from Resident #102's card for Resident #53 because Resident #53's oxycodone prescription had run out. The Unit Manager documented that she borrowed oxycodone 15 mg from Resident #102 for Resident #53 on 12/08/25 at 12:00 PM, 12/09/2025 at 12:00 PM, and 12/10/25 at 12:00 PM. The Unit Manager recalled that Resident #53 required a hard script (a printed order with the provider's signature) for his oxycodone to be refilled in December 2025. The prescription was sent in, but there had been a billing issue which she was aware of because Resident #53's insurance required a prior authorization, and the medication was not delivered from the pharmacy before his supply ran out. Because Resident #53's own oxycodone supply had been exhausted, they borrowed from Resident #102 until Resident #53's prescription could be refilled. The Unit Manager verbalized that there had been a backup supply of oxycodone 5 mg tablets in the facility, but since Resident #53 received 15 mg, they borrowed from Resident #102, who had the same dosage, and she did not attempt to get it out of the backup supply. The Unit Manager stated that it was common for nurses to borrow controlled substances if they ran out from the pharmacy, although borrowing should only have been done upon approval of the DON. The Unit Manager stated that she did not speak with the DON prior to borrowing, nor did she notify the DON that Resident #53's oxycodone had not been received from the pharmacy. The Unit Manager stated that the process for ordering controlled substances was to reorder when the supply was getting low. The refill could be reordered directly from the pharmacy through the medication administration record (MAR). If there were no refills left, the pharmacy required a hard script. The Unit Manager indicated that although the medication might be ordered by one nurse, if that nurse did not work on the same hall every day, the order might not be followed up on. Some refills required prior authorization, and the DON completed those. The Unit Manager stated she did not review the controlled substance accountability records, but those sheets went to the DON. The Unit Manager verbalized she did not know how medication that was borrowed from one resident for another would be replaced, but she believed the DON handled that.
An interview was conducted with the DON on 2/24/26 at 4:32 PM. The DON verbalized that there was no policy for borrowing controlled substances from one resident for another. The DON explained that she had not been aware that controlled substances were borrowed so frequently. The DON stated that nurses were not to borrow medications. The DON indicated that nurses had borrowed medications including controlled substances in the past but were supposed to notify her for approval. The DON stated that she had only received two to three phone calls over the last few months to approve borrowing medication. The DON reported that controlled substances should have been delivered from the pharmacy prior to any residents running out. However, even though controlled substances might be ordered, the pharmacy would not fill them for various reasons, including billing issues. If residents ran out of medication, the nurse should have called the provider for an order. Resident #53's insurance required the facility to complete a prior authorization for every refill of his medications, and that often-caused delays in orders, which had been an ongoing issue. The DON confirmed she completed the prior authorizations. Residents whose medications required prior authorization appeared as an alert on the pharmacy website page, which the DON checked daily. Prior authorization required several steps in the process, and this was usually what caused delays in controlled substance medication refills. Sometimes the provider did not complete their forms, or the pharmacy rejected the request without providing a reason. If the prior authorization was approved, sometimes the pharmacy automatically sent the controlled substance, but sometimes it did not, and the staff had to call the pharmacy to request delivery. The DON reported that she reviewed the controlled substance accountability records when they were returned to her after the medication was completed. She stated she did not review Resident #102's controlled substance accountability record dated 11/30/25 when it was returned but declined to state why she had not reviewed it. The DON indicated that if the nurses told her they borrowed medication, she would call the pharmacy to get the medication replaced. The DON could not produce records showing that Resident #53's oxycodone 15 mg had been reordered, delivered, or that Resident #102 had been reimbursed for the borrowed oxycodone.
An interview with the Regional Nurse Consultant was conducted on 02/24/26 at 11:24 AM. He stated the facility followed all pharmacy policies related to controlled substances. The Regional Nurse Consultant stated that he was unaware that nurses were borrowing controlled substances for other residents and they were not supposed to borrow controlled substances.
An interview with the Administrator was conducted on 2/24/26 at 6:12 PM. The Administrator stated that any concerns with the administration and documentation of controlled substances, including borrowing, should have been addressed by nursing leadership immediately. The Administrator verbalized that she would have expected the nurses to reorder controlled substances prescribed for all residents in a timely manner so they would not run out. If medication was not available from the pharmacy, the nurse would have been expected to call a provider for directions. If it was a billing issue, that should have been addressed quickly so the residents could receive their medication.
A telephone interview with the Consultant Pharmacist was conducted on 02/25/26 at 2:44 PM. The Consultant Pharmacist reported that she performed the medication audits monthly. The audits consisted of checking all the medication carts, reviewing the controlled substance accountability records and reconciling it to the MAR and controlled substances inside the medication cart. She randomly selected a few residents to review records to ensure correct documentation was completed. The Consultant Pharmacist stated that the facility had a history of controlled substance documentation discrepancies and had been an ongoing issue at the facility. However, she had not noticed nurses borrowing from other residents on the controlled substance accountability records. The Consultant Pharmacist indicated she was not familiar with how the facility handled the process for borrowed controlled substances. When asked if borrowing controlled substances from one resident to the other violated pharmacy policy, the Consultant Pharmacist declined to answer but stated it violated best practice.
3. Resident #74 was admitted to the facility on [DATE].
A physician's order for Resident #74 dated 10/28/25 read: oxycodone (an opioid pain medication) 10 milligrams (mg), one (1) tablet by mouth every 4 hours as needed for pain. Do not give 1 hour prior to or after scheduled oxycodone.
A review of Resident #74's medication administration record from December 2025 revealed oxycodone 10 mg by mouth every 4 hours as needed for pain was administered to Resident #74 on the following dates and times: on 12/22/25 at 10:29 AM, on 12/28/25 at 4:34 PM, on 12/29/25 at 9:30 AM and 5:40 PM, and on 12/30/25 at 9:16 AM and 5:54 PM.
Resident #102 was admitted to the facility on [DATE].
A review of Resident #102's physician's orders revealed an order dated 09/23/25 for oxycodone 5 mg one (1) tablet by mouth every 24 hours as needed for pain.
A review of the completed controlled substance accountability record dated December 2025 for Resident #102 for oxycodone 5 mg tablets revealed that Resident #74's prescribed oxycodone dose of 10 mg was administered using 2 tablets of Resident #102's 5 mg oxycodone tablets by multiple nurses. Nurses documented the medication was borrowed for Resident #74 on the controlled substance accountability record for Resident #102. The following staff documented on the controlled substance accountability record for Resident #102 that they borrowed oxycodone 5 mg tablets for Resident #74, the Unit Manager, Nurse #9, and Nurse #8 during December 2025. A total of 12 tablets were borrowed from Resident #102's medication for Resident #74.
An interview with the Unit Manager was conducted on 02/24/26 at 9:39 AM. The Unit Manager stated she remembered she signed out several doses of oxycodone from Resident #102 for Resident #74 because Resident #74 was out of her oxycodone prescription. The Unit Manager documented on Resident #102's control substance accountability record for December 2025 that she borrowed oxycodone 5 mg from Resident #102 for Resident #74 on 12/22/25 at 10:29 AM 2 tablets, 12/29/25 at 9:30 AM 2 tablets, and 12/30/25 at 9:16 AM 2 tablets. The Unit Manager could not recall why Resident #74 was out of her medication but because Resident #74's own oxycodone supply had been exhausted, they borrowed from Resident #102 until Resident #74's could be refilled. The Unit Manager verbalized that there was a backup supply of oxycodone 5 mg tablets, and she could not explain why she did not obtain it from the backup supply and instead borrowed it from Resident #102. The Unit Manager stated it was common for nurses to borrow controlled substances if they ran out. She stated that even though she borrowed the medication, she did not speak with the Director of Nursing (DON) for approval. The Unit Manager stated the process to order controlled substances were if the supply ran low, it could be reordered directly from the pharmacy. If there were no refills left, the pharmacy would require a hard script. The Unit Manager indicated that although the medication might be ordered by one nurse, if they did not work on the same hall every day, it may not be followed up on. Some refills required prior authorization, and the DON completed that. The Unit Manager stated she did not review the controlled substance accountability records, but those sheets all went to the DON when completed. The Unit Manager verbalized she did not know how medication borrowed from one resident for another would be replaced, but she thought the DON handled that.
An interview with the Regional Nurse Consultant was conducted on 02/24/26 at 11:24 AM. He stated the facility followed all pharmacy policies related to controlled substances. The Regional Nurse Consultant stated that he was unaware that nurses were borrowing controlled substances for other residents and they were not supposed to borrow controlled substances.
An interview was conducted with the DON on 02/24/26 at 4:32 PM. The DON verbalized there was no policy to borrow controlled substances from one resident for another. The DON explained she was not aware controlled substances were borrowed so frequently. The DON stated the nurses were not to borrow medications. The DON indicated nurses had borrowed controlled medications in the past but were supposed to notify her for approval. The DON stated she had only received 2–3 phone calls over the last few months to approve borrowed medication. The DON reported controlled substances should have been delivered from the pharmacy prior to any residents running out. However, even though controlled substances might be ordered, the pharmacy did not fill them for various reasons, including billing issues. If they ran out of medication, the nurse should have called the provider for direction. The DON stated residents with certain insurance plans/company required the facility to complete a prior authorization for every refill of their medications, and that often caused a delay in orders; that had been an ongoing issue. The DON stated she was not sure if Resident #74 required prior authorization. The DON confirmed she completed the prior authorizations. The residents whose medications required prior authorization showed up as an alert on the pharmacy website page, which the DON checked daily. Prior authorization required several steps in the process, and this was usually what caused delays in controlled substance medication refills. Sometimes the provider did not complete their forms, or the pharmacy rejected it but did not provide a reason. If the prior authorization was approved, sometimes the pharmacy automatically sent the controlled substance, but sometimes it did not, and the staff would have to call the pharmacy to get them to deliver it. The DON reported she reviewed the controlled substance accountability records when they were returned to her after the medication was completed. She stated she had not reviewed Resident #102's December 2025 controlled substance accountability record when it was returned but declined to say why she had not reviewed it. The DON indicated that if the nurses told her they borrowed, she would call the pharmacy to get the medication replaced. The DON could not produce records of Resident #74's oxycodone 10 mg being reordered, delivered, or that Resident #102 had been reimbursed for the borrowed oxycodone.
An interview with the Administrator was conducted on 02/24/26 at 6:12 PM. The Administrator stated any concerns with the administration and documentation of controlled substances, including borrowing, should have been addressed by nursing leadership immediately. The Administrator verbalized she would have expected the nurses to reorder controlled substances prescribed for all residents in a timely manner so they would not run out. If medication was not available from the pharmacy, the nurse would have been expected to call a provider for direction. If it was a billing issue, that would have been addressed quickly so the residents would receive their medication.
A telephone interview with the Consultant Pharmacist was conducted on 02/25/26 at 2:44 PM. The Consultant Pharmacist reported that she performed the medication audits monthly. The audits consisted of checking all the medication carts, reviewing the controlled substance accountability records and reconciling it to the MAR and controlled substances inside the medication cart. She randomly selected a few residents to review records to ensure correct documentation was completed. The Consultant Pharmacist stated that the facility had a history of controlled substance documentation discrepancies and had been an ongoing issue at the facility. However, she had not noticed nurses borrowing from other residents on the controlled substance accountability records. The Consultant Pharmacist indicated she was not familiar with how the facility handled the process for borrowed controlled substances. When asked if borrowing controlled substances from one resident to the other violated pharmacy policy, the Consultant Pharmacist declined to answer but stated it violated best practice.
4. a. The Monthly Storage Audit form dated 09/24/25 and completed by the Consultant Pharmacist revealed the facility had not met 2 pharmacy requirements under Controlled Substances. The document read in part, shift change count properly documented. Not met with the following comments noted, shift change blank on all carts. Another entry read, medication count reconciles with controlled substance accountability record (a comparison performed by reviewing the controlled substance accountability records and then verifying the administering nurse documented that medication was administered on the Medication Administration Record (MAR)). Not met with the following comments: E hall shift change medication count reconciliation sheet dated 09/18/25 had a discrepancy: 62 cards were documented by oncoming nurse. 8 cards were removed. 53 cards were documented at the end of the shift, but the card count should have been 54. Resident #98 had a physician's order for oxycodone (an opioid pain medication). 29 doses were signed on the controlled substance accountability record and only 27 doses were documented on Resident #98's MAR as administered. Resident #35 had a physician's order for tramadol (an opioid pain medication). 13 doses were signed on the controlled substance accountability record, and only 12 doses were documented on Resident #35's MAR as administered.
b. The Monthly Storage Audit form dated 10/21/25 and completed by the Consultant Pharmacist revealed the facility had not met 2 pharmacy requirements under Controlled Substances. The document read in part, shift change count properly documented. Not met with the following comments for missing nurse signatures noted on all medication carts. Another entry read, medication count reconciles with controlled substance accountability record. Not met with the following comments: Several missing nurse signatures on the controlled substance accountability record (no residents were named). Several controlled substance accountability record numbers did not add up correctly and were hard to follow (no resident names provided). On B hall medication cart, a nurse had documented 11 medication cards were present, but there were 16 medication cards. As needed (PRN) substances were administered before the next dose should have been administered (no specific incidents mentioned).
c. The Monthly Storage Audit form dated 11/19/25 and completed by the Consultant Pharmacist revealed the facility had not met 2 pharmacy requirements under Controlled Substances. The document read in part, shift change count properly documented. Not met with the following comments noted, missing nurse signatures on halls B, C, and D. Another entry read, medication count reconciles with controlled substance accountability record. Not met with the following comments: Resident #100 had a physician's order for oxycodone. Between 11/12/25 and 11/18/25 there were 19 doses signed on the controlled substance accountability record, but only 17 doses were documented on the MAR. The 11/17/25 as needed dose of oxycodone was administered too early for Resident #100. Resident #37 had a physician's order for hydrocodone/acetaminophen (an opioid pain medication) every 6 hours as needed. The 11/16/25 PRN dose was administered at 12:25 PM and again at 4:40 PM.
d. The Monthly Storage Audit form dated 12/23/25 and completed by the Consultant Pharmacist revealed the facility had not met 2 pharmacy requirements under Controlled Substances. The document read in part, shift change count properly documented. Not met with the following comments for missing nurse signatures noted on all medication carts. Another entry read medication count reconciles with controlled substance accountability record. Not met with the following comments: Resident #61 had a physician's order for lorazepam (a psychoactive medication which treats anxiety) as needed. 2 doses were signed on the controlled substance accountability record and were not documented on Resident #61's MAR as administered. Resident #97 had a physician's order for lorazepam as needed. One dose was signed on the controlled substance accountability record but was not documented on Resident #97's MAR as administered. Resident #13 had a physician's order for lorazepam as needed. 12 doses were signed on the controlled substance accountability record but only 5 doses were documented on Resident #13's MAR as administered. Resident #32 had a physician's order for lorazepam as needed. A dose dated 11/25/25 and 11/26/25 were wasted without a witness signature.
e. The Monthly Storage Audit form dated 01/20/26 and completed by the Consultant Pharmacist revealed the facility had not met 2 pharmacy requirements under Controlled Substances. The document read: shift change count properly documented for missing nurse signatures noted on hall A, C, D, and E. Another entry read medication count reconciles with controlled substance accountability record. Not met with the following comments: Resident #82 had a physician's order for oxycodone. 6 doses that were signed on the controlled substance accountability record were not documented on Resident #82's MAR as administered. Resident #6 had a physician's order for tramadol. 2 doses were signed on the controlled substance accountability record were not documented on Resident #6's MAR as administered. Resident #75 had a physician's order for hydrocodone/acetaminophen. 3 doses were signed on the controlled substance accountability record and were not documented on Resident #75's MAR as administered.
An interview with Regional Nurse Consultant was conducted on 02/24/26 at 11:24 AM. He stated that the facility followed all pharmacy policies related to controlled substances. The Regional Nurse Consultant reported that he was not aware of the pharmacy audit findings.
An interview with the Director of Nursing (DON) was conducted on 02/24/26 4:32 PM. The DON stated that the Consultant Pharmacist performed medication storage audits monthly. They would speak to the DON and the Administrator when they arrived, and the audit took 1 to 1.5 hours to complete. The DON indicated that the Consultant Pharmacist would discuss the findings with the DON after the audit was completed. The DON verbalized she was not aware of any of the controlled substance concerns. She stated the only thing reported by the Consultant Pharmacist was that there were holes in the MAR with the controlled substances where nurses had not signed the medication was administered and that was the extent of the conversation. The DON could not recall the date that conversation occurred. The DON reported the Consultant Pharmacist was included in QAPI (Quality Assurance and Performance Improvement) meetings and had not mentioned any controlled substance documentation discrepancies during QAPI. The DON verbalized she was unaware that nurses were wasting controlled substances without a second nurse signature. The DON verbalized she had not reviewed the monthly pharmacy medication storage audits but could not explain why these were not reviewed. The DON stated that she was unaware of discrepancies with the controlled substance accountability records and nurses signing the MAR that the medication was administered. The DON explained she reviewed the controlled substance accountability record sheets when they were returned to her after the medication was completed. The DON stated she had not noted discrepancies, and she had not gone through and performed a full reconciliation. She indicated she did not really audit the nurses, but occasionally performed the shift change count with them as a form of monitoring. The DON could not provide documentation that this action occurred. The DON stated there had been no discrepancies when she had performed the shift change count.
An interview with the Administrator was conducted on 02/24/26 at 6:12 PM. The Administrator stated that she was not aware of the controlled substance issues noted on the medication storage audits. The Administrator verbalized any concerns with the administration and documentation of controlled substances in the building identified by the pharmacy audits should have been addressed by nursing leadership immediately. The Administrator verbalized she would expect the nurses to verify accurate controlled substance counts at shift change, accurately document all controlled medications administered on the MAR, obtain witnesses for wasting controlled substance per policy, maintain accurate records on the controlled substance accountability record, and report any discrepancies to her immediately.
A telephone interview with the Consultant Pharmacist was conducted on 02/25/26 at 2:44 PM. The Consultant Pharmacist reported that she performed the medication au

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, manufacturer's instructions, and staff and Consultant Pharmacist interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 4 medication errors out of 26 opportunities, resulting in a medication error rate of 15.38% for 2 of 3 residents observed during the medication administration (Resident #4 and Resident #85).The findings included:1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD).Review of Resident #4's physician orders revealed orders for 1) fluticasone propionate nasal spray one spray in both nostrils one time a day for allergic rhinitis dated 05/02/23, 2) budesonide/glycopyrrolate/formoterol fumarate (steroid) inhaler 160-9-4.8 MCG/ACT (micrograms per activation) inhalation aerosol inhale 2 puffs two times a day for COPD. Rinse mouth with water after use. Do not swallow, dated 11/21/24, and 3) albuterol sulfate inhalation aerosol solution 108 (90 base) MCG/ACT inhale 2 puffs orally four times a day for COPD dated 03/30/23.Review of Resident #4's Minimum Data Set assessment dated [DATE] revealed her cognition was moderately impaired.On 02/17/26 at 9:19 AM an observation of a medication pass was made of Nurse #2 who was medicating Resident #4. Nurse #2 handed Resident #4 the nasal spray and the two inhalers and allowed the Resident to medicate herself without providing instructions of how to administer the medications. Resident #4 administered herself two sprays of nasal spray inhaler in each nostril, three puffs of the albuterol sulfate inhalation and after the Resident administered the 2 puffs of budesonide/glycopyrrolate/formoterol fumarate inhaler, the Nurse did not instruct the Resident to rinse her mouth with water.An interview was conducted with Nurse #2 on 017/26 at 12:51 PM. The Nurse was asked to review the medication pass for Resident #4 earlier that morning and the Nurse stated that he knew that the Resident gave herself too many puffs of the albuterol inhaler and the nasal inhaler. The Nurse stated he knew that he should have encouraged Resident #4 to rinse her mouth with water after she used the steroid inhaler but that normally she would be having her breakfast and drinking fluids when he gave her the inhalers and that morning, she had already had her breakfast, and he did not think about it. Nurse #2 stated the steroid inhaler could cause oral thrush and he should have encouraged the Resident to rinse her mouth with water.An interview was conducted with the Consultant Pharmacist on 02/17/26 at 2:10 PM who explained that the nurses should encourage the residents to rinse their mouths with water after each use of a steroid inhaler because of the possibility that they could develop oral thrush.During an interview with the Director of Nursing (DON) on 02/19/26 at 10:19 AM the DON explained that if Nurse #2 was going to let Resident #4 administer her inhalers, then he should have instructed her on how to give the inhalers. The DON stated Nurse #2 should have instructed the Resident to rinse her mouth with water after she administered the steroid inhaler. 2. The manufacturer's instructions for prefilled insulin pen indicated that priming the insulin pen each time was an important step to ensure there were no air bubbles in the insulin and the full dose of insulin was given. Priming the insulin pen: 1. Dial up 2 units: turn the dose selector dial to 2 units, 2. Prime the pen: Press the injection button to let out any air bubbles and ensure the insulin is flowing correctly, 3. Check for a drop of insulin: you should see a drop of insulin on the tip of the needle, 4. Repeat if necessary.Resident #85 was admitted on [DATE] with diagnoses that included diabetes mellitus.Review of Resident #85's physician orders dated 02/17/26 revealed Lispro insulin give 8 units subcutaneously if the blood sugar was between 301 and 350 before each meal.On 02/17/26 at 12:05 PM an observation was made of Nurse #3 medicating Resident #85 via an insulin pen. The Nurse removed the Lispro insulin pen from the medication cart and set the counter to 8 units. Nurse #3 administered the 8 units of insulin without priming the insulin pen as advised by the manufacturer's instructions.An interview was conducted with Nurse #3 on 02/17/2026 at 12:05 PM. The Nurse was asked to explain the procedure when giving insulin using an insulin pen and Nurse #3 stated she gave the insulin by the five rights of giving any medication. When the Nurse was asked if she was aware of priming the insulin pen before giving the insulin the Nurse stated yes, I do remember that and realized that she did not prime the pen. She stated she should have primed the pen to 2 units to remove the air from the needle before she set the dial to 8 units. She indicated that she forgot to prime the pen.An interview was conducted with the Consultant Pharmacist on 02/17/2026 at 2:10 PM who explained that it was important to prime the needle when giving insulin via an insulin pen because it was important to remove the excess air from the needle to ensure the full dose of insulin was administered.During an interview with the Director of Nursing (DON) on 02/19/26 at 10:19 AM the DON stated Nurse #3 should have primed the insulin pen before administering the insulin to Resident #85.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to protect a resident's right to be free from abuse when Resident #4 attacked Resident #5 which resulted in cuts above the right eye, bruising around the nose, and bleeding from his gums and required an emergency room visit. This was for 1 of 3 residents reviewed for resident-to-resident abuse (Resident #4). The findings included:Resident #4 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety, and major depressive disorder.Review of Resident #4's care plan, last revised on 03/31/25 revealed no care plan areas for aggressive behaviors.Review of Resident #4's quarterly Minimum Data Set assessment dated [DATE] revealed he was severely cognitively impaired with no delusions, behaviors, rejection of care, or instances of wandering. Resident #4 was independent with mobility and was able to ambulate on his own.Resident #5 was admitted to the facility on [DATE] with diagnoses of dementia without behaviors, unspecified mood disorder, psychosis, stroke, muscle weakness and atrophy, and need for assistance with personal hygiene.Review of Resident #5's most recent quarterly Minimum Data Set assessment dated [DATE] revealed he was severely impaired with no delusions, behaviors, rejection of care, or instances of wandering. Resident #5 was coded as dependent on others for the completion of his Activities of Daily Living (ADL).Review of the facility's Reportable Incidents revealed an incident dated 07/08/25. Review of the facility's investigation revealed Resident #4 was observed with one hand near the throat of another resident (Resident #5) and tried putting a hair comb in Resident #5's mouth with the other. Per the investigation report, Resident #4 and Resident #5 were separated by nurse aides (NA) NA #4, NA #5 and NA #6 and assessed by the nurse (Nurse #3). Resident #5 was observed to have cuts above his right eye and was bruised around his nose. There were no noted injuries to Resident #4. The investigation reported that both residents were sent to the emergency department for further evaluation and were returned to the facility a few hours later. Per the investigation report, Resident #4 was moved to another room by himself and was placed on one-on-one supervision. The investigation report indicated there was no lingering effects from the altercation with Resident #5 not experiencing fear or feelings of intimidation from Resident #4.An interview with NA #4 via telephone on 07/17/25 at 2:03 PM revealed she was familiar with the altercation and verified that she responded to the event on 07/08/25. NA #4 reported she was at the nurse's station when she heard shouting coming from Resident #4 and Resident #5's room. She reported she ran down the hall and when she entered the room, she observed Resident#4 with one hand on Resident #5's neck and the other hand with a comb and it appeared as though Resident #4 was attempting to put the comb in Resident #5's mouth. She stated she called for more assistance and pulled Resident #4 away from Resident #5. She took Resident #4 into the hallway, left him with NA #5 and went in to check on Resident #5. She reported by this time, NA #6 had arrived, and he went in the room as well to check on Resident #5. She reported she observed several small cuts above Resident #5's right eye, some redness around Resident #5's left eye, and some scant bleeding from Resident #5's gums. She reported Resident #4 was taken by NA #5 and NA #6 up to the nurse's station and reported the incident to Nurse #4. She stated Nurse #4 assessed both residents and notified administration and the Director of Nursing arrived at the facility in about 20 minutes. She reported both residents ended up being sent out to the emergency department. NA #4 stated that prior to the altercation, Resident #4 had a quiet evening with no noted agitation or aggression. She reported when she asked Resident #4 why he had attacked Resident #5, all he would say was he was calling me out all night. NA #4 reported, to her knowledge, there had been no previous incidents between Resident #4 and Resident #5. An interview via telephone with NA #5 on 07/17/25 at 9:18 AM revealed she was one of the staff who responded to the altercation. She reported she was at the nurse's station when she heard yelling. She reported when she entered the room, Resident #4 was standing over Resident #5 with one hand on Resident #5's neck and he was using the other hand to put a comb in Resident #5's mouth. She reported Resident #4 was separated from Resident #5 and was taken to the hallway. She stated it appeared as though Resident #5 had cuts above his right eye, had redness on his cheek and appeared to have some cuts on his gums. She stated she overheard Resident #5 asking why did he do that? Resident #4 was taken down the hall to the nurse's station and was asked why he attacked Resident #5, and he would only respond with he was asking for it and would not say anything else. NA #5 reported administration was called, and both residents ultimately were sent to the emergency department for further evaluation.An interview via telephone with NA #6 on 07/17/25 at 11:28 AM revealed he was clocking out from his shift when he heard a commotion and heard NA #4 calling for assistance. He reported when he got to the room, NA #4 and NA #5 were already there and both residents had been separated. Stated he observed Resident #5 to have redness around his eyes and appeared to be bleeding from his gums. He reported he assisted Resident #5 in getting into a wheelchair and Nurse #4 had come to the room. He reported Nurse #4 assessed both residents and Resident #4 was taken to the nurses' station. NA #6 stated administration was called and both residents were sent to the emergency room. NA #6 reported that Resident #4 had seemed to be at his baseline that night and reported he had not been made aware of any aggressive behaviors prior to this incident. Multiple attempts to reach Nurse #4 via telephone calls were unsuccessful.Review of a skin assessment for Resident #4 dated 07/08/25 at 10:00 AM revealed the following: No injuries noted, denies pain, no mental distress noted.Review of a skin assessment for Resident #5 dated 07/08/25 at 11:00 AM revealed the following: mild swelling to right eye/under eye, along cheek bone, scratch to right side of nose. Denies pain, denies any needs, no mental distress or anguish noted.Review of Resident #5's emergency room provider notes revealed he was seen on 07/08/25 and was treated for cuts above his right eye and returned to the facility the same day.An interview with Resident #5 on 07/17/25 at 8:26 AM revealed he had no recollection of the altercation, had no knowledge of Resident #5 and reported no residents or staff members had ever harmed or assaulted him.Multiple attempts to interview Resident #4 throughout the investigation were unsuccessful. When he was approached in his room, he turned his head away, closed his eyes, and became nonresponsive.An interview with the Director of Nursing on 07/17/25 at 10:54 AM revealed she was aware of the incident between Resident #4 and Resident #5. She reported Resident #4 had a previous altercation with another roommate several weeks prior and they had moved Resident #4's roommate to another room. She reported after that incident, the facility started looking at all the residents and roommate compatibility. She reported during this time, they felt that Resident #4 and Resident #5 would be compatible roommates as Resident #5 was a quieter resident and both gentlemen liked the room warm. She reported she was unsure how long Resident #4 and Resident #5 were roommates but reported it had not been a long time. She stated on 07/08/25 she was contacted around 3:45 AM about an altercation between Resident #4 and Resident #5. She reported she was informed that NA #4, NA #5, and NA #6 had gone into the residents' room and observed Resident #4 trying to shove a comb into Resident #5's mouth. The Director of Nursing stated she informed the staff to keep the men separated and to put Resident #4 on one-to-one supervision. She reported Nurse #4 advised that both men should be sent to the emergency department for further evaluation, so they received the order from the on-call physician and both men were sent. She continued, stating when both residents returned from the emergency department, Resident #5 had some minor swelling under his right eye but no other apparent injuries. She reported Resident #4 and Resident #5 were closely observed the rest of the day and reported by the end of the day, the swelling to Resident #5's eye had subsided. She reported Resident #4 continued on one-to-one supervision and was moved to an empty hall in a private room. The Director of Nursing stated that when both men returned from the emergency department, she completed a full body skin assessment on both residents. An interview with the Administrator on 07/17/25 at 1:18 PM revealed she was aware of the altercation between Resident #4 and Resident #5. She stated several weeks prior to that incident, Resident #4 had gotten into another altercation with another resident, who was his roommate at the time. She reported after the initial altercation by Resident #4, the administrative team discussed roommate compatibility and felt that Resident #4 and Resident #5 would have been a good fit to room together. She reported when they moved Resident #5 into the room with Resident #4, they had no initial concerns about them rooming together. She reported it was reported to her that Resident #5 was observed trying to shove a comb into Resident #5's mouth. She reported that both residents were separated, and the Director of Nursing was called. She reported she was notified by the Director of Nursing of the altercation. The Administrator reported that both men were sent to the emergency department for further evaluation. She stated when Resident #4 and Resident #5 returned from the emergency department, both residents were moved to new rooms, with Resident #4 being moved to an empty hall, in a room by himself, and was placed on one-to -one supervision for about a week. She stated when she went to speak with each resident, neither resident could recall the altercation in detail. The Administrator indicated she could not recall what injuries Resident #5 sustained because of the altercation.The facility provided the following corrective action plan with a compliance date of 07/12/25.1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 07/08/2025 at 3:45 AM Director of Clinical Services was notified of allegations of resident to resident abuse involving residents listed above. Staff report that Resident #4 had some skin tears and swelling to his eyes/nose area. Resident #5 without injuries. Residents were immediately separated with Resident #5 being placed on 1:1 supervision. Both residents were sent to the ER per on call provider. Director of Clinical Services notified Administrator. On 07/08/2025, Initial reportable was filed; [NAME] Police Department and Adult Protective Services (APS) were notified by the Administrator.On 07/08/2025, Medical Director was notified by the Director of Clinical Services.On 07/08/2025 Skin assessments were completed on residents listed above by the Director of Clinical Services. Resident #4 mild swelling noted under right eye and scratch noted along right side of nose. Resident is talkative and pleasant; denies pain at this time. No signs of mental distress noted. Resident #5 no negative findings noted. Resident denies pain at this time. No signs of mental distress noted. Resident is talkative per his normal behavior. 07/08/2025, Resident #4 was placed in a private room with 1:1 supervision by Certified Nursing Assistants. 07/08/2025 Care Plans were reviewed on both residents with updates being made as warranted by the MDS Nurse. 07/09/2025 Nurse Practitioner with psychiatric services notified of incident by the Director of Clinical Services . States that he will be in later today. Resident #5 is pending consents, Nurse Practitioner made recommendations to facility Nurse Practitioner. Depakote (an antiepileptic medication that can be used to treat bipolar disorder) was added. 07/10/2025 Follow up assessments completed on both residents by Director of Clinical Services with no changes noted from previous assessments. Resident #4 continues to deny pain, no signs of mental distress noted. 2 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 07/08/2025 Skin Assessments were completed by the Director of Clinical Services for all residents with a BIMS (Brief Interview for Mental Status) of 9 and below. No negative findings were noted. On 07/08/2025 Resident interviews were completed by the Director of Social Services for all residents with a BIMS of 10 and above. As part of the resident interviews, roommate compatibility questions were also looked at. No negative findings were noted.On 07/08/2025, Director of Clinical Services and the Administrator reviewed incident log for the past 30 days looking for trends in resident and resident incidents. At this time it was noted that Resident #5, does not do well with a room mate and at this time would be better suited to remain in a private room.A3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 07/08/2025 to 07/11/2025 Staff were provided education on abuse, neglect and misappropriation based on the facility's policy by the Director of Clinical Services and the Administrator. Education was provided in person and via the telephone for staff that were not working during these dates by the Director of Clinical Services. Education focused on staff intervening early on during situations or conflicts that could potentially escalate along with notifying the Director of Clinical Services and/or Director of Social Services of all roommate incompatibility issues. At the time of education, there was a period for questions and answers to review information provided. I4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Ad Hoc Quality Assurance and Performance Meeting held on 07/12/2025 with the Administrator, Director of Clinical Services and Medical Director to accept and approve of the plan. Director of Nursing/ or designee to complete random audits weekly of 5 residents with a BIMS of 10 and higher, to inquire about abuse while also looking at roommate compatibility. Immediate action to be taken for any positive findings. The Director of Nursing Services will bring results of these audits/interviews before the Quality Assurance and Performance Improvement Committee monthly with the QAPI Committee responsible for ongoing compliance. In the monthly Quality Assurance and Performance Improvement Meeting, the Interdisciplinary Team will review all allegations of abuse to ensure appropriate interventions are in place and care plan updated x8 weeks. QAPI Committee will determine the need for further intervention and auditing beyond three months to assure compliance is sustained ongoing. Compliance date: 07/13/2025The corrective action plan was validated on 07/17/25. Review of the facility provided monitoring tools revealed the facility had ongoing monitoring to ensure that no residents were subject to acts of abuse from any source. There was evidence of in-services with sign-in sheets, audits, and other interventions that were mentioned in the corrective action plan. Interviews with staff revealed they were able to verbalize the education regarding abuse policies and procedures. The staff interviewed were able to verbalize the steps needed to take in the event that they observed aggressive behaviors and concerns regarding the compatibility of roommates. The interviewed staff also were able to verbalize the steps they should take if they observe an altercation between residents. The completion date of 07/13/25 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews with staff and the Medical Director, the facility failed to maintain a medication error rate of less than 5% as evidenced by the administration of a wrong dosage and failure to have the resident rinse their mouth after being given a steroid inhaler (2 medication errors out of 31 opportunities), resulting in a medication error rate of 6.45% for 2 of 4 residents observed during medication pass (Resident #2 and Resident #3).The findings included:1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included vitamin D deficiency.The Physician's Orders in Resident #2's electronic medical record indicated an active order dated 7/1/20 for Vitamin D3 tablet 25 micrograms (1000 units) (Cholecalciferol) - give 1 tablet by mouth one time a day related to vitamin D deficiency.On 7/16/25 at 9:19 AM, Nurse #2 was observed as he prepared and administered Resident #2's medications. Nurse #2 administered one tablet of Vitamin D 10 micrograms (400 units) to Resident #2.A phone interview with Nurse #2 on 7/17/25 at 10:03 AM revealed he didn't notice the formulation or label on the Vitamin D bottle before he administered the medication to Resident #2. Nurse #2 stated that he should slow down and look at the medication label to make sure the dosage was accurate.An interview with the Unit Manager (UM) and observation of the medication cart on 7/17/25 at 2:31 PM revealed Vitamin D was only available in the 10-microgram formulation. The UM stated he wasn't sure about the other medication carts, but Nurse #2 could have given Resident #2 two and half tablets from the Vitamin D bottle for the correct dose.An interview with the Director of Nursing on 7/16/25 at 4:22 PM revealed the nurse should have given the correct dose of Vitamin D to Resident #2. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD).The Physician's Orders in Resident #3's electronic medical record indicated an active order dated 3/22/25 for Trelegy Ellipta inhalation aerosol powder breath activated 100-62.5-25 micrograms/actuation (Fluticasone-Umeclidinium-Vilanterol) 1 puff inhale orally one time a day for COPD. A review of the manufacturer's recommendations indicated to rinse mouth with water after taking a dose of the medicine and spit the water out. Do not swallow the water. This is important to prevent the development of oral thrush, a fungal infection that can occur due to the presence of corticosteroids in the inhaler. On 7/16/25 at 9:27 AM, Nurse #2 was observed as he administered Resident #3's medications. Nurse #2 activated Resident #3's Trelegy inhaler and handed it to Resident #3 who took a deep breath while inhaling into the inhaler. Resident #3 handed the inhaler back to Nurse #2 who handed Resident #3 her other medications. Resident #3 swallowed her pill medications and took a sip of water through a straw.An interview with Nurse #2 on 7/16/25 at 9:49 AM revealed he had thought about instructing Resident #3 to rinse her mouth after he gave her the inhaler, but it was too late because she had already reached for her pills. Nurse #2 stated that he should have asked her to rinse her mouth and spit the water out.A phone interview with the Medical Director on 7/17/25 at 9:37 AM revealed it was part of the facility's policy that the nurses were supposed to have the residents rinse their mouths and spit out the water after giving them a Trelegy inhaler. The Medical Director stated that the reason for this was that the effects of the medication could stay in the oral mucosa and cause irritation.An interview with the Director of Nursing on 7/16/25 at 4:22 PM revealed the nurse should have instructed Resident #3 to rinse her mouth and spit the water out after the administration of the inhaler.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with the resident's responsible party, staff, and the Medical Director, the facility failed to supervise a severely cognitively impaired resident who demonstrated wandering behaviors in the facility and prevent him from entering into an unlocked kitchen door and then exiting the facility through the kitchen's exterior door for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 who had a diagnosis of dementia exited from the facility without staff's knowledge for an undetermined length of time on the evening of 7/11/25 and was observed by staff through the door at the end of C hall standing by the facility's transport van parked outside the facility in the back parking lot in socked feet. There was the high likelihood of a serious adverse outcome for Resident #1, who had a diagnosis of dementia, when he entered the unlocked kitchen and walked through the kitchen and exited the facility through the kitchen's exterior door. Resident #1 could have wandered into and been entrapped in the walk-in freezer or walk-in cooler, been injured by contact with kitchen equipment, or experienced a fall or serious injury if he had wandered into the nearby wooded area or the 4-lane main highway.The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included left femur fracture, abnormalities of gait and mobility, muscle weakness, and dementia.A review of the Elopement Risk Evaluation for Resident #1 dated 3/19/25 indicated Resident #1 had potential risk factors for elopement that included cognitive impairment, poor decision-making skills and ability to exit the facility, but he had no exit-seeking behaviors so Resident #1 was not considered at risk for elopement.The significant change in status Minimum Data Set assessment dated [DATE] indicated Resident #1 was severely cognitively impaired, but did not exhibit wandering behaviors during the assessment period. Resident #1 had range of motion impairment on one side of the lower extremities, used a wheelchair, and required substantial/maximal assistance with most activities of daily living including walking 10 feet. Resident #1 had one fall with no injury and one fall with minor injury since admission or prior assessment.Resident #1 did not have a care plan for wandering behaviors or risk for elopement prior to 7/11/25.A review of an Incident Report for Elopement dated 7/11/25 at 7:45 PM prepared by Nurse #1 indicated the nurse aide witnessed Resident #1 outside walking past C hall door. The nurse aide ran outside and assisted Resident #1 back inside the building. Nurse #1 assessed Resident #1 for any type of injury. There were none (injuries) to be found.A review of Resident #1's medical record indicated a late entry nursing progress note dated 7/12/25 at 3:29 PM by Nurse #1 which read, in part: Nurse Aide (NA) #1 and NA #2 witnessed Resident #1 outside, walking past the C hall door at approximately 7:45 PM. NA #1 immediately ran outside to assist him back into the building while NA #2 came and alerted Nurse #1. Nurse #1 assisted NA #1 with guiding Resident #1 back into the building via C hall door. NA #2 went to find Resident #1's wheelchair, finding it in the dining room just outside the door going into the kitchen. Once Resident #1 was assessed, Nurse #1 checked the doors and found all doors to be closed and locked. When NA #2 checked the kitchen door, she found it to be unlocked. Apparently, Resident #1 went through the unlocked kitchen door and outside through the back door of the kitchen. Nurse #1 notified the Director of Nursing as well as the Administrator who came to the facility shortly thereafter. A phone interview with NA #1 on 7/16/25 at 12:05 PM revealed she was talking to NA #2 when she noticed Resident #1 outside the facility through the door at the end of C hall on 7/11/25. Resident #1 was standing and holding onto the facility's transport van which was parked in the back parking lot. NA #1 stated that she immediately went out the C hall door to get Resident #1 while NA #2 alerted Nurse #1 who helped her walk Resident #1 back into the building. NA #1 stated Resident #1 was wearing long sleeves and pants, and she noticed that his face was red from being outside. NA #1 stated that she observed Resident #1 pulling on the van door, and she thought he was trying to get in the van. NA #1 asked Resident #1 what he was doing, and he just shrugged his shoulders at her, and did not say anything. NA #1 stated that Resident #1 moved around on his own in his wheelchair both by rolling his wheelchair and sometimes standing up and walking while pushing his wheelchair. NA #1 further stated that she wasn't assigned to Resident #1 on 7/11/25, and had not seen Resident #1 prior to him being outside. She shared that NA #3 and NA #4 were assigned to Resident #1, but they were doing their rounds when NA #1 saw Resident #1 outside the facility. NA #1 further shared that when NA #2 looked for Resident #1's wheelchair, she found it right at the interior kitchen door from the dining room which was unlocked, and they suspected he had gotten out through the exterior kitchen door on the left side close to the dishwasher because he had grass all over his socks, and that he must have walked through the grass outside that door. NA #1 stated that nobody was in the kitchen at that time because all dietary staff had already left for the day. An interview with NA #2 on 7/16/25 at 3:47 PM revealed she was talking to NA #1 when NA #1 saw Resident #1 outside the C hall door. NA #1 took off running to get Resident #1, and hollered to everyone that Resident #1 was outside. NA #2 stated that she observed Resident #1 standing by the facility's transport van, which was parked at the back parking lot, but his wheelchair was not out there. NA #2 stated she went back into the facility to get Resident #1's wheelchair and on the way to his room, NA #2 alerted Nurse #1 that Resident #1 was outside. NA #2 further stated that she checked Resident #1's room but his wheelchair was not there. NA #2 said that she found Resident #1's wheelchair in the dining room parked right by the interior kitchen door which was unlocked. NA #2 stated that the interior kitchen door from the dining room was normally locked and could not be accessed unless a code was entered on the door. NA #2 shared that only the dietary staff knew the code to the interior kitchen door. NA #2 shared that she walked into the kitchen and observed an unlocked exterior door on the left side close to the dishwasher leading to the outside. NA #2 further shared that she suspected Resident #1 walked out through this door because his socks were covered with grass, and they were wet.A phone interview with Nurse #1 on 7/18/25 at 7:50 PM revealed the elopement incident involving Resident #1 must have happened between 7:55 PM and 8:00 PM on 7/11/25, and she had been in the facility for about an hour. Nurse #1 stated that she last saw Resident #1 around 7:30 PM, and he was propelling himself in his wheelchair around the nurses' station. Nurse #1 stated that NA #1 and NA #2 both saw Resident #1 through the end of the C hall door. She further stated that she and NA #1 both ran to get Resident #1 while NA #2 looked for his wheelchair. Nurse #1 shared that Resident #1 was wearing long sleeves, pull-on pants, and socks. She said that Resident #1 was strong, but he couldn't stand upright well. As they were walking Resident #1 back inside, he was trying to pull away from them, and he acted like he did not want to sit down. While NA #2 was looking for Resident #1's wheelchair, they sat him down in the chair by the nurses' station so Nurse #1 could assess him. Nurse #1 stated she checked his skin to look for any signs of injuries and she found none. She checked his vital signs which were normal. Nurse #1 stated Resident #1 had grass on his socks which led them to believe he had gotten out through the exterior kitchen door leading to the back parking lot. Nurse #1 stated she called the Administrator and the Director of Nursing to notify them about the incident.An interview with NA #3 on 7/16/25 at 3:25 PM revealed she came in to work on 7/11/25 at 7:15 PM, and she was assigned to Resident #1's hall. NA #3 stated she saw Resident #1 in the dining room at 7:15 PM sitting in his wheelchair. NA #3 further stated as soon as she got to the facility, she was advised that all the nurse aides had to split D hall, so she and NA #4 went ahead and assisted a resident into bed on D hall. NA #3 stated that when they went down to Resident #1's hall and got ready to start their round, NA #4 heard another employee say that Resident #1 had gotten out of the facility. NA #3 stated that after staff got Resident #1 back into the facility, she put him in his recliner in his room, and then about 20 minutes before 9:00 PM, she assisted him to bed. NA #3 stated that she was glad NA #1 and NA #2 had turned around and saw Resident #1 through the door at the end of C hall. NA #3 stated that all staff had to lay eyes on Resident #1, because he liked to go to doors and mash on them. NA #3 added that she would often try to redirect Resident #1 whenever she saw him mashing on the hall doors. NA #3 shared that Resident #1 usually sat by the doors, and liked to look outside. She further shared that he normally wore non-skid socks, long-sleeve shirt, and pants. She said that Resident #1 was always confused, and she asked him what he was doing outside, but he did not answer her and just looked at her. A phone interview with NA #4 on 7/16/25 at 12:59 PM revealed when she walked in to work around 7:00 PM on 7/11/25, she saw Resident #1 in his wheelchair propelling himself around by the nurses' station. NA #4 stated that she was getting ready to do rounds on Resident #1's hall when she walked up to the nurses' station and NA #1 and NA #2 told her that they had found Resident #1 wandering by the facility van which was parked in the back parking lot. NA #4 stated the incident must have happened around 7:30 PM because it was not long after she had been in the facility. NA #4 stated that Resident #1 had wandering behaviors, and he was always walking or propelling around in his wheelchair. NA #4 stated that she had seen him near the doors at the end of A hall and C hall, and he often tried to push them open, but these doors wouldn't open. NA #4 shared that the interior kitchen door was supposed to be locked, and that there was a code to get in it. NA #4 stated that from what she heard, the interior kitchen door was left open and didn't close all the way.An interview with the Unit Manager (UM) on 7/16/25 at 2:22 PM revealed he was in the conference room between 7:00 PM and 8:00 PM on 7/11/25 when he heard commotion from staff. The UM stated he came out of the conference room and observed staff walking Resident #1 back into the facility. The UM stated that they brought Resident #1 into the nurses' station and Nurse #1 obtained his vital signs and did a skin assessment. The UM shared that he was assigned to two other halls that evening, and had seen Resident #1 occasionally wheeling himself around, but he couldn't remember the time he had seen him.An interview with the Dietary Manager (DM) on 7/16/25 at 1:24 PM revealed she had a cook and two dietary aides who worked the supper service on 7/11/25, and all of them left at 7:00 PM. The DM stated that they all reported that they locked all the doors to the kitchen before they left. The DM shared that there was one interior kitchen door coming from the dining room, and two exterior doors leading to the outside, and her staff said they made sure they locked all the interior and exterior kitchen doors. The DM stated that the interior kitchen door was locked through a code, while the two exterior doors were locked through a knob. She shared that her staff locked the exterior doors with a key from the outside, but it was easy to open from the inside just by turning the doorknob. An observation inside the kitchen on 7/16/25 at 1:15 PM revealed an industrial gas range with turn knobs, a sink and a dishwasher which were around 50 feet from the interior kitchen door. There were several cabinets and countertops with various kitchen gadgets, a walk-in freezer, a walk-in cooler, reach-in refrigerators, and multiple meal carts.An observation was made on 7/16/25 at 1:34 PM of the outside area from the kitchen door on the left side right by the dishwasher. Right outside the exterior door was approximately 50 feet of grassy area before reaching the side walk on the left side of the exterior door. The back parking lot and the end of the C hall door was approximately 85 feet from the exterior kitchen door. The 4-lane main road with a posted speed limit of 45 miles per hour (mph) was approximately 150 feet from the back parking lot at the end of the C hall door where Resident #1 was observed. There was a wooded area approximately 200 feet towards the right side from the exterior door. Behind the wooded area was ditch approximately three feet deep with a sharp incline.A review of the weather conditions per Weather Underground website revealed the following data for [NAME], North Carolina on 7/11/25 at 7:54 PM: 76 degrees Fahrenheit with no precipitation, Southeast wind speed at 3 mph. An interview with Resident #1's responsible party (RP) on 7/16/25 at 11:01 AM revealed Resident #1 had gotten out of the facility on the evening of 7/11/25 around 8:00 PM. Resident #1's RP stated that from what was reported to her, Resident #1 had wheeled himself into the dining room, opened the interior door to the kitchen, which was left unlocked, and went outside through an exterior door inside the kitchen. Resident #1's RP stated nobody knew how long Resident #1 was inside the kitchen or outside of the facility. The nurse and the nurse aides brought Resident #1 back in after they had seen him through a hall door. Resident #1's RP stated that she didn't find out about the incident until the next day, and it had upset her. She further stated that it scared her because something bad could have happened to Resident #1. She added that Resident #1 could have gotten hurt while he was unsupervised in the kitchen, as well as while he was outside by himself because the facility was right by a busy road. During the RP interview, an attempt was made to interview Resident #1, but he did not answer any questions. He was observed sitting in a wheelchair while facing the door at the end of A hall. Resident #1's RP stated that Resident #1 recognized her but did not talk much to her either. During an interview with the Maintenance Director on 7/16/25 at 2:17 PM, an observation of the interior kitchen door revealed he had removed the latch or the locking mechanism at the back of it. The Maintenance Director stated that it had been reported to him that on the evening of 7/11/25, the latch at the back of the interior kitchen door had been kept unlocked and this prevented it from requiring a code to unlock it. He stated that removing the latch prevented staff from keeping the interior kitchen door unlocked without having to enter a code on the keypad. He also stated that he had changed the code to the interior kitchen door on 7/15/25 and again on 7/16/25, because he found out that some nurse aides knew about the code to the interior kitchen door. The Maintenance Director stated that the nurse aides were not supposed to have the code to the kitchen, and that only kitchen staff should have access to the interior kitchen door. He also pointed out that he had removed the door stop to the interior kitchen door to prevent staff from propping it open during meal service. An interview with a Physical Therapist (PT) on 7/17/25 at 9:30 AM revealed physical therapy had worked with Resident #1 from 3/6/25 to 4/17/25 following repair of his left femur fracture. The PT stated that when Resident #1 was discharged from physical therapy, his mobility depended on the day, but he had walked up to 300 feet with contact guard which meant a staff member held onto a gait belt while he walked. The PT stated Resident #1 always had to have assistance with walking, but his dementia prevented him from remembering that it was unsafe for him to walk unassisted. The PT further stated that it was not safe for Resident #1 to walk on grass at the time of discharge from therapy. She also shared that Resident #1 always wore gripper socks because wearing shoes caused him to trip more, and he had better traction with gripper socks.A phone interview with the Medical Director (MD) on 7/17/25 at 9:37 AM revealed he was informed about Resident #1's elopement shortly after it had happened when he received a text message letting him know about Resident #1 getting outside the facility through an unlocked kitchen door. The Medical Director stated that it was an unfortunate coincidence that Resident #1 made it through a kitchen door to the outside of the facility. The Medical Director stated that it was not safe for Resident #1 to be outside unassisted. The Medical Director further stated that he could go on and on about the dangers of a resident with dementia being outside unsupervised, and that this caused a potential for serious harm. An interview with the Director of Nursing (DON) on 7/16/25 at 4:22 PM revealed she received a phone call from Nurse #1 that Resident #1 had gotten out of the building on 7/11/25. A nurse aide saw him outside and brought him back in. They assessed him and checked him for any signs of injuries, and he didn't have any. The DON stated that staff told her that Resident #1 exited through the kitchen because his wheelchair was found right at the interior kitchen door which was unlocked. The DON shared that NA #2 observed that the interior kitchen door was unlocked because the door latch had been unlocked from the inside.An interview with the Administrator on 7/17/25 at 1:34 PM revealed Nurse #1 texted her at 8:04 PM on 7/11/25 about Resident #1 being found outside the facility. She stated that she got to the facility about 10 to 15 minutes later. The Administrator stated that as soon as she arrived at the facility, she made sure Resident #1 was alright, and he was already back in his room. She said she tried to interview him, but he was staring at the television in his room with his hands behind his head, and he didn't say anything to her after she asked him what he was doing outside the facility. The Administrator further stated that she checked all the doors to make sure they were all locked. She shared that every door was locked except the exterior kitchen door leading to the outside close to the dishwasher, so she locked it back. The Administrator also stated that she texted the Medical Director to notify him about the incident, and she started talking to staff about what to do when someone eloped.The Administrator was informed of immediate jeopardy on 7/17/25 at 11:48 AM.The facility provided the following corrective action plan:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 07/11/2025 at approximately 8 PM Director of Clinical Services was notified by nurse at the facility that resident had exited the building and was seen walking in the back parking lot. Nurse stated that resident was assisted back into the building by staff without incident. Wheelchair was located in the dining room by the door that leads into the kitchen. Door was closed at this time and secured, requiring key pad to open the door. Director of Clinical Services notified the Administrator along with the [NAME] President of Clinical Services and Regional [NAME] President. On 07/11/2025 the Administrator walked perimeter of building checking all exit doors, all were secure. On 07/11/2025 a complete assessment including a skin assessment was completed by the nurse assigned to resident with no negative findings. Resident's vital signs were within normal limits/baseline, with temperature being 98.4. The temperature outside at this time was between 79-81 degrees. On 07/11/2025 15 minute checks were initiated by the Director of Clinical Services on resident. The Director of Clinical Services provided this instruction to the nurse assigned to resident and it would be on-going until further notice. The 15 minute checks are documented on the monitoring form with the nurses verbally reporting confirmation of the completion of the 15 minute checks for resident shift to shift. On 07/11/2025 the Director of Clinical Services verified using the census from electronic medical record that every resident was accounted for. All residents were present and accounted for. On 07/12/25 the Unit Manager completed an elopement risk evaluation in electronic medical record which was used to update the Elopement Book to include the resident that eloped and any residents at high risk for elopement. The Elopement Book is maintained at the sole nurses station which is behind a secured entrance in which all visitors must be assisted in or out by a facility staff member. On 07/12/2025 the nurse assigned to the resident completed a skin assessment on resident with no negative findings noted.On 07/13/2025 Skin assessment was completed on resident by the Director of Clinical Services, no changes noted. No negative findings noted.On 07/13/2025 the Director of Clinical of services updated the care plan to include exit seeking behaviors. Interventions included: alert/call resident's wife to sit with resident as needed, facility to attempt to look for a more secure facility for resident with responsible party permission, include resident in activities that are ongoing in the facility, and to monitor resident's whereabouts more frequently. Kardex was updated at this time to reflect the current interventions added to the care plan for nursing staff to be aware. Care plan updates and Kardex updates were included in the education that was provided to facility staff. On 07/13/2025 BIMS assessment was completed on resident by the Director of Clinical Services. Previous BIMS was a 3, with current BIMS a 2, thus validating no changes in cognitive ability. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 07/11/2025 once the resident was back inside the building, the Certified Nursing Assistant noted resident's wheelchair sitting at the kitchen door where the lock was manually unlocked and immediately locked the door. Administrator obtained statements from current staff working at time of elopement. After review of statements a root cause was found to be the kitchen door was unlocked and not secured. From 07/11/2025 all exterior doors along with the door leading from the dining room into the kitchen have been checked by the Administrator and/or Maintenance. All doors have been closed and secured.On 07/12/2025 the locking knob for the kitchen door keypad was removed by the Maintenance Director. This removal has made the keypad an automatic locking door. The kitchen staff have the code and must use the keypad each time to open the door. On 07/12/2025 to 07/13/2025 Elopement Risk Assessments were completed on current residents in the facility by the Unit Manager and the Director of Clinical Services. Any residents triggering for elopement risk were updated in the Elopement Book that is placed at the nurses station and their care plans were updated accordingly. Elopement Risk Assessments are completed by the nursing staff upon admission, quarterly and as deemed necessary. Staff are made aware of care plan updates through education. On 07/13/2025 and 07/14/2025 Elopement Drills were conducted on all three shifts by the Administrator and/or Maintenance Personnel. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 07/11/2025 - 07/13/2025 Director of Clinical Services provided education on elopement and ensuring doors are closed and locked to current staff. Education was conducted via text messaging and/or email via scheduling portal immediately. Upon start of staff's next working shift, education was reviewed with staff signing acknowledgment of education and understanding. On 07/13/2025, Administrator and Director of Clinical Services continued to provide one on one education and answered any questions to nursing department, therapy department, dietary department, housekeeping department, and management team with validation of education via question and answer time. Education focused on residents at high risk for elopement (Elopement Book which is located at the nurses station), what to do in the event of a missing resident, and when to notify Director of Clinical Services and Administrator. Effectiveness of education will be measured by conduction of elopement drills one time per week for 4 weeks alternating between shifts, then monthly thereafter for 2 months to ensure understanding of elopement procedure. The Executive Director will bring the results of the elopement drills to the Quality Assurance Performance Improvement meetings.On 07/12/2025 Dietary staff were provided education by the Administrator pertaining to making sure that kitchen is secure upon leaving at night and that the door from the kitchen to the dining room is not propped open. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.On 07/13/2025 the Administrator held an Ad Hoc Quality Assurance Performance Improvement with the Medical Director and Director of Clinical Services to approve the plan.Starting on 07/14/2025 Maintenance and/ or designee to complete audits 2 times/day 7 days/week at random times for 4 weeks then daily for 4 weeks to ensure that all exterior doors are secure and the door leading from the dining room into the kitchen is closed. Immediate action to be taken for any positive findings. The Director of Clinical Services will bring results of these audits before the Quality Assurance and Performance Improvement Committee monthly with the QAPI Committee responsible for ongoing compliance. In the monthly Quality Assurance and Performance Improvement Meeting, the Interdisciplinary Team will review all elopements to ensure appropriate interventions are in place and care plan updated x8 weeksQAPI Committee will determine the need for further intervention and auditing beyond three months to assure compliance is sustained ongoing.Alleged date of IJ removal date: 7/15/2025 Validation of the facility's corrective action plan was conducted on 7/17/24 through record review and staff interviews. A review of the 15-minute check sheets indicated Resident #1 was monitored every 15 minutes by staff from 7/11/25 at 8:00 PM to 7/15/25 at 8:00 PM. The Elopement Book included residents at high risk for elopement, and it was maintained at the nurses' station. A review of the Elopement Drill sign-in sheets indicated elopement drills were conducted on 7/13/25 at 2:19 PM and 7/14/25 at 5:16 AM to cover staff on all three shifts. A review of the facility's monitoring audits conducted on 7/14/25 through 7/16/25 indicated all outside doors were locked and secured, including the door leading from the dining room to the kitchen, and all door alarms were active. Interviews were conducted with nursing, therapy, dietary, and housekeeping staff which indicated they received education on the facility's elopement policy and ensuring doors were closed and locked. The staff revealed the education included residents at high risk for elopement, what to do in the event of a missing resident, and when to notify the DON and the Administrator. Interviews with dietary staff revealed they received education related to making sure that the kitchen was secure upon leaving at night and that the door from the kitchen to the dining room was not propped open.The corrective action plan completion date and IJ removal date of 7/15/25 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the resident's responsible party and staff, the facility failed to notify the responsible party of elopement for 1 of 3 residents reviewed for notification of change (Resident # 1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia.The significant change in status Minimum Data Set assessment dated [DATE] indicated Resident #1 was severely cognitively impaired.A review of Resident #1's medical record indicated a late entry nursing progress note dated 7/12/25 at 3:29 PM by Nurse #1 which read, in part: Nurse Aide (NA) #1 and NA #2 witnessed Resident #1 outside, walking past the C hall door at approximately 7:45 PM. NA #1 immediately ran outside to assist him back into the building while NA #2 came and alerted Nurse #1. Nurse #1 assisted NA #1 with guiding Resident #1 back into the building via C hall door. NA #2 went to find Resident #1's wheelchair, finding it in the dining room just outside the door going into the kitchen. Once Resident #1 was assessed, Nurse #1 checked the doors and found all doors to be closed and locked. When NA #2 checked the kitchen door, she found it to be unlocked. Apparently, Resident #1 went through the unlocked kitchen door and outside through the back door of the kitchen. Nurse #1 notified the Director of Nursing as well as the Administrator who came to the facility shortly thereafter. An interview with Resident #1's responsible party (RP) on 7/16/25 at 11:01 AM revealed Resident #1 had gotten out of the facility on the evening of 7/11/25 around 8:00 PM. Resident #1's RP stated that from what was reported to her, Resident #1 had wheeled himself into the dining room, opened the door to the kitchen, which was left unlocked, and went outside through another door inside the kitchen. Resident #1's RP stated that she didn't find out about the incident until the next day, and it had upset her. She further stated that a resident first told her about Resident #1 getting outside the facility as she was walking up the sidewalk towards the facility on 7/12/25. The RP also stated that the nurse who was supposed to call her on the evening of 7/11/25 had called her since and apologized to her.A phone interview with Nurse #1 on 7/18/25 at 7:50 PM revealed she had thought the Administrator was going to call Resident #1's RP on the evening of 7/11/25. Nurse #1 stated that she knew it was her responsibility to notify Resident #1's RP about the incident, but she had gotten behind, had tried to get her medication pass started, and had forgotten about calling his RP that night. Nurse #1 further stated she called Resident #1's RP on 7/14/25 to apologize.An interview with the Unit Manager (UM) on 7/16/25 at 2:22 PM revealed whenever Nurse #1 did the assessment on Resident #1 after he was brought back inside the facility, he had assumed that she had taken the responsibility of notifying his RP. The UM stated that she heard Nurse #1 talking on the phone, and he thought she was calling his RP. The UM also shared that he worked day shift on 7/12/25, and he found out that Resident #1's RP was not called from the night before, but he knew Nurse #1 called her later to apologize.An interview with the Director of Nursing (DON) on 7/17/25 at 11:04 AM revealed that attempts were made to call Resident #1's RP on the evening of 7/11/25, but the phone number they had in his medical record was not correct. The DON stated that the RP was told about the incident on 7/12/25 when she came into the facility.A follow-up interview with Resident #1's RP on 7/17/25 at 11:15 AM revealed the Administrator told her that they called the phone number listed in Resident #1's medical record and it was inaccurate. The RP stated she looked at Resident #1's medical record and they had two phone numbers listed, but one of them was correct. She asked them why they didn't call both numbers listed but she didn't get a clear answer. She stated that Nurse #1 had called her at 6:30 AM on 7/14/25 to tell her that it was her responsibility to call her on the evening of 7/11/25 and she didn't, and she apologized.An interview with the Administrator on 7/17/25 at 1:34 PM revealed she did not call Resident #1's RP to notify her about the elopement because she thought Nurse #1 would call her as it was part of the incident report. The Administrator stated that there were two phone numbers listed in Resident #1's medical record, but one of them was correct, and that the nurse should have called both numbers to try to get in touch with Resident #1's RP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident and staff interviews, the facility failed to obtain an order for the use of supplemental oxygen and post oxygen cautionary signage for 1 of 1 resident (Resident #75) reviewed for respiratory care.
Findings included:
Resident #75 was admitted to the facility on [DATE] with diagnoses that included left lower lobe pneumonia, sepsis and pleural effusion.
The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 was cognitively intact.
A review of Resident #75's medical record revealed there was no order for supplemental oxygen.
A review of Resident #75's Medication Administration Record (MAR) for September 2024, October 2024, November 2024 and December 2024 indicated there was no order for supplemental oxygen administration on the records.
On 12/09/24 at 10:23 AM an observation and interview were conducted with Resident #75 who was lying in bed and wearing continuous oxygen at 1.5 liters via nasal cannula. The Resident reported she has worn oxygen since her admission to the hospital prior to her admission to the facility and wore it all the time except when she was eating. There was no oxygen cautionary sign posted on or about the Resident's door.
An observation was made on 12/10/24 at 9:39 AM of Resident #75 wearing continuous oxygen at 1.5 liters via nasal cannula. There was no oxygen cautionary sign posted at the Resident's door.
On 12/10/24 at 1:23 PM during an interview with Nurse Aide (NA) #1, she explained that only the nurses were responsible for initiating oxygen, changing the rate of oxygen flow and checking the residents' oxygen saturation. The NA stated she was not sure who was responsible for posting the oxygen signage on the residents' door.
During an interview with Nurse #1, on 12/10/24 at 2:17 PM, the Nurse explained that Resident #75 had been on continuous oxygen since she has been on his hall, and he checked her oxygen saturation level every day. He stated he had not checked it yet today (12/10/24) but the check for 12/09/24 was 96%. He stated he automatically checked the oxygen saturation while on his rounds because he knew the Resident wore oxygen. When Nurse #1 was asked how much oxygen Resident #75 should be on the Nurse referred to the MAR and realized there was no order for oxygen on the MAR. Nurse #1 then looked to see if Resident #75 had an order for supplemental oxygen, but he could not find the order. The Nurse explained that the nurse who admitted Resident #75 to the facility or initiated the oxygen was responsible for starting the oxygen and posting the cautionary signs on the residents' door and if the Resident did not have an order for oxygen but was wearing oxygen the nurse should have addressed that with the physician and obtain an order for the oxygen.
During an interview with the Director of Nursing (DON) on 12/11/24 at 10:38 AM, the DON explained that there should be an order for supplemental oxygen administration with the amount of liter flow included in the order. The DON also stated the person who initiated the oxygen should have posted the cautionary sign on the door. She also indicated the department manager should have made sure the oxygen sign was posted on the door when they made their daily rounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident, staff, and detective interviews, the facility failed to protect the resident's (Resident #70) right to be free from misappropriation of property when Housekeeper #1 used Resident #70's debit card to set up a mobile payment application account on his [Housekeeper #1's] phone without Resident #70's permission or knowledge. Housekeeper #1 was alleged to have sent approximately $4,000.00 of unauthorized payments from Resident #70's bank account to his mobile payment application account from February 2024 to May 2024. Resident #70 stated, I am poor and he took everything I had. He indicated he was very upset that someone he trusted had taken advantage of him and he was worried to death over the loss of money and the potential for identity theft. This deficient practice occurred for 1 of 3 residents (Resident #70) reviewed for abuse, neglect, and misappropriation of resident property.
The findings included:
Resident #70 was admitted to the facility on [DATE].
A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #70 was cognitively intact.
A review of the facility's reportable incidents revealed an initial allegation report dated 5/30/24 indicating the facility became aware on 5/29/24 that money was transferred from Resident #70's bank account to a former employee's (Housekeeper #1) mobile payment application account. The report indicated there was reasonable suspicion of a crime, and the alleged misappropriation of resident property was reported to law enforcement on 5/30/24.
A review of Resident #70's bank account records from January 2024 to May 2024 revealed there were transactions of sending money from Resident #70's bank account to mobile payment application accounts starting on 2/05/24 along with overdraft fees charged by the bank. There were five transactions on 2/05/24, each sending $10.00 to Housekeeper #1's mobile payment application account. Transactions sending money from Resident #70's bank account to various mobile payment application accounts, including Housekeeper #1's, continued to recur several times a day from 2/5/24 through 5/6/24 in amounts ranging from $5.00 to $60.00. The transactions made to mobile payment application accounts and the bank overdraft charges totaled approximately $4,000.00.
A review of the police department incident report indicated a report was filed on 5/10/24 at 11:11 AM concerning Resident #70 and stolen money from his bank account.
An interview with Resident #70 was conducted on 12/20/24 at 11:27 AM. Resident #70 stated he was very sick and had not been able to use his debit card or monitor his bank account after his admission to the facility. Resident #70 revealed he did not recall the date, but a week or 2 after he was admitted to the facility, he asked Housekeeper #1 if he would purchase him a drink from the facility's vending machine. He indicated he gave Housekeeper #1 his debit card, he purchased the drink and then returned his debit card. Resident #70 revealed that was the only time he recalled Housekeeper #1 having possession of his debit card. He revealed a few months later the Business Office Manager (BOM) came to see him to discuss paying his bill. Resident #70 indicated he realized his debit card was missing and he asked the BOM to assist him with calling the bank to request a new card. He stated when they called the bank, he was informed that his account had been overdrawn for several months due to debit transactions that were made to a mobile payment application account. Resident #70 revealed he never had an account with a mobile payment application, and the only time his debit card was used after his admission to the facility was when Housekeeper #1 purchased him a drink from the vending machine. He further revealed he was not aware of any other staff members having possession of his debit card which indicated to him Housekeeper #1 was responsible for taking his money. Resident #70 stated, I am poor and he took everything I had. He indicated he was very upset that someone he trusted had taken advantage of him and he was worried to death over the loss of money and the potential for identity theft. Resident #70 indicated that he was interviewed by the police and wanted to press charges against Housekeeper #1, but there was not enough evidence to charge him, and the case was closed.
An interview with the BOM on 12/11/24 at 11:37 AM indicated she did not recall the date but at the end of April she met with Resident #70 to discuss payment of his monthly bill, and he told her he lost his debit card and needed assistance contacting the bank. She revealed they called the bank a few days later and were informed that Resident #70's account had been overdrawn since January and there were several transactions of sending money to a mobile payment application account. She indicated that Resident #70 did not know what a mobile payment application was and had never set up an account. The BOM stated she obtained Resident #70's bank account records with is his permission from January 2024 to May 2024 and reviewed them on 5/10/24. She revealed there were several transactions sending money to various mobile payment application accounts, one of which was Housekeeper #1's. The BOM stated she contacted the mobile payment application company, and they informed her Housekeeper #1 had opened an account linked to Resident #70's debit card. She stated she immediately notified the Former Administrator of the concern, and he called the police. The BOM indicated the police assigned a detective to the case and an investigation was completed but no charges were filed. She revealed when the detective requested records from the mobile application company, he was told they had no record of Housekeeper #1's account. She stated she worked with the bank and tried to get them to credit the money Resident #70 lost but they would only go back 60 days from the date they became aware of the fraudulent activity. She indicated that Resident #70 agreed to set up a trust account managed by the facility and his social security check began to directly deposit into the account in June. The BOM revealed that Resident #70 had an outstanding bill with the facility that she planned to write off.
An attempt was made to call Housekeeper #1 on 12/11/24 at 3:36 PM and the number was no longer in service.
A phone interview was conducted with the Former Administrator on 12/12/24 at 8:59 AM. He stated the BOM notified him on 5/10/24 that she reviewed Resident #70's bank account transaction records and identified concerns related to mobile payment application withdrawals made by Housekeeper #1. He revealed that Housekeeper #1 was no longer employed at the facility when the concern was identified. He indicated he filed a police report on 5/10/24. He indicated that the police assigned a detective to the case, and records were requested from the mobile payment application company, however they informed the police they had no records of Housekeeper #1's account. He stated the detective informed him on 5/30/24 that Resident #70's bank account records did not provide enough evidence to file charges against Housekeeper #1, and they would be closing the case.
A phone interview conducted with the Detective on 12/16/24 at 9:11 AM indicated the facility filed a police report on 5/10/24 related to Housekeeper #1 setting up a mobile payment application account linked to Resident #70's debit card without his knowledge or permission. He stated the facility provided Resident #70's bank account records which he reviewed and determined there was enough evidence to open a case. He indicated he obtained a search warrant requesting the mobile payment application company release the records of Housekeeper #1's account, however they informed him there was no record of the account. The Detective revealed that without records from Housekeeper #1's mobile payment application account there was not sufficient evidence to file charges and the case was closed.
The Administrator was notified of immediate jeopardy on 12/11/24 at 10:52 AM.
The facility provided the following corrective action plan:
Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice:
On 05/10/2024, the Business Office Manager obtained bank statements for Resident #70 and identified on the bank statements that Housekeeper #1 transferred no more than $3,963.15 through a money transfer application from Resident #70's bank account to Housekeeper #1's phone application between 02/05/2024 - 04/08/2024. Housekeeper #1 no longer worked at the facility effective 03/07/2024. The facility recognized that residents who manage their own personal funds have the potential to be affected by the noncompliance of misappropriation of resident property.
On 05/13/2024, the Business Office Manager, with consent from Resident #70, requested a direct deposit for Resident #70's Social Security checks into his RFMS (Resident Fund Management System) account. Beginning on 06/03/2024 Resident #70's Social Security checks were direct deposited into his resident trust account managed by the facility. RFMS is a complete resident fund accounting system for handling resident funds, to provide banking solutions, such as direct deposit and direct debits.
The Executive Director reported the misappropriation of Resident #70's property to local law enforcement on 05/10/2024. The Executive Director filed the initial allegation to the State agency on 05/30/24.
On 05/24/2024, Resident #70 was seen by the psychiatric nurse practitioner, the progress note indicated Resident #70 denied feeling depressed, anxious, and stated Resident #70 left his room to socialize with others. He continued to be followed by psychiatric services. Resident #70's liability from June 2024 through December 2024 with a total balance of $628 has been written off without any penalty to the resident. The decision was made by the Regional Business Office Manager to write off the balance on 5/21/2024.
Address how the facility will identify other residents having the potential to be affected by the same deficient practice:
The Business Office Manager audited the current Resident Financial Management System (RFMS) on 05/15/2024 to ensure no unauthorized activity had occurred. No discrepancies or suspicious activity were identified. Also, during this time no concerns were noted by any other residents/responsible parties regarding unauthorized activity with their personal banking accounts. No other residents/responsible parties reached out to the business office for additional assistance with their personal banking accounts. The Business Office Manager reconciled the asset account (bank account and register statement balance) to the resident trust fund liability account (balance of residents account in the RFMS) to verify the accounts monthly. All disbursements made from the Resident Trust Fund must be documented with a properly signed withdrawal ticket. The facility maintains a pre-numbered withdrawal book with withdrawal tickets in a triplicate to record the disbursements made from the Resident Trust account. A Resident Trust fund statement is mailed to the patient and or Guardian/Responsible Party quarterly. The statement included all accounting transactions to include debits and credit. This process pertains to interviewable and non-interviewable residents with RFMS accounts. On 05/30/2024, the Social Worker interviewed alert and oriented residents to ensure no employee had asked any resident for money or use of their debit, credit, EBT (food stamps) and or Ucard (United Healthcare debit card). No issues or concerns identified. The RFMS reconciliation process was utilized for the non-interviewable residents. Staff were interviewed regarding misappropriation of resident property by the Executive Director and/or Director of Nursing on 05/30/2024. No concerns identified.
Address the measures put into place or systemic changes made to ensure that the deficient practice will not occur:
The Executive Director and/or Director of Nursing re-educated current staff including contracted staff with validation of understanding on the Abuse Policy with emphasis on misappropriation of resident property, unauthorized use of a resident's debit, credit, EBT and or UCard for personal use or gain on 05/30/2024 - 06/05/2024. Education also included the use of a sign out sheet for snacks and drinks purchases. The form included date, name, items purchased, amount given by the resident to the staff, amount returned to the resident, staff signature, resident signature, and a place to have two staff sign if the resident is unable to sign. The snacks and drinks form is located at the nursing station and is reviewed weekly by the Director of Nursing for accuracy to ensure the amount of money given by the resident to the staff minus the item purchased equals the amount of money returned to the resident. Newly hired staff will be educated in orientation. Staff were educated to not accept debit cards from residents for vending machine purchases on 06/05/2024. The Executive Director verbally educated Residents educated the use of debit cards by staff is not allowed for vending machine purchases on 06/05/2024 via room to room. Residents are made aware upon admission and throughout their stay of having the option to secure valuables. The Maintenance Director handled the request of a resident's need for a lock on their nightstand. A key is provided by the Maintenance Director and/or Executive Director. In the event the nightstand does not have locking capabilities, the Maintenance Director will install a lock and provide the key to unlock the nightstand to the resident and the spare key is in a locked box / drawer in the Maintenance Directors office. All residents/responsible parties were offered a RMFS account upon admission and can make changes any time during their stay with consent to the business department.
Address how the facility will monitor its corrective actions to ensure the deficient practice will not recur:
On 06/05/2024, the Executive Director held an ADHOC Quality Assurance Performance Improvement meeting. The Executive Director presented the deficient practice of misappropriation of resident property and implemented a plan of action to include quality improvement monitoring and the frequency of monitoring. The Executive Director and/or Director of Nursing to complete quality monitoring of five residents weekly for twelve weeks to ensure residents are protected from misappropriation of personal property. Questions asked of the 5 residents included in the quality monitoring are Do you have any concerns related to your finances to include your debit card, EBT card and/or U card? and Do you know who to report concerns to?. The Business Office Manager reconciled the asset account (bank account and register statement balance) to the resident trust fund liability account (balance of residents account in the RFMS) to verify the accounts monthly. All disbursements made from the Resident Trust Fund must be documented with a properly signed withdrawal ticket. The facility maintains a pre-numbered withdrawal book with withdrawal tickets in a triplicate to record the disbursements made from the Resident Trust account. A Resident Trust fund is mailed to patient and or Guardian/ Responsible Party quarterly. The statement includes all accounting transactions to include debits and credit. This process pertains to interviewable and non-interviewable residents. Members of the Quality Assurance Performance Improvement committee include Executive Director, Medical Director, Director of Nursing, the Manager of Social Services, the Housekeeping Manager, the Business Office Manager, the Human Resources Coordinator, Medical Records Clerk, Central Supply Clerk, Admissions Director, Nurse Managers, Dietary Manager, and the Environmental Services Director. The results of the quality monitoring will be brought to the Quality Assurance Performance Improvement meeting monthly to ensure ongoing compliance for 3 months. Quality Improvement monitoring schedule will be modified based on findings of monitoring. The Executive Director is responsible for overseeing the plan of correction. The center Executive Director alleges compliance 06/06/2024.
Alleged date of IJ removal: 06/06/24.
Validation of the facility's corrective action plan was conducted 12/17/24 through record review and staff interviews. A review of the resident trust account audits indicated they were completed by the Business Office Manager on 5/15/24 and no concerns or discrepancies were identified. An interview conducted with the BOM revealed she continues to audit and reconcile the resident trust accounts monthly and there have been no discrepancies identified. A review of the facility's monitoring audits conducted 6/6/24 through 8/20/24 revealed 5 alert and oriented residents were interviewed weekly and voiced no concerns related to their finances, misappropriation of their personal property or unauthorized charges on their personal bank accounts. Interviews were conducted with housekeeping, nursing, therapy and dietary staff which indicated they received education on the facility's abuse and reporting policy including misappropriation of resident property. The staff revealed the education also included the procedure to follow if a resident requests assistance with purchasing a snack or drink, which included only using cash (no payment cards), documenting the amount of cash the resident gave them, the item purchased, and the amount of cash returned to the resident.
The corrective action plan completion date and IJ removal date of 6/06/24 was validated.

Based on record review, and staff and Adult Protective Services (APS) Intake Social Worker interviews, the facility failed to file a report with the state agency no later than 24 hours after becoming aware of an allegation of misappropriation of resident property and failed to report the incident to APS for 1 of 3 residents reviewed for abuse (Resident #70).
The findings included:
A review of the facility's abuse, neglect, exploitation and misappropriation policy and procedure revised 11/16/22 read in part: Reporting/Response: Once an allegation of abuse is reported, the Administrator, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notification of Law Enforcement if a reasonable suspicion of crime has occurred. The Abuse Coordinator will refer any or all incidents and reports of resident abuse to the appropriate state agencies.
Resident #70 was admitted to the facility 1/05/24.
A review of the police department incident report indicated on 5/10/24 at 11:11 AM they received a report that Resident #70 had money stolen from his bank account.
A review of the facility's initial allegation report dated 5/30/24 revealed the facility became aware on 5/29/24 that Resident #70's bank statement had several transactions transferring money from his account to a former employee's (Housekeeper #1) mobile payment application account. The report indicated there was reasonable suspicion of a crime, and the alleged misappropriation of resident property was reported to law enforcement on 5/30/24 however it was not reported to Adult Protective Services. The report was completed by the Former Administrator.
An interview with the Business Office Manager (BOM) on 12/11/24 at 11:37 AM indicated she did not recall the date but at the end of April she met with Resident #70 to discuss payment of his monthly bill, and he told her he lost his debit card and needed assistance contacting the bank. She revealed they called the bank a few days later and were informed that Resident #70's account had been overdrawn since January and there were several transactions sending money to a mobile payment application account. She stated she reviewed Resident #70's bank statements on 5/10/24 and there were several transactions sending money to various mobile payment application accounts, one of which was Housekeeper #1's. She indicated she contacted the mobile payment application company, and they informed her Housekeeper #1 had opened an account linked to Resident #70's debit card. The BOM revealed she immediately notified the Former Administrator of the concern, and a police report was filed on 5/10/24.
A phone interview was conducted with the APS Intake Social Worker on 12/16/24 at 9:27 AM. She stated they had no record of the facility reporting an incident of misappropriation of property for Resident #70.
A phone interview with the Former Administrator on 12/12/24 at 8:59 AM revealed the BOM was reviewing Resident #70's bank statements and there were several transactions transferring money from his account to Housekeeper #1's mobile payment application account. He stated the BOM notified him of the concern on 5/10/24 and he filed a police report. He further stated he did not submit an initial allegation report within 2 hours because he wanted to investigate it further along with the police to see if it was anything. He revealed Housekeeper #1 was no longer employed at the facility when the concern was identified. He stated he submitted the initial allegation report on 5/30/24 once the police investigation was completed and they determined no charges would be filed against Housekeeper #1. The Former Administrator indicated because the police did not file charges against Housekeeper #1, he unsubstantiated the allegation of misappropriation and did not file a report with APS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #35 was admitted to the facility on [DATE] with diagnoses that included paraplegia, and neuromuscular dysfunction of bladder.
A review of Resident #35's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her to be cognitively intact and having an indwelling catheter and she was always continent of bladder.
A review of Resident #35's treatment administration record indicated she received indwelling catheter care every shift during the lookback period for the assessment.
During an interview with Resident #35 on 12/11/24 at 4:46 PM, she reported she had the catheter since before her admission to the facility. Resident #35 stated she had not had the catheter removed, even temporarily, since it was placed.
An interview with MDS Nurse #1 on 12/12/24 at 9:00 AM, she stated she had worked as the facility's MDS nurse since April of 2024. She reported Resident #35 had a catheter the entire time she had worked at the facility and that if a resident had a catheter for the entirety of the lookback period of a MDS assessment, then their bladder continence should be coded as not rated. She went on to say the answers in the assessment system were typically automatically generated and she attempted to double check the answers. MDS Nurse #1 stated she thought she had changed Resident #35's continence to not rated but must have missed it.
An interview with the Director of Nursing on 12/12/24 at 2:04 PM revealed to her knowledge, Resident #35 had never had her catheter removed and that her bladder continence should have been coded as not rated. She also indicated she expected MDS assessments to accurately reflect the resident, their care needs, and their conditions.
Based on observation, record review, and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 2 of 2 residents reviewed for bladder continence (Resident #74 and Resident #35).
Findings included:
1. Resident #74 was admitted to the facility on [DATE] with diagnoses including a stage 4 pressure ulcer to the sacrum.
A review of Resident #74's physician orders showed an order dated 10/21/2024 for a 16 French (FR) foley catheter with a 10 milliliter (ml) balloon due to stage 4 sacral pressure ulcer.
A review of Resident #74's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was marked as having an indwelling catheter in place but was always incontinent of bladder.
An interview was completed on 12/12/2024 at 9:00 AM with the MDS Coordinator. During the interview the MDS Coordinator reported if a resident's MDS assessment was marked for an indwelling catheter then the continence needed to be marked as Not Rated. The MDS Coordinator explained Resident #74's MDS assessment should have been marked as Not Rated, instead of Always Incontinent for incontinence because he had an indwelling catheter. The MDS Coordinator also said the answers in the MDS assessments were system generated, and normally she would [NAME] check those answers but somehow missed it.
During an interview on 12/12/2024 at 12:59 PM with the Director of Nursing (DON) she said she expected to see accurate coding on all MDS assessments.
An interview was completed on 12/12/2024 at 2:40 PM with the Administrator where she said she expected to see all MDS assessments completed accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to develop a comprehensive, individualized, and person-centered care plan in the area of behavior for 1 of 2 residents reviewed for behaviors (Resident #37).
The findings included:
Resident #37 was admitted to the facility on [DATE] with the following diagnoses: cerebral infarction, anxiety disorders, metabolic encephalopathy, and vascular dementia.
A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had moderate cognitive impairment. The MDS further indicated no negative behaviors during the lookback period.
On 12/9/2024 at 11:10 am an interview and observation were made of Nursing Assistant (NA) #4 sitting outside of Resident #37's room. The resident was observed lying in bed with his eyes closed. NA #4 reported she sat outside of the room since Resident #37 needed 1 on 1 supervision due to a history of physical behaviors with other residents and staff.
An additional observation and interview were completed on 12/11/2024 at 10:26 am of Resident #37's room. NA #4 sat outside of the resident's room. NA #4 explained for the past 9 weeks or so she had sat outside of Resident #37's room to provide 1 on 1 supervision due to his behaviors. NA #4 also said there were staff members who sat with the resident on every shift.
A review of Resident #37's care plan last reviewed on 12/6/2024 revealed no care plan in place for behaviors towards staff or residents.
An interview was completed on 12/12/2024 at 9:00 am with the MDS Coordinator regarding Resident #37's care plan.
During the interview the MDS Coordinator reported there should have been a care plan in place for Resident #37 related to his history of physical behaviors towards residents, especially since he had 1 on 1 supervision. The MDS Coordinator went on to say any type of changes in a resident, including 1 on 1 care would have been discussed in morning meeting and care planned, but she was unsure how this had been missed.
On 12/12/2024 at 12:559 pm an interview was conducted with the Director of Nursing (DON) where she said she expected to see care plans be accurate to reflect the resident and their needs. The DON reported she was aware the resident had physical and verbal behaviors towards others and had been receiving 1 on 1 supervision since July of 2024 and should have been care planned.
An interview was completed on 12/12/2024 at 2:40 pm with the Administrator. During the interview the Administrator said she expected to see all care plans completed accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to update a resident's care plan after she ingested wound cleanser for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #8).
The findings included:
Resident #8 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety, major depressive disorder, and adult failure to thrive.
A review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her to be severely impaired with no delusions, behaviors, or rejection of care. Resident #8 was coded as having wandering behaviors daily. Resident #8 required supervision with mobility and was coded as using a manual wheelchair.
A review of facility incident and accident logs revealed a report dated 03/11/24 that indicated Resident #8 had obtained a bottle of wound cleanser and ingested an unknown amount. Per the incident report, Resident #8 was assessed along with telephone calls made to her representative, the on-call physician, and poison control. The report stated that Resident #8 was placed on observation and with no negative side effects observed. The report also indicated that Resident #8's confused cognition and wandering behaviors contributed to the incident.
A review of Resident #8's care plan that was last reviewed on 08/01/24 revealed a care plan for Resident #8 being at risk for wandering behaviors due to dementia. Interventions included to assess for elopement risk, distract Resident #8 from wandering by offering pleasant distractions, and to attempt to identify pattern of wandering and intervene as appropriate. There was no mention of the potential for Resident #8 to attempt to ingest non-food items or any interventions to prevent this from occurring.
An interview with MDS Nurse #1 on 12/12/24 at 9:27 AM revealed the MDS nurse was typically responsible for updating care plans that were nursing specific with the Director of Nursing updating care plans when she was not working. MDS Nurse #1 stated she updated care plans anytime there is a change in condition with a resident, which would include changes in behavior. MDS Nurse #1 also stated she had no knowledge of Resident #8 ingesting wound cleanser and reported a behavior like that would be something that should be mentioned in her care plan. She reported she was not working at the facility at the time the incident occurred and provided the contact information for MDS Nurse #2, whom she indicated was the MDS nurse at the time of the incident. MDS Nurse #1 reported she did not know why Resident #8's care plan had not been updated.
An interview with MDS Nurse #2 via telephone on 12/12/24 at 11:36 AM revealed she was the MDS Nurse in March of 2024 and reported she was unaware of the incident regarding Resident #8 ingesting wound cleanser. She also reported she did not recall if the interdisciplinary team discussed the incident after it occurred. MDS Nurse #2 reported if she had been made aware of the incident, she would have updated Resident #8's care plan to reflect the potential for Resident #8 to ingest non-food items. MDS Nurse #2 reported she did not know why Resident #8's care plan had not been updated.
An interview with the Director of Nursing on 12/12/24 at 1:52 PM revealed she was familiar with Resident #8 and that she was severely cognitively impaired and had wandering behaviors. She stated in March, she was made aware of an incident by Nurse #4 regarding Resident #8 ingesting an unknown amount of wound cleanser. She reported the day after the incident, it was discussed in the interdisciplinary team meeting, and she verified that MDS Nurse #2 was present. The Director of Nursing reported Resident #8's care plan should have been updated immediately after the interdisciplinary team meeting to reflect the potential for Resident #8 to ingest non-food items. She did not know why Resident #8's care plan had not been updated after she ingested the wound cleanser.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident, staff, Nurse Practitioner (NP) and Medical Director (MD) interviews, the facility failed to ensure the correct medications were administered to the correct resident for 1 of 5 residents reviewed for unnecessary medications (Resident #80).
The findings included:
Resident #80 was readmitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, neuropathy, and necrotizing fasciitis.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was cognitively intact and was marked as receiving routine and as needed pain medication.
Review of a progress note written by Nurse #2 dated 12/8/2024 at 6:05 pm indicated Resident #80 was administered Baclofen (muscle relaxer) 10 milligram (mg) and Norco (pain reliever) 5/325 mg. Further review of the progress note revealed the on-call provider was notified and Nurse #2 was instructed to monitor the resident's level of consciousness, breathing, and cognition.
A review of an additional progress note written by Nurse #2 dated12/8/2024 at 6:43 pm revealed Resident #80 had been notified by Nurse #2 of receiving the wrong medication and he responded, I did not even notice a difference.
A telephone interview was completed on 12/10/2024 at 2:05 PM with Nurse #2. During the interview Nurse #2 explained during her medication pass on 12/8/2024 she was putting medications into a medication cup for who she thought was Resident #80. Nurse #2 went on to say there was another resident sitting in his wheelchair behind her yelling while she was putting the medication in the medication cup, and she was distracted by it. Nurse # 2 said she administered the medications to Resident #80 and shortly afterwards she realized she had given Resident #80 the wrong medications. She stated the medications she had given to Resident #80 were Norco 5/325 mg and Baclofen 10 mg and were prescribed for Resident #59. Nurse #2 reported she informed Resident #80 that he received the wrong medications and took his vital signs before calling the on-call provider because she knew she would need to know the resident's vital signs before calling. Nurse #2 said she was told by the on-call provider to monitor Resident #80 for any change in level of consciousness (LOC) and breathing and call back if anything changed. Nurse #2 stated the Director of Nursing (DON) was also notified.
Review of Resident #80's current physician orders dated December 2024 revealed Resident #80 was ordered the following medications; Acetaminophen 325 mg (milligrams), give 1 tablet my mouth every 4 hours PRN (as needed) for pain, Roxicodone 5 mg, give 1 tablet my mouth every 4 hours PRN for severe pain with 7-10 pain rating, Gabapentin 600 mg, 1 tablet 3 times a day for neuropathy, and Methocarbamol (a muscle relaxer) 1000 mg, give 1 tablet three times a day for pain.
A review of the electronic medication administration record (MAR) for 12/8/2024 showed Resident #80 received Roxicodone 5 mg at 6:32 am and Gabapentin 600 mg was administered three times.
A review of Resident #59's MAR for 12/8/2024 revealed he received the medications that were ordered for him which included Baclofen 10 mg and Norco 5/325 mg for pain. Resident #59 reported pain rated at a 2/10.
Review of Resident #80's respirations revealed on 12/8/2024 at 6:30 PM his breathes per minute (BPM) were 18 and again on 12/8/2024 at 10:00 PM his BPM were 16.
An interview was completed on 12/10/2024 at 1:39 pm with Resident #80. During the interview the resident reported he received medication over the past weekend that was not his. Resident #80 went on to say the medication he received was weak pain medication and it did not really affect him because he was prescribed a stronger pain medication than what he received. Resident #80 reported he did not have any breakthrough pain due to receiving the wrong pain medication.
An interview was completed on12/11/24 at 11:36 AM with the DON revealed she was aware of a medication error that occurred on 12/8/2024. The DON explained she was notified by Nurse #2 that she had given Resident #80 a 10 mg Baclofen and a 5/325 mg Norco that was ordered for Resident #59. The DON said Nurse #2 went through all of the necessary steps following the medication administration including making sure Resident #80 was ok by checking his vital signs prior to calling the on-call provider and notifying the on-call provider and herself. The DON reported Resident #59 received his ordered medication. The DON explained neither resident had any complaints about pain and additional education will be provided to Nurse #2 to include Medication Administration involving the 6 rights and how to attempt to limit distractions.
On12/10/24 at 4:16 PM a telephone interview was conducted with the Nurse Practitioner (NP). The NP reported she had was notified of a medication error that occurred on 12/8/2024 by Nurse #2 about Resident #80 receiving pain medication and a muscle relaxer that was ordered for Resident #59. The NP stated she instructed Nurse #2 to monitor Resident #80's LOC and breathing and to reach back out if there were any changes. The NP explained she did not see the medication that Resident #80 received as a significant medication error due to the resident having no adverse outcomes and the medications and dosages he received were less than what he was prescribed.
An additional interview was conducted on 12/12/2024 at 12:55 PM with the DON where she stated she expected all Nurses to follow the 6 rights of medication administration. The DON also said if a medication error occurred, she expected for the Nurse to notify herself, the provider, and the resident or responsible party.
On 12/11/2024 at 2:36 PM an interview was completed with the Medical Director (MD). During the interview the MD reported the difference in medication and dosage that Resident #80 received would not be considered a significant medication error due to Resident #80 did not have any adverse effects related to the medications he received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff, Resident, Wound Nurse and Medical Director interviews, the facility failed to provide care in a safe manner when a dependent resident (Resident #57) fell off the bed during incontinence care. The facility also failed to provide an environment free from a potential hazard when wound cleanser was left unattended on top of the treatment cart and an unmeasurable amount was ingested by Resident #8. This was for 2 of 4 residents reviewed for accidents.
The findings included:
1. Resident #57 was admitted to the facility on [DATE] with diagnoses that included Fredrick's Ataxia (a condition that mainly affects the neuromuscular system and the heart and causes poor muscle control and coordination).
A review of Resident #57's admission nursing assessment dated [DATE] indicated she was alert and oriented to person, place, time and situation.
A review of a baseline care plan dated 10/28/24 indicated Resident #57 required extensive assistance of one staff for bed mobility, toileting and personal hygiene.
A review of Resident #57's medical record revealed an order dated 10/28/24 to x-ray the right ankle.
A review of an Incident Report dated 10/28/24 at 3:14 PM completed by Nurse #2 indicated Nurse #2 was notified that Resident #57 was on the floor by Nurse Aide (NA) #3. Upon entering the room NA #2 informed Nurse #2 that she was providing incontinent care to Resident #57 and the Resident rolled out of bed. Resident #57 stated she rolled out of bed but denied hitting her head. The Resident indicated her right ankle was hurting. The report also indicated Resident #57 was alert and oriented to person, place, time and situation.
A review of Resident #57's medical revealed the result of the right ankle x-ray dated 10/29/24 was negative for fracture.
A review of an Investigative Report: Root Cause Analysis dated 10/29/24 completed by the Director of Nursing revealed Resident #57 was admitted [DATE] at 11:30 AM and fall occurred on 10/28/24 at 3:14 PM. NA #2 was providing incontinent care to Resident #57 and when the NA rolled the Resident onto her side while keeping her left hand on the Resident attempting to remove the soiled brief, Resident #57 rolled off the bed. Therapy to screen for bed mobility.
An interview and observation of Resident #57 were conducted on 12/09/24 at 11:29 AM. The Resident was lying in the middle of her bed watching television with her bed up against the wall and without side rails. Resident #57 stated, they let me roll out of bed the first night I got here. Resident #57 explained that the first day she was admitted she was soiled and had to be changed. When Nurse Aide (NA) #2 came to provide care, the NA asked her how many people it took to take care of her and Resident #57 told NA #2 that it only took one person to provide care for her. The Resident continued to explain that when the NA turned her over, she continued to roll over and out of the bed onto the floor. Resident #57 reported she hurt her right ankle, and they obtained an x-ray which showed no fracture. She stated her ankle hurt for a few days and since she was on routine pain medication the pain did not last very long at all.
During an interview with NA #2 on 12/10/24 at 3:02 PM the NA confirmed that she was scheduled to work on Resident #57's hall on 10/28/24 and was present when the Resident rolled out of the bed. The NA explained that when she made rounds on Resident #57 on 10/28/24 at the end of her shift the Resident needed to be changed. The Nurse Aide reported that she received a brief report about Resident #57 from the Resident's family member who was with her during her admission and the family reported the Resident was total care. The NA stated she had never worked with Resident #57, so she was going to obtain assistance from another staff member when Resident #57 told her that it only took one person to change her. The NA explained that the Resident had soiled herself, so she gathered her supplies and raised her bed to about waist high and made sure the Resident was in the middle of the bed. She reported she then rolled Resident #57 over onto her left side and crossed her right leg over her left leg and while keeping her hand on the Resident's hip, she pulled the brief out from under the Resident and the Resident continued to roll over off the bed and onto the floor. NA #2 indicated she immediately went around to the other side of the bed and Resident #57 was lying on her left side. The NA asked the Resident if she was hurt, and Resident #57 stated she was not hurt but that she just wanted to get up out of the floor. The NA stated she went to the door and saw Nurse Aide #3 standing in the hallway, so she asked her to come to the room because Resident #57 was on the floor. NA #2 stated NA #3 came into the room and saw that Resident #57 was on the floor and then went and got Nurse #2. NA #2 continued to explain that when Nurse #2 came into the room, she assessed Resident #57 before they transferred her back into the bed where she and NA #3 continued to provide incontinence care for the Resident. NA #2 reported she knew she could review the Resident's care plan to determine how many staff it took to provide care for Resident #57, but the Resident told her it only took one person to provide care for her but in retrospect she should have reviewed the care plan.
An interview was conducted with Nurse Aide #3 on 12/10/24 at 4:14 AM. The NA explained that she was standing in the hallway near Resident #57's door when NA #2 hollered for her to come in the room because the Resident had fallen on the floor. The NA stated that when she went into the room and noticed the Resident lying on the floor, she asked her if she was hurt which the Resident denied and stated she just wanted to get out of the floor. NA #3 continued to explain that she went to get Nurse #2 who immediately went to the room and assessed Resident #57 who again reported to the Nurse that she was not hurt. She stated they transferred the Resident back to bed. NA #3 reported she understood that Resident #57 rolled out of bed when NA #2 rolled her over to provide incontinent care. She explained that she often worked with the Resident and one person can provide care for Resident #57 because she can help hold herself over.
On 12/10/24 at 2:32 PM an interview was conducted with Nurse #2 who explained that she was summoned to Resident #57's room on the afternoon of 10/28/24 and observed the Resident lying on the floor lying on her left side. The Nurse reported she assessed Resident #57, and she had no injuries, but she did complain of pain in her right ankle. The Nurse stated she along with other staff transferred the Resident back to bed where Nurse Aide #2 completed incontinence care. Nurse #2 continued to explain that both Nurse Aide #2 and Resident #57 informed her that the Resident told NA #2 that she could manage the Resident by herself before the NA began to provide the incontinent care. Nurse #2 stated that she reported the fall to the Director of Nursing who obtained an order for an x-ray of her right ankle.
An interview was conducted with the Director of Nursing (DON) on 12/11/24 at 10:13 AM. The DON explained that on the afternoon of 10/28/24 Nurse #2 informed her that Resident #57 had rolled off the bed during incontinence care provided by NA #2. Nurse #2 stated she had assessed Resident #57, and her only complaint was right ankle pain, so the DON requested an order for an x-ray which was obtained on 10/29/24 and was negative for fracture. She continued to explain that when she investigated the fall, she had NA #2 explain and demonstrate what happened and the NA indicated when she rolled Resident #57 over onto her side the NA kept her left hand on the Resident's hip and when she removed the brief the Resident rolled off the bed and onto the floor. The DON stated Resident #57 was alert and oriented and told NA #2 that she could do the Resident by herself, but the DON stated she felt that because Resident #57 had poor lower trunk control related to her diagnosis of Fredrick's Ataxia and with the momentum of being turned to her side, she could have kept on rolling. The DON stated in retrospect NA #2 should have obtained assistance from another staff member since it was the NA's first-time taking care of Resident #57.
2. Resident #8 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety, major depressive disorder, and adult failure to thrive.
A review of Resident #8's quarterly Minimum Data Set assessment dated [DATE] revealed her cognition was severely impaired with no delusions, behaviors, or rejection of care. Resident #8 was coded as having wandering behaviors daily. Resident #8 required supervision with mobility and was coded as using a manual wheelchair for mobility.
A review of Resident #8's care plan that was last reviewed on 08/01/24 revealed Resident #8 being at risk for wandering behaviors due to dementia. Interventions included to assess for elopement risk, distract Resident #8 from wandering by offering pleasant distractions, and to attempt to identify pattern of wandering and intervene as appropriate.
A review of facility incident and accident logs revealed a report dated 03/11/24 that indicated Resident #8 had obtained a bottle of wound cleanser and ingested an unknown amount. Per the incident report, Resident #8 was assessed along with telephone calls made to her representative, the on-call physician, and poison control. The report stated that Resident #8 was placed on observation and with no negative side effects observed. The report also indicated that Resident #8's confused cognition and wandering behaviors contributed to the incident.
Review of Resident #8's progress notes revealed a note dated 03/11/24 that read: At approximately [10:15] Resident [#8] picked up a bottle of wound cleaner off of the treatment care and opened it up and drank an unmeasurable amount. Staff immediately obtained the cleaner from the resident and obtained vital signs (blood pressure 141/69, pulse 71, oxygen saturation 98%, respirations 16, and temperature 98.5 [degrees Fahrenheit]. This nurse immediately called on-call clinicians and spoke with physician whom stated to call poison control. This nurse then called poison control . and informed them of the situation. She gave orders to give [Resident #8} one or two sips of water only and give nothing else for one hour and to closely observe [Resident #8] for any drooling, trouble swallowing, or blisters in the mouth or throat. If none of those symptoms occurred after one hour, to go ahead and give one or two more sips of water and resume regularly scheduled food/drinks and medications. If [Resident #8] does exhibit any of the above listed signs and symptoms, then she needs to be sent to the Emergency Room. This nurse gave detailed instructions to staff and staff are following clinician's instructions. The progress note was written by Nurse #4.
Review of the facility's safety data sheet (SDS) for the wound cleanser that was ingested by Resident #8 revealed the following instructions if accidentally ingested: Ingestion - [look for] nausea, vomiting, and diarrhea. Drink water.
An interview with Nurse #4 on 12/13/24 at 12:17 PM revealed he was familiar with Resident #8 and described her as very confused with aimless wandering behaviors. He also stated he remembered the incident and stated that two, now unknown, nurse aides came to him that evening with Resident #8 and a bottle of wound cleanser and informed him Resident #8 had ingested an unknown amount of wound cleaner. Nurse #4 stated he immediately assessed Resident #8 and obtained her vitals and did not believe there was anything out of the normal. He continued, stating that he called the on-call physicians who informed him to contact poison control. Poison control suggested that he closely monitor Resident #8 for any vomiting, nausea or the development of blisters in Resident #8's mouth and throat. He stated he then contacted the Director of Nursing and Resident #8's responsible party. Nurse #4 stated he monitored Resident #8 closely for the rest of his shift and did not note any nausea, vomiting, or blisters. He stated when he observed the wound cleanser bottle it did not appear to have much missing and estimated that the bottle was almost full. Nurse #4 reported he was informed that Resident #8 had obtained the bottle of wound cleanser from the wound treatment cart which was kept at the end of a hall near the nurse's station. He stated it was routine for the wound cleanser not to be locked on the wound cart and was either stored in a side pocket or on top of the wound cart. Nurse #4 also reported that, to his knowledge, Resident #8 never had to receive additional medical treatment, in house, or at the hospital due to the ingestion of the wound cleanser. He reported that he had not seen Resident #8 attempt to ingest non-food items before or since the incident.
Attempts were made to identify and speak to the unknown nurse aides that brought the incident to Nurse #4's attention but those attempts were unsuccessful.
An interview with the Wound Nurse on 12/11/24 at 2:33 PM revealed she did not know anything about Resident #8 ingesting wound cleanser. She stated if the wound cleanser was ingested it could cause some gastrointestinal discomfort, nausea, and/or vomiting. She stated she was aware Resident #8 had wandering behaviors and admitted to knowledge of Resident #8 having touched things on the cart but denied knowledge of Resident #8 taking anything off of the cart and attempting to or actually ingesting it. The Wound Nurse reported she typically kept wound cleanser on the cart and available for other staff when she was not in the facility. The Wound Nurse reported she stored the wound cleanser either on top of her cart or in a side pocket of the wound treatment cart and not locked away inside the cart.
An observation of the wound treatment cart on 12/12/24 at 1:37 PM revealed it was at the end of a hall outside of a resident's room. The room was posted as being on enhanced barrier precautions and the wound cart was outside the room, with the door closed. An observation of the wound cart revealed a bottle of wound cleanser sitting on top of the wound cart with the top unscrewed. There were no observed residents around the wound cart.
An interview with the Director of Nursing on 12/12/24 at 1:52 PM revealed she was familiar with Resident #8 and that she was severely cognitively impaired and had wandering behaviors. She stated in March, she was made aware of an incident by Nurse #4 regarding Resident #8 ingesting an unknown amount of wound cleanser. She stated poison control was contacted but reported she did not believe they instructed the staff to do a whole lot. She indicated Resident #8 was monitored and given a few sips of water. The Director of Nursing reported Resident #8 had no adverse reaction to ingesting the wound cleanser. She reported the administrative staff discussed the incident in their interdisciplinary team meeting but could not recall if they implemented any additional care plan interventions or policies to help keep the incident from happening again. She stated wound cleanser should always be kept locked away to prevent residents from accessing it, and that nothing should be stored in the side pockets or on top of the wound treatment cart.
An interview with the Medical Director on 12/11/24 at 2:33 PM revealed he had taken over as the medical director in August and was not aware of the Resident #8 ingesting wound cleanser. He reported there was always a potential concern with a resident ingesting wound cleanser and stated he would expect the staff to closely monitor the resident post ingestion for metabolic and other issues which included vomiting, diarrhea, or changes in their general condition. He did report small doses would not necessarily be concerning.

Based on record review and staff interviews, the facility failed to allow a resident with behaviors to remain in the facility and to provide written documentation which stated the reason the facility could not meet the residents needs for 1 of 3 resident (Resident #6) reviewed for transfer and discharge.
The findings included:
Resident #6 was admitted to the facility for respite services through Hospice on 5/09/24 and discharged on 5/09/24. Diagnosis included malnutrition, chronic pain, depression, and anxiety.
Review of nursing note dated 5/09/24 written by the Director of Nursing (DON) at 4:06 PM revealed telephone call placed to Hospice Nurse, updated that Resident #6 is agitated and wanting to smoke. She stated Resident #6 was agitated at home; wife needs a break. She verbalized that he received Haldol (treat behavioral issues) 1 MG and Ativan (treat anxiety) 1 MG prior to leaving on transport to facility. Hospice Nurse speaks with Hospice provider, orders received for Xanax 1 MG by mouth now and to repeat in 1 hour: Rocephin (treat possible urinary tract infection) IM (intramuscularly) 1 gram (GM) now.
Review of nursing note dated 5/09/24 written by the DON at 6:25 PM revealed Resident #6 had been up and down, propelling wheelchair throughout facility. Offered snack, which was accepted. An on-call Hospice Nurse was in the facility, asked if willing to continue with 5-day respite, stated the facility was not able to meet his needs and cannot do respite. She was arranging transport to hospital.
A telephone interview with the Hospice nurse on 5/30/24 at 4:11 PM revealed she was familiar with Resident #6 and had been providing for his care at his home through Hospice. She stated during her home visits with Resident #6, he was alert and oriented but would show signs of agitation off and on and attempt to get up out of his wheelchair unassisted to walk around the house to go to the bathroom, or to go outside and smoke but was easily re-directed. She revealed on 5/09/24 around lunchtime she and the Hospice Social Worker (SW) were at Resident #6 home and observed him showing signs of agitation and trying to get up out of his wheelchair to walk around and go outside to smoke and although he was easily re-directed his spouse informed them that she was exhausted and needed a break. The Hospice Nurse stated the Hospice SW began trying to find respite services for Resident #6 so his spouse could have a break and she administered him medication to calm his agitation. She revealed the Hospice SW spoke with the facility and informed them of why Resident #6 needed respite services and sent Hospice notes from the previous day which documented his agitation and behaviors and the facility agreed to take him. She stated she was present at Resident #6 home when he left for the facility around 2 PM and had informed transport that he had been having some agitation and wanting to get up from his wheelchair to walk around, the medications she had administered him prior, and sent those medications with him to the facility. She also stated that she called the facility, but could not recall who she spoke with, at 2:45 PM while Resident #6 was in transit to give a report and informed them of his behaviors and that she had administered medications to help calm him and those medications had been sent with him to the facility. The Hospice Nurse revealed after Resident #6 had arrived at the facility she received a telephone call from the Director of Nursing (DON) between 3:30- 4:00 PM stating Resident #6 was agitated and trying to get up from his wheelchair unassisted and that they were not going to be able to provide for his care due to these behaviors because they did not have the staff to be able to provide one-on-one supervision. She stated she informed the DON that Resident #6 did not require one-on-one supervision that he was easily re-directed and that she had administered him Haldol and Xanax earlier to help calm him, both of which were sent with him to the facility, and she would call the Hospice NP for orders to administer these medications. She revealed she contacted Hospice NP and received a verbal order for Resident #6 to be administered the Xanax and Haldol and repeat in an hour if needed and received a verbal order for him to be administered a shot of Rocephin IM. She stated she called back to the DON and informed her of the verbal orders from the Hospice NP to administer Resident #6 the Xanax and Haldol that was sent with him to the facility and repeat in an hour if needed and to also administer Rocephin IM which he was not sent with, but the DON stated the facility had access to medication in their emergency cart. The Hospice Nurse revealed after staffing the situation with her supervisor they decided it would be best for the on-call Hospice Nurse to go to the facility that evening and check on Resident #6 and when she contacted the facility to check on Resident #6 and let them know the on-call Hospice Nurse would be coming she spoke with DON who informed her they had not administered Resident #6 the medications she had given them verbal orders for an hour prior to assist with calming his agitation and behaviors. She stated later that evening she spoke with on-call Hospice Nurse who stated when she arrived at the facility they informed her Resident #6 was not going to be able to stay, they were not be able to provide for his needs, he would need other placement, and requested for him to be sent out to the hospital and they would not allow her to administer him his medications that had been ordered. She also stated while the on-call Hospice Nurse was there she observed Resident #6 to have some agitation and wanting to get out of his wheelchair unassisted but that he was easily re-directed and was even calm when she was pushing him around the facility in his wheelchair. She revealed she did speak with the Hospital NP the following day on 5/10/24 who was very upset Resident #6 had been sent out to the hospital in the first place and once they administered Resident #6 medications the facility had been ordered to administer and didn't, he was calm, polite, and fell asleep with no issues. The Hospice Nurse revealed she believed that if the facility had followed their instructions and administered Resident #6 the medications as ordered there would have been no issues and she was not sure why the facility had decided they did not want to keep Resident #6 because they were made aware of his agitation and behaviors prior to him being admitted , he was sent with medications to assist with his agitation behaviors, did not require one-on-one services, and he was not combative or harmful to himself or others.
A telephone interview with the on-call Hospice nurse on 5/30/24 at 5:27 PM stated she was familiar with Resident #6. She stated on 5/09/24 at 5:00 PM she had received a telephone call from her supervisor asking if she would go to the facility and check on Resident #6 who was just admitted for respite services and was showing some signs of agitation and trying to get up from his wheelchair unassisted and the facility had received orders from Hospice NP to administer medications to assist with these behaviors. She revealed on the way to the facility she had called to let them know she was coming to check on Resident #6 and spoke with DON who informed her they had not administered him any medications, he could not stay at the facility per Administration and Hospice would be finding him alternative placement. The on-call Hospice Nurse stated when she arrived at the facility the DON was standing in the hallway next to Resident #6 who was sitting in his wheelchair, and he was showing no signs of being aggressive or attempting to hurt himself or others. She revealed Resident #6 did attempt to stand up from his wheelchair, but was easily re-directed, and when she asked if she could administer medications that had been ordered to assist with making him more comfortable, the DON stated no, and they wanted him out. She stated she assisted Resident #6 around the facility in his wheelchair and assisted him with laying down on the bed in his room and he was compliant with no issues. The on-call Hospice Nurse revealed she asked the DON for Resident #6 paperwork that had been sent to the facility prior to his admission and she stated the facility did not receive any paperwork and the facility would not be able to provide for his care and he could not stay at the facility and needed to be sent to the hospital and find placement elsewhere. She stated she spoke with her supervisor and to accommodate the facility wishes, Resident #6 was sent out to the hospital along with his medications that had been sent with him from home. The on-call Hospice Nurse revealed the hospital performed a urinalysis and minimal labs on Resident #6 which came back clear and showed no issues and administered him the medications the facility had previously been ordered to administer, Resident #6 was pleasant and did not appear agitated during this time.
An interview with Nurse #3 on 5/31/24 at 9:05 AM revealed she had worked 2nd shift on 5/09/24 and was familiar with Resident #6. She stated when she arrived for shift on 5/09/24, Resident #6 was at the facility and was having some agitation and trying to get up out of his chair unassisted but was easily re-directed by staff. She recalled being told by the DON Resident #6 did not need to be at the facility and a Hospice nurse would be coming to visit and would have to find him another placement. She revealed once the Hospice nurse arrived, Resident #6 was sent to the hospital, and she assumed he had been discharged from the facility based on what she was told earlier by the DON. She stated she was not aware of Resident #6 having any orders for medications to assist with his behaviors while at the facility and was not instructed to administer him any medications.
A telephone interview with the Hospital Nurse Practitioner (NP) on 5/31/24 at 10:34 AM revealed he was working at the hospital on evening of 5/09/24 and was familiar with Resident #6. He stated Resident #6 arrived at the hospital from the facility, with concerns of agitation and increased behaviors. He stated while at the hospital, they completed lab work and a urinalysis which revealed no issues and administered the medications the facility had been ordered to administer previously. He revealed he never observed Resident #6 to be aggressive, agitation was minimal, attempted to get up and walk around but was easily re-directed and once his medications were administered, he was calm and fell asleep. The Hospital NP stated he was never given a clear understanding as to why the facility did not administer Resident #6 the medication that had been previously ordered by Hospice, why the facility was not able to provide for his care, or why Resident #6 was sent to the hospital, and felt like the facility had dumped Resident #6 for no reason.
An interview with the Director of Nursing (DON) on 5/31/24 at 1:52 PM revealed she was familiar with Resident #6. She stated she was working on 05/09/24 and received a telephone call she believed from the admission Director or the Administrator that Resident #6 was in route to the facility for a 5-day respite stay admission. She revealed she was not notified of Resident #6 care needs or behaviors and after he arrived, he became agitated and was trying to get up and down out of his wheelchair unassisted trying to walk around the facility. The DON stated that she called the Hospice Nurse and informed her of Resident #6 behaviors, and she did not think they would be able to provide for his care and he may need to be sent to another placement and the Hospice Nurse gave verbal orders to administer medications to help calm him and to assist with the agitation and repeat in one hour. She revealed she could not recall whether the medication was ever administered or not and had no reason for why they did not administer the medications. She stated she contacted the interim Administrator and discussed Resident #6 behaviors and the facility not being able to provide for his care and the decision was made to contact Hospice and inform them the facility could not provide care for Resident #6 and they would need to find alternative placement. The DON revealed when the on-call Hospice Nurse arrived at the facility, she informed her that per administration, Resident #6 would not be able to stay at the facility due to them not being able to provide for his care and they would need to send him out to the hospital or find alternative placement. The DON revealed the on-call Hospice nurse assisted with Resident #6 being sent out to the hospital, per the facility request.
A telephone interview with the interim Administrator on 6/03/24 at 4:00 PM revealed he was not present at the facility on 5/09/24 but had received a telephone call from the admission Director sometime after lunch stating they would be admitting Resident #6 on this date under respite services for Hospice. He stated later that afternoon he received a telephone call from the DON stating Resident #6 had arrived at the facility and had started to become agitated, was trying to get up out of his wheelchair to walk around and would require one-on-one supervision and they did not have the staff available to provide him with one-on-one supervision. He revealed the DON stated they were not aware of him having these behaviors prior to him being admitted to the facility and were not able to provide for his care needs, and that she had contacted Hospice to inform them of this and that they would need to find an alternative placement and Hospice agreed. The Administrator stated to his knowledge, Hospice came to the building that evening and decided it was best for him to be sent out to the hospital and he did not return. When asked if he was aware of the Hospice notes received by the facility as part of the admission referral documenting Resident #6 had been showing signs of agitation and having behaviors such as getting up from his wheelchair to walk around or of the Hospice social worker relaying this information by telephone to the admission Director prior to him being accepted by the facility, the Administrator stated no he had not been made aware of that information. He also stated that he was not aware the DON had spoken with the Hospice nurse and received orders to administer medications that were sent with Resident #6 to the facility for his agitation and repeat in an hour and to administer an injection for agitation if needed that was available at the facility and those orders were not followed and medications were not administered. The Administrator revealed he was not informed of on-call Hospice nurse not being allowed to administer these medications and being told Resident #6 was not allowed to stay at the facility and for him to be sent to the hospital, he was of the understanding that Hospice had made the decision for him to leave. He also revealed the information that he had received was Resident #6 was agitated and trying to get up out of his wheelchair and staff were not able to care for him, he was not aware Resident #6 behaviors were easily redirected or that there was medication available that could have helped. The Administrator stated had he known all of the information he would have instructed staff to follow recommendations from Hospice, administer Resident #6 medications as instructed, and communicate with Hospice prior to Resident #6 being sent out and discharged from facility.

Based on record review, Hospice staff, Hospital Nurse Practitioner, and staff interviews, the facility failed to allow resident to return to the facility after being sent to the hospital for a medical evaluation using the residents' behaviors prior to discharge as a basis for their decision for 1 of 3 residents reviewed for transfer and discharge (Residents #6).
The findings included:
Resident #6 was admitted to the facility for respite services through Hospice on 5/09/24 and discharged on 5/09/24. Diagnosis included malnutrition, chronic pain, depression, and anxiety.
Review of nursing note dated 5/09/24 written by the Director of Nursing (DON) at 4:06 PM revealed telephone call placed to Hospice Nurse, updated that Resident #6 is agitated and wanting to smoke. She stated Resident #6 was agitated at home; wife needs a break. She verbalized that he received Haldol (treat behavioral issues) 1 MG and Ativan (treat anxiety) 1 MG prior to leaving on transport to facility. Hospice Nurse speaks with Hospice provider, orders received for Xanax 1 MG by mouth now and to repeat in 1 hour: Rocephin (treat possible urinary tract infection) IM (intramuscularly) 1 gram (GM) now.
Review of nursing note dated 5/09/24 written by the DON at 6:25 PM revealed Resident #6 had been up and down, propelling wheelchair throughout facility. Offered snack, which was accepted. Hospice on-call Nurse was in the facility, asked if willing to continue with 5-day respite, stated the facility was not able to meet his needs and cannot do respite. She was arranging transport to hospital.
A telephone interview with the on-call Hospice nurse on 5/30/24 at 5:27 PM stated she was familiar with Resident #6. She stated on 5/09/24 at 5:00 PM she had received a telephone call from her supervisor asking if she would go to the facility and check on Resident #6 who was just admitted for respite services and was showing some signs of agitation and trying to get up from his wheelchair unassisted and the facility had received orders from Hospice NP to administer medications to assist with these behaviors. She revealed on the way to the facility she had called to let the know she was coming to check on Resident #6 and spoke with DON who informed her they had not administered him any medications, he could not stay at the facility per Administration and Hospice would be finding him alternative placement. The on-call Hospice Nurse stated when she arrived at the facility the DON was standing in the hallway next to Resident #6 who was sitting in his wheelchair, and he was showing no signs of being aggressive or attempting to hurt himself or others. She revealed Resident #6 did attempt to stand up from his wheelchair, but was easily re-directed, and when she asked if she could administer medications that had been ordered to assist with making him more comfortable, the DON stated no, and they wanted him out. She stated she assisted Resident #6 around the facility in his wheelchair and assisted him with laying down on the bed in his room and he was compliant with no issues. The on-call Hospice Nurse revealed she asked the DON for Resident #6 paperwork that had been sent to the facility prior to his admission and she stated the facility did not receive any paperwork and the facility would not be able to provide for his care and he could not stay at the facility and needed to be sent to the hospital and find placement elsewhere. She stated she spoke with her supervisor and to accommodate the facility wishes, Resident #6 was sent out to the hospital along with his medications that had been sent with him from home. The on-call Hospice Nurse revealed the hospital performed a urinalysis and minimal labs on Resident #6 which came back clear and showed no issues and administered him the medications the facility had previously been ordered to administer, Resident #6 was pleasant and did not appear agitated during this time. She stated she called and spoke with the DON while Resident #6 was at hospital requesting him to return to the facility and explaining he had been administered the ordered medications, appeared calm with no issues, and that his labs were normal and the DON stated no, he would not be able to return. She revealed due to the time of night she was not able to find alternative placement, so the hospital agreed to keep Resident #6 for the night until alterative placement with another facility could be arranged the following morning. The on-call Hospice Nurse stated Resident #6 was sent to another facility for respite the following morning.
An interview with Nurse #3 on 5/31/24 at 9:05 AM revealed she had worked 2nd shift on 5/09/24 and was familiar with Resident #6. She stated when she arrived for shift on 5/09/24, Resident #6 was at the facility and was having some agitation and trying to get up out of his chair unassisted but was easily re-directed by staff. She recalled being told by the DON Resident #6 did not need to at the facility and a Hospice nurse would be coming to visit and finding him another placement. She revealed once the Hospice nurse arrived, Resident #6 was sent to the hospital, and she assumed he had been discharged from the facility based on what she was told earlier by the DON. Nurse #3 stated later in the evening she received a call from hospital physician stating Resident #6 was ready to return to the facility and requested to speak with the DON, so she contacted the DON and informed her the hospital had called and Resident #6 was ready to return to the facility and she stated no that he was not to return to the facility and needed to find alternative placement. She revealed she called back and relayed the information from the DON to the hospital physician who stated there was nothing wrong with Resident #6 and if they did not agree to take him back, they would report the issue to the state. She stated she called the DON back and relayed the information from the hospital physician and the DON stated that was fine, but they were not going to allow him back. Nurse #3 revealed her shift ended after her last conversation with the DON and she had no knowledge of what happened after that conversation. She stated she was not aware of Resident #6 having any orders for medications and was not instructed to administer him any medications.
A telephone interview with the Hospital Nurse Practitioner (NP) on 5/31/24 at 10:34 AM revealed he was working at the hospital on evening of 5/09/24 and was familiar with Resident #6. He stated Resident #6 arrived at the hospital from the facility, with concerns of agitation and increased behaviors. He stated while at the hospital, they completed lab work and a urinalysis which revealed no issues and administered the medications the facility had been ordered to administer previously. He revealed he never observed Resident #6 to be aggressive, agitation was minimal, attempted to get up and walk around but was easily re-directed and once his medications were administered, he was calm and fell asleep. The hospital NP stated the on-call Hospice Nurse had contacted the facility about Resident #6 being able to return and the facility would not allow him to return, stating they needed to find him an alternative placement. He revealed at this point, Resident #6 had been at the hospital for 5 hours with no signs of medical issues and showing no signs of behaviors, so he contacted the facility himself to inform them Resident #6 was ready to return to the facility and spoke with a nurse who stated she had been informed that Resident #6 had been discharged and would not be returning and she would have to contact her DON for further instructions. He stated the facility nurse called him back stating that per the DON, the facility would not be accepting Resident #6 back to the facility and would need to find alternative placement. The hospital NP revealed he requested to have the DON contact him so they could discuss why Resident #6 was not able to return to the facility and even offered to send him back with medications and scripts for medications to assist with his care, and if the facility refused to allow Resident #6 back, he would make a report to the state. He stated the facility nurse stated she would inform the DON and ask her to contact him, and he never received a call back. He stated he was never given a clear understanding as to why the facility did not administer Resident #6 the medication that had been previously ordered, why he was sent to the hospital, or why he was not allowed to return and felt like the facility had dumped Resident #6 for no reason causing him to have to spend the night at the hospital when they could have taken him back that evening, provided for his care, and found placement the following day if needed.
An interview with the Director of Nursing (DON on 5/31/24 at 1:52 PM revealed she was familiar with Resident #6. She stated she was working on 05/09/24 and received a telephone call she believed from the admission Director or the Administrator that Resident #6 was in route to the facility for a 5-day respite stay admission. She revealed she was not notified of Resident #6 care needs or behaviors and after he arrived, he became agitated and was trying to get up and down out of his wheelchair unassisted trying to walk around the facility. The DON stated that she called the Hospice Nurse and informed her of Resident #6 behaviors, and she did not think they would be able to provide for his care and he may need to be sent to another placement and the Hospice Nurse gave verbal orders to administer medications to help calm him and to assist with the agitation and repeat in one hour. She revealed she could not recall whether the medication was ever administered or not and had no reason for why they did not administer the medications. She stated she contacted the interim Administrator and discussed Resident #6 behaviors and the facility not being able to provide for his care and the decision was made to contact Hospice and inform them the facility could not provide care for Resident #6 and they would need to find alternative placement. The DON revealed when the on-call Hospice Nurse arrived at the facility, she informed her that per administration, Resident #6 would not be able to stay at the facility due to them not being able to provide for his care and they would need to send him out to the hospital or find alternative placement. She stated the on-call Hospice Nurse assisted with Resident #6 being sent out to the hospital and someone from the hospital (she could not recall the name) called her later that evening asking again if Resident #6 could return to the facility, and she informed no he could not return due to the facility not being able to provide care for his needs and to contact Hospice. She revealed the hospital physician did contact the facility about Resident #6 returning and spoke with Nurse #3 who did call her about the situation, and she informed her that Resident #6 was not allowed to return but she did not speak with the hospital physician herself. The DON stated the decision for Resident #6 not to return to the facility was a decision made by her and the Administrator.
An interview with the admission Assistant on 5/31/24 at 2:35 PM revealed she was familiar with Resident #6. She stated on 5/09/24 she had received a telephone call from the admission Director who was not at the facility, informing her of Resident #6 admission for respite services. She revealed Resident #6 arrived at the facility around 2:45 PM and she went to discuss the Advanced Directive and admission paperwork with him at 3:30 PM and observed Resident #6 sitting in the hallway in his wheelchair with the DON standing beside of him. She stated Resident #6 did appear to be slightly agitated and did attempt to get up out of his wheelchair one time but was easily re-directed but was not being combative or attempting to hurt himself or others. The admission Assistant revealed after having Resident #6 sign his Advance Directive, the DON stated there was no use to go over the admission paperwork with Resident #6 because he would not be staying due to his behaviors and not being able to provide his care and Hospice would have to find him another placement. She stated after that she left the hallway and went back to her office, the following day she was notified Resident #6 was sent out to the hospital and did not return.
A telephone interview with the interim Administrator on 6/03/24 at 4:00 PM revealed he was not present at the facility on 5/09/24 but had received a telephone call from the admission Director sometime after lunch stating they would be admitting Resident #6 on this date under respite services for Hospice. He stated later that afternoon he received a telephone call from the DON stating Resident #6 had arrived at the facility and had started to become agitated, was trying to get up out of his wheelchair to walk around and would require one-on-one supervision and they did not have the staff available to provide him with one-on-one supervision. He revealed the DON stated they were not aware of him having these behaviors prior to him being admitted to the facility and were not able to provide for his care needs, and that she had contacted Hospice to inform them of this and that they would need to find an alternative placement and Hospice agreed. The Administrator stated to his knowledge, Hospice came to the building that evening and decided it was best for him to be sent out to the hospital and he did not return. When asked if he was aware of the Hospice notes received by the facility as part of the admission referral documenting Resident #6 had been showing signs of agitation and having behaviors such as getting up from his wheelchair to walk around or of the Hospice social worker relaying this information by telephone to the admission Director prior to him being accepted by the facility, the Administrator stated no he had not been made aware of that information. He also stated that he was not aware the DON had spoken with the Hospice nurse and received orders to administer medications that were sent with Resident #6 to the facility for his agitation and repeat in an hour and to administer an injection for agitation if needed that was available at the facility and those orders were not followed and medications were not administered. The Administrator revealed he was not informed of on-call Hospice nurse not being allowed to administer these medications and being told Resident #6 was not allowed to stay at the facility and for him to be sent to the hospital, he was of the understanding that Hospice had made the decision for him to leave. He also revealed the information that he had received was Resident #6 was agitated and trying to get up out of his wheelchair and staff were not able to care for him, he was not aware Resident #6 behaviors were easily redirected or that there was medication available that could have helped. He stated he was also not aware of the hospital NP attempting to contact the DON to discuss Resident #6 behaviors and that once he was administered the medications at the hospital he was less agitated and continued to be easily re-directed, and the DON would not return the hospital NP call and messages had to be sent through Nurse #3 at the facility that Resident #6 was not allowed to return. The Administrator stated had he known all of the information he would have instructed to follow recommendations from Hospice, administer Resident #6 medications as instructed, and communicate with Hospice and the Hospital NP prior to not allowing Resident #6 to return to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to provide incontinence care to a resident prior to her wetting through her brief and her pants for 1 of 3 residents (Resident #4) reviewed for activities of daily living (ADL).
The findings included:
Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral vascular accident (CVA or stroke), hypertension, diabetes mellitus type II, congestive heart failure and muscle weakness.
Review of Resident #4's Care Area Assessment (CAA) summary dated 01/15/24 for activities of daily living (ADL) revealed resident was to receive assistance of 1 to 2 staff members with ADL, transfers, mobility, and toileting to prevent falls or injury. Resident #4 was to receive peri-care every 2 hours and as needed to prevent skin breakdown and infection.
Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired, and staff were to anticipate her needs. The assessment also revealed she required partial to moderate assistance of 1 to 2 staff members with toileting hygiene and required substantial to maximal assistance of 1 to 2 staff members with lower body dressing.
Review of Resident #4's care plan dated 05/10/24 revealed a focus area for the resident having an ADL self-care performance deficit related to disease process, impaired balance and pain. The interventions included for toilet use the resident required assistance of 1 to 2 for toileting hygiene and for dressing required 1 staff assistance with dressing and undressing. Resident #4's care plan also revealed a focus area for the resident having frequent urinary incontinence related to disease process, inability to communicate needs and poor toileting habits. The interventions included the resident used disposable briefs, clean peri-area with each incontinent episode, check as required for incontinence, wash, rinse and dry perineum, change clothing as needed (prn) after incontinence episodes and monitor/document any signs or symptoms of urinary tract infection (UTI).
An observation on 05/31/24 at 11:17 AM of incontinence care on Resident #4 revealed the resident being assisted to the bathroom in her room via wheelchair by Nurse Aide (NA) #4 and NA #5. NA #4 assisted the resident up out of her wheelchair and Resident #4 stood at the grab bar in the bathroom while NA #4 held onto her, and NA #5 proceeded to clean her from front to back. When NA #4 removed the resident's brief it was saturated from front to back with urine and there were stool smears on the brief and the inside of the brief had begun to bunch up. When NA #4 threw the brief in the trash can it made a loud thud. NA #5 continued to clean Resident #4 until she was clean and then NA #4 and NA #5 put a clean brief on the resident and sat her down in the wheelchair to change her pants because she had saturated her brief and wet through her pants. NA #4 changed the resident's pants, washed the resident's hands and washed her hands and pushed the resident in her wheelchair to the dining room for lunch.
An interview on 05/31/24 at 12:40 PM with NA #4 revealed she was assigned to care for Resident #4 on the 7:00 AM to 3:00 PM shift. She stated she typically rounded every 2 hours on her residents but said she had not gotten to round on Resident #4 the first time until 11:17 AM. NA #4 stated the NA on night shift (11:00 PM to 7:00 AM) must have gotten her up early because Resident #4 typically didn't wet her brief through to her pants. She said she had just been busy and had just not gotten to the resident. NA #4 explained that Resident #4 was typically up when she arrived for her shift at 7:00 AM and usually early riser residents are gotten up on the last round between 5:00 AM and 6:30 AM and that was likely the last time she received incontinence care until 11:17 AM.
A telephone interview on 06/04/24 at 2:01 PM with the Director of Nursing revealed it was her expectation that all residents be round on every 2 hours and changed as needed. She stated if NA #4 was busy she should have asked for assistance from one of the other NAs working and said no resident should be left without incontinence care and wet through their pants.

Based on observations, record reviews, and staff interviews, the facility failed to follow their Infection Control Policy for Enhanced Barrier Precautions (EBP), when the Wound Nurse failed to wear a gown while providing wound care to 2 of 3 residents (Resident #2 and Resident #3) reviewed for infection control.
The findings included:
Review of the facility's Infection Control Policy, Enhanced Barrier Precautions last updated on 08/2022 revealed the following:
Under Policy Interpretation and Implementation:
1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MRDOs) to residents.
2. EBPs employ targeted gown and glove use during high contact activities when contact precautions do not otherwise apply.
3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:
h. wound care (any skin opening requiring a dressing).
5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.
6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.
a. An observation on 05/31/24 at 10:31 AM of wound care by the Wound Nurse assisted by the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) was completed on Resident #2. There was no personal protective equipment (PPE) available on the door or in a bin outside the door of the resident's room. The Wound Nurse had on gloves and changed them according to their handwashing policy and procedure during the resident's wound care but did not wear a gown while providing wound care.
An interview on 05/31/24 at 11:44 AM with the Wound Nurse revealed she realized after providing Resident #2 wound care that she should have donned a gown prior to doing the wound care because the resident was on Enhanced Barrier Precautions (EBP). She stated she knew better but was nervous and just forgot to put on the gown. The Wound Nurse said the facility lets staff know who is on EBP by putting signage on the door and providing PPE on the door or in a bin near the resident's door.
An interview on 05/31/24 at 10:55 AM with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) revealed she thought the wound care for Resident #2 went well except the Wound Nurse did not wear a gown while providing wound care. She stated she wasn't sure why the resident didn't have PPE on her door or near her room unless it was because she was recently moved, and the caddie of PPE did not move with her to her new room. The ADON/IP further stated the facility utilized signage on the door and PPE on the door or near the resident's room in a bin to communicate the resident was on EBP to the staff. She said she didn't think about the Wound Nurse not wearing a gown until after the wound care had been completed. The ADON/IP indicated she would provide the Wound Nurse with additional education on wearing PPE during wound care.
A telephone interview on 06/04/24 at 2:01 PM with the Director of Nursing (DON) revealed it was her expectation that the Wound Nurse follow the EBP Policy and Procedure and wear a gown while providing wound care to residents.
b. An observation on 05/31/24 at 10:44 AM of wound care by the Wound Nurse assisted by the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) was completed on Resident #3. There was a caddie on the door to the resident's room with PPE supplies including masks, gowns, and gloves. The Wound Nurse had on gloves and changed them according to their handwashing policy and procedure during the resident's wound care but did not wear a gown while providing wound care.
An interview on 05/31/24 at 11:44 AM with the Wound Nurse revealed she realized after providing Resident #3 wound care that she should have donned a gown prior to doing the wound care because the resident was on Enhanced Barrier Precautions (EBP). She stated she knew better but was nervous and just forgot to put on the gown. The Wound Nurse said the facility lets staff know who is on precautions by putting signage on the door and providing PPE on the door or in a bin near the resident's door.
An interview on 05/31/24 at 10:55 AM with the Assistant Director of Nursing (DON) / Infection Preventionist (IP) revealed she thought the wound care for Resident #3 went well except the Wound Nurse did not wear a gown while providing wound care. She stated there was PPE readily available in the caddie on the resident's door, but the Wound Nurse had not donned a gown prior to performing wound care on the resident. The ADON/IP further stated the facility utilized signage on the door and PPE in a caddie on the door or near the resident's room in a bin to communicate the resident was on EBP to the staff. She said she didn't think about the Wound Nurse not wearing a gown until after the wound care had been completed. The ADON/IP indicated she would provide the Wound Nurse with additional education on wearing PPE during wound care.
A telephone interview on 06/04/24 at 2:01 PM with the Director of Nursing (DON) revealed it was her expectation that the Wound Nurse follow the EBP Policy and Procedure and wear a gown while providing wound care to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interview the facility failed to honor resident requests for two showers per week for 2 of 4 residents reviewed for choices (Resident #2 and Resident #4).
The findings included:
1. Resident #2 was admitted to the facility on [DATE].
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact and required extensive assistance for bathing.
Review of the facility's shower schedule revealed Resident #2 was scheduled for a shower on Mondays and Thursdays on second shift.
Review of the facility shower documentation from 10/01/23 through 10/23/23 revealed no showers were documented as given to Resident #2. The documentation revealed Resident #2 was provided a bed bath instead of shower on the scheduled shower dates of: 10/02/23, 10/05/23, 10/09/23, 10/12/23, 10/16/23, 10/19/23, and 10/23/23.
An observation and interview were conducted with Resident #2 on 10/24/23 at 11:55 AM. Resident #2 was sitting up in bed, her hair, face, and clothing appeared clean. She stated she was supposed to get two showers a week on Mondays and Thursdays, however staff would not take her to the shower room and would only give her a bed bath. She stated she would rather go to the shower room for a shower, but the staff had told her they did not have time to take her for a shower. Resident #2 stated she had told staff she preferred a shower however they still were giving her a bed bath. The interview revealed during the month of October she had not received a shower on her assigned days, only bed baths. She revealed not receiving a shower made her feel dirty and nasty and she rested better when she was able to have a shower and feel clean.
An interview conducted on 10/24/23 at 12:38 PM with Nurse Aide (NA) #9 revealed to her knowledge Resident #2 had only received bed baths over the past month. She stated typically on second shift the staff that were scheduled had to cover two halls apiece and there was not enough time or staff to complete the assigned showers for residents, so most residents received bed baths unless they refused.
An interview conducted on 10/24/23 at 12:45 PM with NA #10 revealed she was familiar with Resident #2 and her preference for showers on second shift. She stated over the past month when she had been assigned to Resident #2's hall she had been assigned to another hall as well and did not have time to provide Resident #2 with her assigned showers. NA #10 revealed when she was not able to provide residents with their scheduled showers, she did offer and provide them with a bed bath.
An interview conducted on 10/24/23 at 1:14 PM with the Director of Nursing revealed the facility did not have a shower team but if there were extra staff in the building, she would schedule them to do showers. She stated due to a low census they were sending some of the staff home and there might only be one person completing showers but the Nurse Aides on the hall would also be responsible. She stated she didn't know why Resident #2 had not gotten a shower on her scheduled days. The interview revealed showers should be completed as scheduled and per the resident's preference.
2. Resident #4 was admitted to the facility on [DATE] with diagnosis which included Parkinson's, neurogenic bladder, and diabetes mellitus.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact and required maximal assistance for bathing. Resident #4 was documented to weigh 337 pounds during the assessment.
Review of the facility's shower schedule revealed Resident #4 was due a shower on Monday's and Thursdays on first shift.
Review of the facility shower documentation from 10/01/23 through 10/23/23. The documentation revealed no showers were documented as given to Resident #4. The documentation revealed Resident #4 received a bed bath on 10/2, 10/4, 10/5, 10/9, and 10/11.
An observation and interview were conducted with Resident #4 on 10/23/23 at 11:21 AM. Resident #4 was sitting up in bed dressed in a hospital gown. She stated she was supposed to get two showers a week on Mondays and Thursdays, however staff would not take her to the shower room and would only give her a bed bath. She stated she would rather go to the shower room for a shower, but the staff had told her they could not get her on the shower stretcher. She stated she was unable to use the shower chair because of mobility. Resident #4 stated she had told staff she preferred a shower however they still were giving her a bed bath. The interview revealed during the week of 10/16/23 through 10/19/23 she had not received a shower on her assigned days but finally was given one on 10/20/23. Resident #4 stated the Nurse Aide was able to place her on the shower stretcher and give a shower without difficulty, so she did not understand why other staff continued to tell her they could not take her to the shower room.
A facility invoice dated 10/26/22 revealed an order for a bariatric shower bed with a 900-pound weight capacity.
On 10/23/23 at 10:45 AM an observation was conducted of the facility shower room. A bariatric shower bed was observed in the shower room.
An interview conducted on 10/23/23 at 11:32 AM with Nurse Aide (NA) #7 revealed Resident #4 only received bed baths. She stated the facility had a shower team and they had told her that the shower stretcher was not large enough to accommodate Resident #4.
An interview conducted on 10/23/23 at 11:40 AM with NA #3 revealed Resident #4 had told her during the week of 10/16/23 through 10/19/23 that she would prefer to have a shower. NA #3 stated she had taken care of Resident #4 during that week and had not given her a shower or bed bath. She stated she thought the facility had a shower team during that week. The interview revealed no staff members from the shower team had told her they were unable to give Resident #4 a shower or bed bath.
An interview conducted on 10/23/23 at 2:07 PM with NA #8 revealed she was assigned to complete showers for the facility on Resident #4's assigned shower days of 10/16/23 and 10/19/23. She stated she was by herself on both days and had up to 20 residents to give a shower to. NA #8 stated she was not able to give Resident #4 a bed bath on her assigned days due to being alone and not having the time during her shift. The interview revealed she thought she told NA #3 that she hadn't given Resident #4 a bed bath but wasn't sure. NA #8 stated she didn't think Resident #4 took showers because she did not fit on the shower stretcher.
An observation and interview were conducted on 10/24/23 at 8:30 AM with Resident #4. She was observed sitting up in the bed dressed in a hospital gown. She stated she felt so good because NA #3 had put her on the shower stretcher on 10/23/23 and gave her a shower. She stated, that was what I wanted all along.
An interview conducted on 10/23/23 at 9:26 AM with NA #3 revealed she had given Resident #4 a shower on 10/23/23. She stated the shower team had thought Resident #4 was over the weight limit for the shower stretcher and were scared to take her to shower room. The interview revealed she had no issues while giving the resident a shower.
An interview conducted on 10/24/23 at 1:14 PM with the Director of Nursing revealed the facility did not have a shower team but if there were extra staff in the building, she would schedule them to do showers. She stated due to a low census they were sending some of the staff home and there might only be one person completing showers but the Nurse Aides on the hall would also be responsible. She stated she didn't know why Resident #4 had not gotten a shower on her scheduled days and was not aware the resident had told NA #3 that she wanted a shower last week. The interview revealed showers should be completed as scheduled and per the resident's preference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to ensure a resident had been assessed to self-administer over the counter medications located in a residen'st room. This occurred for 1 out of 3 residents reviewed for medication administration (Resident #3).
The findings included:
Resident #3 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes and vascular dementia.
Resident #3's self-administration of medication evaluation dated 09/15/23 completed by Director of Nursing (DON) revealed approval for self-administration of a pain ointment and pain relief topical 4% cream.
Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact requiring extensive assistance of one staff member for most activities of daily living (ADL).
On 10/23/23 at 11:19 AM an observation was conducted of Resident #3's room revealed an open 32-ounce bottle half-full of hydrogen peroxide located on bedside dresser. During interview with Resident #3 he stated that he used the hydrogen peroxide for whatever he wanted to whether that was putting it on his hair or on a cut. He revealed he was not aware if he had an order to administer the hydrogen peroxide himself or not. Resident #3 stated he was not aware if staff knew about him using the hydrogen peroxide but that he always kept it on his bedside dresser or bedside tray and staff had never asked him about it. Resident #3 opened the top drawer to his bedside dresser and revealed a partially full tube of arthritis pain gel 1% gel that he stated he had been using for pain in his shoulders and knees. Resident #3 revealed he was not aware if he had an order to self-administer the arthriti pain gel 1% or not and was not aware if staff knew that he was self-administering it. He stated that he had purchased these items and had them delivered to the facility. Resident #3 stated that he had been assessed to be able to self-administer his over the counter pain ointment for shoulder pain which had been provided to him by the facility but he did not feel that it helped with his pain so he had given it away to another resident but could not recall which resident he had given it to.
On 10/24/23 at 11:30 AM an observation conducted of Resident #3 room revealed the open Hydrogen Peroxide bottle still located on top of Resident #3 bedside dresser and the partially full tube of arthritis pain gel 1% still located in the top drawer of the bedside dresser.
An interview conducted on 10/24/23 at 11:49 AM with Nurse #1 revealed she was familiar with Resident #3 and was responsible for administering him his medications and treatments. She stated Resident #3 was allowed to keep his over the counter pain ointment and topical pain relief cream inside a locked drawer in his bedroom and self-administer as needed. She revealed Resident #3 had no order for Hydrogen Peroxide and his arthritis pain gel 1% was to be administered twice a day by nursing staff and initialed on the treatment administration record (TAR). Nurse #1 stated she was not aware Resident #3 had those items in his possession. She revealed Resident #3 had ordered over the counter medications online before and had them delivered to the facility and was told then that all medications including over the counter medications had to have an order for him to be able to use them.
An interview conducted on 10/24/23 at 1:13 PM with the Director of Nursing (DON) revealed she was familiar with Resident #3. She stated she was not aware that he had an open bottle of Hydrogen Peroxide or a tube of arthritis pain gel 1% gel in his possession that he was self-administering. She stated back in September 2023 she had been made aware that Resident #3 had ordered over the counter medications online and she had spoken with him and his family about all medications including over the counter medication had to have a physician order before being administered and she completed a self-administration medication evaluation with Resident #3 for over the counter pain ointment and topical pain relief cream for him to be able to administer on his own for shoulder pain. The DON revealed Resident #3 did not have an order for use of Hydrogen Peroxide and his arthritis pain gel was a treatment to be administered twice daily by nursing staff. She revealed Resident #3 should not have those items in his possession to self-administer and assumed he had purchased those online. The DON stated residents in the facility should not have access to, possession of, or self-administer any medications without a physician order and staff should be more observant of any medications or treatments in resident's rooms.
An interview was conducted on 10/24/23 at 2:02 PM with the Administrator revealed he was familiar with Resident #3 and was not aware of him being in possession of and self-administering his own Hydrogen Peroxide and arthritis pain gel 1%. He stated no resident should have possession of or be self-administering any medication or treatments without a physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident, family and staff interviews, the facility failed to provide hair care to a dependent resident for 1 of 3 residents reviewed for activities of daily living (Resident #1). Resident #1 was observed with matted hair while waiting to go for an outside Physician appointment. Resident #1 stated the matted hair was painful and she felt like the staff did not care.
The findings included:
Resident #1 was admitted to the facility on [DATE] with diagnoses that included cancer.
An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact and required extensive assistance of two staff members for personal hygiene and was dependent for bathing. It further indicated no rejection of care or behaviors.
Review of the nurse's progress notes from 09/08/23 through 10/24/23 revealed no notes regarding Resident #1 refusing showers or personal hygiene care. Review of the Nurse Aide (NA's) documentation of the same period revealed no indication Resident #1 refused hair care.
An observation and interview with Resident #1 on 10/24/23 at 10:40 AM revealed Resident #1 sitting in her wheelchair at the nurse's station. Resident #1 stated she was ready and waiting to go to her cancer treatment appointment. The back of Resident #1's hair was matted and protruding over the back of the resident's wheelchair. She was observed to have long, thick hair. Resident #1 stated the last time her hair had been washed was 3-4 weeks prior. She stated she knew her hair was matted because she could not brush it herself due to not being able to lift her arms above her head. Resident #1 stated her matted hair caused her scalp and head to hurt all the time on a pain level of 4 on a 0-10 scale. She stated staff had tried to brush it today, but it hurt too bad. The interview revealed she had told staff her hair was matted, and they were aware of it. She stated her husband had even offered to pay to have her hair cut but the facility did not have a hairdresser. Resident #1 stated, I feel like the staff don't care. Resident #1 then went on to say that it really wasn't the staff's fault because she had thick hair that needed to be cut and the facility did not have a hairdresser.
An interview conducted with Resident #1's Family Member #1 on 10/24/23 at 10:48 AM revealed he had wanted Resident #1's hair cut for several months. He stated he had talked with the former Administrator of the facility. The interview revealed the former Administrator had told him they did not have anyone to cut her hair but if he wanted to, they would make an area in the beauty shop for him to wash and cut her hair. The family member stated he had medical conditions himself and he was not able to wash Resident #1's hair or cut it.
A review of the undated shower schedule revealed Resident #1 was to receive bathing and personal hygiene twice weekly on Monday and Thursdays during day shift (7AM- 3PM).
An interview with Nurse Aide (NA) #1 on 10/24/23 at 10:22 AM revealed he had been assigned to Resident #1 on 10/23/23 on day shift (7A-3P) and had not provided hair care. He stated the hall Resident #1 is on had 12 dependent residents requiring a mechanical lift for transfers including Resident #1. He stated he often had to give the residents bed baths because he could not get them up for a shower due to staffing and bed baths did not always include washing the resident's hair. NA #1 stated Resident #1's hair was matted because nobody was brushing it and with the number of residents on the hall the staff didn't have time. He stated Resident #1 had told him for several months she wanted her hair cut, so he stated he told the nurses, but nothing had been done. The interview revealed Resident #1's hair was matted to the point the staff could not brush it out.
An interview with Nurse Aide (NA) #2 on 10/24/23 at 11:05 AM revealed she had been assigned to Resident #1 on the week prior to 10/24/23. She stated she had to get Resident #1 ready for a cancer treatment appointment and had noticed her hair was matted. NA #2 stated Resident #1 was screaming and stated it hurt when she tried to brush the hair because it was matted. She stated, her hair is matted because staff aren't brushing it. The interview revealed she had seen Resident #1's hair matted for the last several months. NA #2 stated she had not told the Nurse on duty about the resident's hair condition.
An interview with Nurse #1 on 10/24/23 at 11:38 AM revealed she had been assigned to Resident #1 in the past. She stated she knew Resident #1's hair was matted in the back, but it was to the point the Nurse Aides could not brush it out without hurting the resident. Nurse #1 stated Resident #1 was getting up daily to go out for cancer treatments and staff were brushing the hair over the matted hair to make it less obvious. Nurse #1 stated she had not told the Director of Nursing about Resident #1's hair because she thought everyone knew.
An interview with Nurse #2 on 10/24/23 at 12:09 AM revealed she had been assigned to Resident #1 on 10/24/23. Nurse #2 stated Resident #1 had matted hair for several months. She stated she got Resident #1 up on the morning of 10/24/23 for her appointment and tried to brush her hair but it was hurting the resident so she just put what she could in a ponytail. Nurse #2 stated, I did the best I could. The interview revealed Resident #1 had asked Nurse #2 to cut her hair the week prior. She stated she told the Director of Nursing on 10/24/23 after she got her up for the appointment that the resident had matted hair. Nurse #2 stated she did not cut the resident's hair because she did not feel comfortable doing so.
An interview with the Director of Nursing on 10/24/23 at 1:24 PM revealed she expected all residents to receive hair care on bath days and when needed by nurse aides. She stated Nurse #2 told her about the matted hair on 10/24/23. The DON stated no staff members had come to her and told her about the matted hair prior to 10/24/23.
An interview with the Administrator on 10/24/23 at 2:01 PM revealed that he had only been in the facility 3 weeks. He stated each resident should receive hair care on their shower day and no resident's hair should be in a matted condition. The interview revealed the facility would have someone come in to cut Resident #1's hair and staff would wash the resident's hair.

Based on observations and staff interviews, the facility failed to date opened items stored in the dry storage area located in the main kitchen. These practices had the potential to affect food served to residents.
Findings included:
A tour of the facility's dietary department on 10/23/23 beginning at 9:30 AM revealed the following items:
Dry storage area:
- A 35 ounce (oz) opened and undated bag of cereal
- A large bag of opened and undated cake mix
An interview with [NAME] #1 on 10/23/23 at 9:45 AM revealed they had been educated all items should be labeled and dated with an open/discard date. He stated the opened bag of cereal should have been sealed and labeled with the date it was opened.
An interview with the Regional Dietary Manager on 10/24/23 at 1:38 PM revealed she was made aware of items that were unlabeled and dated in the dry storage area stated all items should be labeled and dated with an open and discard date.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following a recertification and complaint survey dated 9/08/23. This was for two repeat deficiencies that were cited in the areas of self-determination, activities of daily living care provided for dependent residents that were originally cited during a recertification and complaint survey dated 03/21/23, 09/08/23 and subsequently recited during the onsite revisit and complaint survey dated 10/24/23. The area of food procurement was originally cited during a recertification and complaint survey dated 09/08/23 and subsequently recited during the onsite revisit and complaint survey dated 10/24/23. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program.
The findings included:
The tag is cross referenced to:
F561- Based on observations, record review, resident and staff interview the facility failed to honor resident requests for two showers per week (Resident #2 and Resident #4) for 2 of 4 residents reviewed for choices.
During the recertification and complaint survey dated 9/08/22, the facility failed to honor resident request for two showers per week and the facility also failed to honor a resident's request to get out of bed this affected 4 of 6 residents reviewed for choices.
During the recertification and complaint survey dated 3/21/22 the facility failed to honor a resident's bathing preferences for 3 of 7 residents reviewed for choices.
F677- Based on observations, record reviews, resident, family and staff interviews, the facility failed to provide hair care to a dependent resident for 1 of 3 residents reviewed for activities of daily living (Resident #1). Resident #1 was observed with matted hair while waiting to go for an outside Physician appointment. Resident #1 stated the matted hair was painful and she felt like the staff did not care.
During the recertification and complaint survey dated 9/08/23, the facility failed to provide nail care to a dependent resident for 1 of 2 residents reviewed for providing activities of daily living.
During the recertification and complaint survey dated 3/21/22 the facility failed to provide facial grooming for 1 of 4 dependent residents reviewed for activities of daily living.
F812- Based on observations and staff interviews, the facility failed to date opened items stored in the dry storage area located in the main kitchen. These practices had the potential to affect food served to residents.
During the recertification and complaint survey dated 9/08/22 the facility failed to label and date leftover food items available for resident consumption stored in 1 of 1 reach in refrigerator and failed to date pre-filled bowls of cereal stored in the dry storage area located in the main kitchen. These practices had the potential to affect food served to residents.
An interview with the Director of Nursing (DON) and Administrator on 10/24/23 at 4:00 PM revealed monthly Quality Assurance (QA) meetings were held to review measures put in place and discussed with the Medical Director and other departments for their response and feedback to issues identified. When issues were identified a review and corrective action plan was implemented and if there was no improvement, the QA committee revisited it. The DON and Administrator felt interventions put into place were beginning to aid in preventing repeat deficiencies but need to be revisited by the QA committee to ensure ongoing compliance in all areas.

Based on observations, record reviews and staff interviews the facility failed to provide sufficient nursing staff resulting in residents not having their choices honored for receiving two showers a week, failed to honor a resident's request to get out of bed and the facility failed to provide nail care for 5 of 5 residents reviewed (Resident #36, #23, #39, #60, and #64) for choices and activities of daily living.
The findings included:
This tag is crossed referred to:
F-561: Based on observations, record review, resident, and staff interviews, the facility failed to honor resident request for two showers per week (Resident #23, Resident #39, Resident #60, Resident #64, Resident #6, and Resident #36) and the facility also failed to honor a resident's request to get out of bed (Resident #64) this affected 6 of 6 residents reviewed for choices.
F-677: Based on observations, record reviews, resident and staff interviews, the facility failed to provide nail care to a dependent resident for 1 of 2 residents reviewed for providing activities of daily living (Resident #36).
An interview conducted with Nurse #1 on 09/06/23 at 5:07 PM the Nurse explained that the facility was short of nurse aides and nurses. The facility used to staff 4 nurses and 6 nurse aides to staff the halls (on first shift) and a shower team to provide the showers but in the last month and a half we have been working short of that schedule and no shower team. We used to utilize agency staff which helped with the staffing, but the facility stopped allowing agency in the building and we do not have enough facility to sufficiently staff the facility. The scheduled showers are not getting done because of working short staffed. Our Director of Nursing and Unit Manager must work a lot of third shift because we do not have the nurses to work.
During an interview with Nurse Aide (NA) #10 on 09/07/23 at 2:25 PM the NA explained she has been at the facility since June 2023 was recently transferred to first shift but when she worked second shift, she was unable to give the scheduled showers because of working short staffed. She continued to explain that some nights she was expected to work three halls because of call outs and when that happened there was no way the residents received their scheduled showers.
An interview was conducted with the Unit Manager (UM) on 09/07/23 at 4:01 PM who explained the facility did not utilize a shower team and now the nurse aides on the halls were responsible for completing the showers for their halls. The UM indicated that she had been pulled to work the hall and other shifts and was not able to monitor the showers to ensure they were getting done.
The Scheduler was interviewed on 09/08/23 10:47 AM who explained she was hired in June 2023 to be the Scheduler and scheduled both nurses and nurse aides. She continued to explain they have a problem with staffing, but they were currently waiting on several background checks to clear in order to hire more nurses and nurse aides. The Scheduler stated she needed 5 medicators and 8 nurse aides to sufficiently staff first shift and if she had extra nurse aides, she scheduled them to give showers but if they had call outs the extra staff was pulled to the halls to provide resident care. She stated the hall staff would then be responsible for providing the resident showers.
During the interview with the Director of Nursing (DON) on 09/08/23 at 2:30 PM who has been employed since June 2022 explained she felt the facility had enough staff to get the work done and if they were short staffed the department heads jumped in and helped where they could. The DON continued to explain the facility needed more staff and were currently in the process of hiring more staff but had to wait for the background checks to clear. She indicated they needed nurses and nurse aides for all three shifts. The DON added she had no other choice but to work the halls as a charge nurse 3 to 5 nights a week and the unit manager was working third shift a lot to help cover for being so short staffed. When the DON was asked how she monitored the staff to ensure the daily duties such as showers and personal care was being done if she was not in the building, she reported the corporate staff was in the building when she could not be there to ensure the resident care was being done.

Based on observations, record reviews and staff interviews, the facility failed to discard expired medications and failed to store a controlled substance in a permanently affixed compartment in the refrigerator in 1 of 1 medication room (main medication room) for review of medication storage.
The findings included:
1. On 09/06/23 at 11:47 AM an observation of the main medication room was conducted accompanied by Nurse #1. On the cabinet shelf was an opened box of Ipratropium bromide/albuterol nebulizing solution (vials of 0.5 milligram (mg) and 3 mg / 3 milliliter (ml) ipratropium / albuterol inhalation solution) used to treat chronic obstructive pulmonary disease. The solution was prescribed for Resident #4 with the delivery date of 07/04/23. The box contained an open and undated foil pouch that had 20 out of 30 vials left in the foil pouch. The manufacture's instructions on the box indicated to discard unused vials in opened foil pouch within 14 days.
An interview conducted with Nurse #1 on 09/06/23 at 11:48 AM revealed the Nurse stated the medication was stored in the medication room because there was not enough room to store it on the medication cart. The Nurse stated the nebulizing solution should have been discarded in one week after opening the foil pouch. After directing the Nurse to read the manufacture's instructions on the box of the medication the Nurse stated she was not aware that it was 14 days then remarked it did not matter because the foil pouch was not dated when it was opened so it could have been opened for longer than 14 days.
On 09/06/23 at 12:55 PM during an interview with the Regional Director of Clinical Services the Nurse acknowledged the medication was discovered on the shelf in the medication room ready for use. The Nurse stated the foil pouch should have dated when opened and should have been discarded in 14 days.
2. On 09/06/23 at 11:50 AM during an interview and observation of the main medication room accompanied by Nurse #1 the observation yielded a bottle of Marinol 2.5 milligram (mg) caplets of 20 caplets sitting on the top shelf in the refrigerator. Marinol is one of the psychoactive compounds present in cannabis and is abusable and controlled Schedule III under the Controlled Substance Act. The Nurse explained that the Marinol was prescribed for a resident who was discharged over the weekend, and she thought the medication was sent home with the resident. The Nurse explained that the Marinol was a controlled substance and should be locked in the affixed locked box that the facility had in the refrigerator.
An interview was conducted with the Director of Nursing (DON) on 09/08/23 at 3:15 PM who explained she had the descending count sheet that indicated the Marinol was sent home with the resident therefore she could not explain how the Marinol got on the top shelf in the refrigerator. The DON stated the Marinol was a controlled substance and should have been in the affixed locked box in the refrigerator.

Based on observations and staff interviews, the facility failed to label and date leftover food items available for resident consumption stored in 1 of 1 reach in refrigerator and failed to date pre-filled bowls of cereal stored in the dry storage area located in the main kitchen. These practices had the potential to affect food served to residents.
Findings included:
A tour of the facility's dietary department on 9/5/23 beginning at 10:00 AM revealed the following items:
Dry storage area:
A 35 ounce (oz) opened and undated bag of cereal
3 Meal trays which contained 47 bowls filled with various cereal unlabeled or dated
Reach in refrigerator:
1 plastic gallon container of fruit cocktail labeled 8/29
1 large bag of salad mix which was yellow and brown lettuce unlabeled or dated
½ cucumber cut and undated
1 package of sliced ham undated
1 small bag of shredded carrots undated
1 small bag of shredded red cabbage undated
1 package of bologna opened and undated
An interview with [NAME] #1 and Dietary Aide #1 on 9/5/23 at 10:30 AM revealed they had been educated all items should be labeled and dated with an open/discard date. Dietary Aide #1 indicated cereal was usually prepared in the evening and should always be labeled with the prepared date and discarded no later than 7 days after it is prepared. She also stated the opened bag of cereal should have been sealed and labeled with the date it was opened. [NAME] #1 stated all items in the reach-in fridge should have been labeled with an open and discard date. He stated the fruit cocktail should have been discarded yesterday (9/4/23).
An interview with the Regional Dietary Manager on 9/8/23 at 7:07 AM revealed she was made aware of items that were unlabeled and dated in the dry storage area and reach-in fridge on 9/5/23 and stated all items should be labeled and dated with an open and discard date.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following a recertification and complaint survey dated 3/21/22. This was for six repeat deficiencies that were cited in the areas of self-determination, accuracy of assessment, care plan timing and revision, activities of daily living care provided for dependent residents, sufficient nursing staffing, and label and storage of drugs and biologicals that were originally cited during a recertification and complaint survey dated 3/21/22 and subsequently recited during the recertification and complaint survey dated 9/8/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program.
The findings included:
The tag is cross referenced to:
F561- Based on observations, record reviews, resident and staff interviews, the facility failed to honor a resident's request to receive two showers per week and the facility also failed to honor a resident's request to get out of bed which affected 4 of 6 residents reviewed for choices.
During the recertification and complaint survey dated 3/21/22, the facility failed to honor a residents bathing preference for 3 of 7 residents reviewed for choices.
F641- Based on observations, record reviews, resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of limb prosthesis, the area of hospice, and the use of antipsychotic medications for 4 of 22 residents MDS's reviewed.
During the recertification and complaint survey dated 3/21/22, the facility failed to accurately code the MDS for diagnoses and for antipsychotic medication review for 1 of 5 residents reviewed for unnecessary medications.
F657-Based on record review, resident and staff interviews the facility failed to invite 2 of 2 residents to a care plan meeting that were reviewed for care plans.
During the recertification and complaint survey dated 3/21/22, the facility failed to invite 3 of 3 residents to a care plan meeting, failed to update a care plan that addressed a residents suicidal ideations, and attempt for 1 of 5 residents reviewed for unnecessary medications and failed to update a residents' care plan to address interventions related to pressure ulcer prevention for 1 of 5 residents reviewed for pressure ulcers.
F677- Based on observations, record reviews, resident and staff interviews, the facility failed to provide nail care to a dependent resident for 1 of 2 residents reviewed for providing activities of daily living.
During the recertification and complaint survey dated 3/21/22, the facility failed to provide facial grooming for 1 of 4 residents reviewed for activities of daily living.
F725- Based on observations, record reviews and staff interviews, the facility failed to provide sufficient nursing staff resulting in residents not having their choices honored for receiving two showers per week, failed to honor a residents request to get out of bed and the facility failed to provide nail care for 5 of 5 residents reviewed for choices and activities of daily living.
During the recertification and complaint survey dated 3/21/22, the facility failed to maintain sufficient nursing staff to provide scheduled showers and facial grooming. These failures affected 3 of 7 residents in the area of activities of daily living.
F761- Based on observations, record reviews and staff interviews, the facility failed to discard expired medications and failed to store a controlled substance in a permanently affixed compartment in the refrigerator in 1 of 1 medication room (main medication room) for review of medication storage.
During the recertification and complaint survey dated 3/21/22, the facility failed to remove medications from room (A-101), failed to remove mediations from 1 of 6 hallway side railed (F-hall), failed to remove an undated and unlabeled insulin pen, failed to remove expired and undated breathing solutions, failed to remove an unopened insulin pen from 3 of 5 medication carts (B Hall, C hall, and F hall) reviewed for medication storage.
An interview with the Director of Nursing (DON) and Administrator on 9/8/23 at 4:00 PM revealed monthly Quality Assurance (QA) meetings were held to review measures put in place and discussed with the Medical Director and other departments for their response and feedback to issues identified. When issues were identified a review and corrective action plan was implemented and if there was no improvement, the QA committee revisited it. The DON and Administrator felt interventions put into place were beginning to aid in preventing repeat deficiencies but need to be revisited by the QA committee to ensure ongoing compliance in all areas.

Based on record reviews and Director of Nursing (DON) interview the facility failed to ensure the DON for the Skilled Nursing Facility worked full time as the DON of the facility. The DON served as a charge nurse having a resident care assignment that included working on the medication cart with a facility census of greater than 60 residents for 8 of 8 days reviewed for sufficient nurse staffing. 07/24/23, 07/25/23, 08/09/23, 08/10/23, 08/14/23, 08/29/23, 08/30/23 and 08/31/23.
The findings included:
A review of the staffing schedules revealed:
On 07/24/23 the DON worked the 10:45 PM - 7:15 AM shift with an average daily resident census of 92.
On 07/25/23 the DON worked the 10:45 PM - 7:15 AM shift with an average daily resident census of 90.
On 08/09/23 the DON worked the 10:45 PM - 7:15 AM shift with an average daily resident census of 85.
On 08/10/23 the DON worked the 10:45 PM - 7:15 AM shift with an average daily resident census of 84.
On 08/14/23 the DON worked the 10:45 PM - 7:15 AM shift with an average daily resident census of 83.
On 08/29/23 the DON worked the 10:45 PM - 7:15 AM shift with an average daily resident census of 85.
On 08/30/23 the DON worked the 10:45 PM - 7:15 AM shift with an average daily resident census of 84.
On 08/31/23 the DON worked the 10:45 PM - 7:15 AM shift with an average daily resident census of 85.
An interview was conducted with the Director of Nursing on 09/08/23 at 2:30 PM who explained that the company did away with utilizing agency staff back in late July 2023 or early August 2023 and since then there were not enough nurses to cover the schedule. The DON indicated she was aware the DON could not function as a charge nurse with an average daily census of greater than 60 residents but stated if she did not function as the charge nurse there would be no coverage. The DON indicated the facility did not have a waiver for less than full time DON coverage and stated she had to work the floor to ensure the residents were taken care of. The DON confirmed the dates cited above were accurate. The DON added the facility was in the process of hiring more nurses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews with residents, staff, Pharmacist and Nurse Practitioner (NP #1), the facility failed to acquire medications ordered for administration which resulted in 2 missed doses of the controlled substance medication prescribed for pain for 1 of 2 residents reviewed for the provision of pharmaceutical services (Resident #289).
The findings included:
An undated document provided by the pharmacy read in part, Labor Day [pharmacy name] will be operating and delivering with modified hours on September 4th in observance of the Labor Day holiday. New orders received after 4 PM on Monday, September 4th will be shipped by 6 PM. New orders received after 4 PM and refill orders received after noon will be shipped on Tuesday, September 5th at regular shipments times. Please contact [phone number provided] for emergency needs. Fax early and often.
An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #289 was cognitively intact, had pain present constantly, and received 6 days of opioids (narcotic pain medication) during the 7-day assessment period.
Review of the hospital discharge date d 9/4/23 revealed Resident #289 was admitted to the hospital on [DATE] due to bright red bloody stools and abdominal pain. The document indicated during his hospitalization, Resident #289 was transitioned from his routine opioid medication (Ztampza) to Oxycontin and continue
Oxycodone/Acetaminophen every 4 hours as needed to better manage his pain.
Resident #289 was re-admitted to the facility on [DATE] with diagnoses of gastrointestinal hemorrhage following surgical intervention for septic shock from bowel ischemia and chronic pain syndrome.
Review of the Resident #289's physician's orders revealed orders dated 9/4/23 and entered into the electronic medical record between 2:33 PM and 2:42 PM and entered by the Unit Manager which read:
-Oxycontin 20 milligram (mg) Extended Release (XR) every 12 hours to be given twice daily.
-Oxycodone/Acetaminophen 10/325 mg every 4 hours as needed (PRN).
An electronic copy of the hard script (a written order required for controlled substance dispensing) revealed an order for Oxycontin 20mg extended release one tablet twice daily was faxed to the pharmacy on 9/4/23 at 6:24 PM.
An interview with the Unit Manager on 9/7/23 at 10:32 AM revealed she recalled obtaining and entering orders in the electronic medical record for Resident #289 on 9/4/23 although she could not recall what time they were entered. The Unit Manager stated these orders were received in the facility prior to Resident #289's arrival on 9/4/23 and she could not recall what time he arrived and the documentation in the medical record did not reflect the exact time of admission. She stated she thought she faxed the hard script to the pharmacy before she left for the day but was unsure and could not recall what time this was completed or what time she left the facility that day. The Unit Manager stated when it is a holiday, and the pharmacy closes early the facility doesn't get the medications if it is after a certain time designated for that holiday and the resident has to wait until it arrived for staff to administer the medication. The Unit Manager also indicated staff should have called the provider to make them aware they were unable to obtain the medication that evening and requested further treatment. The Unit Manager stated when staff alerted her the following day (9/5/23) that the medication had not arrived she called the pharmacy and faxed another copy to the pharmacy to ensure it was received. The Unit Manager stated she was told the medication would be delivered on the next delivery that day (9/5/23). She did not contact the medical provider for further orders because she was aware he was receiving his PRN pain medications until the medication arrived.
A review of the September 2023 Medication Administration Record (MAR) revealed that Resident #289 did not receive his scheduled Oxycontin on 9/4/23 at 9:00 PM nor on 9/5/23 at 9:00 AM as the items were documented as 9 by MA #1 at 9 PM and Nurse #4 at 9 AM which according to the legend means see nurses notes however, there were no notes regarding the medication located. The MAR also reflected Resident #289 requested and received Oxycodone/Acetaminophen 10/325 mg PRN every four to five hours on 9/4/23 through 9/5/23. Resident #289 received his first dose of scheduled Oxycontin on 9/5/23 at 9:00 PM.
An observation and interview with Resident #289 on 9/5/23 at 3:36 PM revealed he was in pain which he described as all over but primarily in the abdominal region. Resident #289 stated he had not received his scheduled pain medications since re-admission to the facility and it made him uncomfortable, and he wondered how long he would have to wait before he could have it. During the interview, Resident #289 grimaced and shifted his weight multiple times. Resident #289 requested his PRN pain medication when Nurse #4 entered the room but was told it was not time to have his next dose administered. Resident #289 stated he had received his PRN pain medications as often as possible, and they were effective short term but were not holding him until the next dose could be given.
An interview with Nurse #4 on 9/5/23 at 3:40 PM was conducted when she entered Resident #289's room to answer his call light. She indicated she was aware Resident #289 had complained of pain and had requested all his pain medication to manage his discomfort. Nurse #4 stated he had received a dose of the Oxycodone 10/325 mg PRN less than 2 hours prior and it could not be administered again for another 2 hours. Nurse #4 stated his Oxycontin had not arrived from pharmacy and the ordered medication was not available to administer from the back-up stock kept in the facility. Nurse #4 explained Resident #289 had requested and received his PRN dose of Oxycodone/ APAP every 4 hours since readmission without full pain relief vocalized. Nurse #4 stated the facility was able to provide the PRN dose because the card dispensed from pharmacy during his initial admission remained in the facility and had not been returned to the pharmacy at the time he was readmitted .
An interview with Medication Aide (MA #1) on 9/6/23 at 4:00 PM revealed she was familiar with Resident #289 and had worked the B hall where Resident #289 resided on the evening of 9/4/23 from 7:00 PM to 9:00 PM. MA #1 indicated Resident #289 had notified a Nurse Aide (name unable to recall) that he had pain and needed his pain medications quickly because it was going to throw his schedule off if he did not receive it and he was hurting all over. MA #1 verified his scheduled Oxycontin XR was not available to administer so she administered him a PRN dose of his Oxycodone/ APAP to help manage his pain at approximately 8:45 PM. MA #1 stated she reported the pain medication not being available to the nurse through a shift-to-shift report before she left for the evening so the nurse could call the pharmacy to locate the medication or contact the physician for further orders.
An interview with Nurse #3 on 9/8/23 at 3:08 PM revealed he covered the hall where Resident #289 resided from 9:00 PM to 11:00 PM on 9/4/23; however, MA #1 had administered the last medication pass for the shift, and he was available for acute changes until Nurse #6 arrived on duty at 11:00 PM. He stated Resident #289 had received a PRN dose of his pain medication from MA #1 and he did not administer any medications to Resident #289 on that night. Nurse #3 could not recall discussing Resident #289's scheduled pain medication not being in the facility that evening with MA #1 before the end of her shift.
An interview with Nurse #6 on 9/6/23 at 4:07 PM revealed she worked the night shift (11 PM- 7 AM) which began on 9/4/23. Nurse #6 recalled Resident #289 being consistently on the call light asking for pain medications about every 4 hours and she provided him his PRN Oxycodone each time for his complaints of severe pain which was described as located all over. She stated she did not recall Nurse #3 reporting to her that Resident #289's scheduled Oxycontin had not arrived and been administered that evening and therefore she did not notify the oncoming day shift nurse (Nurse #7).
An interview with Nurse #7 on 9/6/23 at 4:24 PM revealed she worked B-hall on day shift (7 AM-3 PM) on 9/5/23. Nurse #7 indicated she identified Resident #289 was without his scheduled pain medication during her morning medication pass. Nurse #7 stated after she completed the medication pass (sometime before lunch), she called the pharmacy and requested an update about Resident #289's order for Oxycontin 20mg XR. Nurse #7 stated the pharmacy told her it would be filled and shipped that evening on the routine delivery. Nurse #7 thought since the medication would be there that day and it was already mid-morning; Resident #289 would be ok with the use of PRN medications until it arrived.
A telephone interview with Pharmacist #1 on 9/6/23 at 1:27 PM was conducted. Pharmacist #1 stated the local branch of the pharmacy closed early on Monday 9/4/23 in observance of the Labor Day holiday, however, the Spartanburg location remained open 24 hours/ 365 days a year. Pharmacist #1 explained the pharmacy had sent out multiple flyers in the medication tote which indicated the early closing with directions to contact a specified branch for all urgent/emergency needs for medications. Pharmacist #1 confirmed the pharmacy received a faxed request for Resident #289's Oxycontin 20 mg XR tablets at 6:24 PM on 9/4/23 which was after the cut off time for filling that day and should have been requested from the urgent/emergency phone number provided on the flyer or contacted the medical provider for further orders.
An interview with the Director of Nursing (DON) and the [NAME] President of Clinical Services on 9/6/23 at 5:11 PM was conducted. The DON and the VP of Clinical Services stated they were aware that the pharmacy typically closed early on holidays; however, the DON stated she did not recall seeing a flyer provided by the pharmacy regarding instruction on how to obtain medications needed after the local branch closed on 9/4/23. The VP of Clinical Services explained the local branch always has a pharmacist on-call and they were responsible for transferring any new orders to the Spartanburg office or other local pharmacies for dispensing after hours of controlled substances. Both DON and the VP of Clinical Services stated they did not expect staff to contact the Spartanburg location, but the on-call pharmacist should have requested the medication be delivered on a stat run or dispensed through a local pharmacy who is contracted to deliver the medications to the facility. The DON and VP of Clinical Services explained they were unaware of any phone numbers to contact aside from the local branch and had never been told to contact the Spartanburg office after hours or on holidays and Pharmacist #1 must be mistaken.
An interview with the Nurse Practitioner (NP) on 9/6/23 at 4:46 PM revealed she had not been made aware Resident #289 did not receive his first two scheduled doses of Oxycontin 20mg upon readmission and facility staff should have notified the on-call provider when the mediation was unavailable so an alternative order could be provided to best manage Resident #289's pain needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4a. Resident #64 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, anxiety, depression and fibromyalgia.
The care plan dated 06/15/22 revealed Resident #64 had a self-care deficit. The goal the Resident would improve in her current level of function in her activities of daily living (ADL) would be attained by utilizing interventions such as: providing a sponge bath when a full bed bath or showers cannot be provided.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64's cognition was moderately intact and had no behaviors of rejection of care. The MDS indicated the Resident required extensive assistance of two staff for transfers, personal hygiene and dressing. The MDS also indicated the Resident was incontinent of bladder and bowel.
A review of the Shower Schedule for room [ROOM NUMBER]-B revealed Resident #64 was scheduled to receive her showers on Wednesday and Saturday on first shift.
A review of Resident #64's Bathing record from August 22, 2023, through September 06, 2023, revealed there were no showers documented on the record.
The Bathing record indicated Nurse Aide #1 worked on Saturday 08/26/23 and Saturday 09/02/23. The record also indicated Nurse Aide #3 worked on Wednesday 08/23/23, Wednesday 08/30/23 and Wednesday 09/06/23.
A review of a handwritten note, which was not part of the medical record, was provided by the Director of Nursing indicated Resident #64 received a shower on 08/26/23 and the shower was given by Nurse Aide #1.
An interview and observation made with Resident #64 on 09/05/23 at 2:59 PM revealed the Resident was sitting in her wheelchair and had just returned to her room from afternoon activities. The Resident appeared well groomed and was oriented to person, place and time. Resident #64 explained she was supposed to receive two showers a week but lately she only received one shower a week if she got any. She continued to explain she enjoyed and looked forward to her showers because she was incontinent of her bladder and bowels, and she wanted a complete shower to make her feel as if she was thoroughly cleaned.
An interview was conducted with Nurse Aide (NA) #2 on 09/06/23 at 3:00 PM who according to the shift assignment was scheduled to work Resident #64's hall on Wednesday 09/06/23 from 7:00 AM to 3:00 PM. The NA explained the shower sheets indicated which days the residents' showers were scheduled for and were kept in the schedule book at the nursing desk. The NA continued to explain that Wednesday 09/06/23 was her first day assigned to Resident #64's hall and she thought the Resident was scheduled for a shower on Tuesday 09/05/23 but NA #3 who worked the hall on 09/05/23 did not have time to shower the Resident so NA #3 gave the Resident a bed bath today on Wednesday 09/06/23.
During an interview with Nurse Aide #3 on 09/06/23 at 3:14 PM the NA explained she was routinely assigned to work Resident #64's hall and the Resident was scheduled to receive her showers on Wednesday and Saturday during first shift. The NA confirmed that she worked on Wednesday, 08/23/23, and Wednesday, 8/30/23, and did not give Resident #64 a shower because she had the entire hall to do by herself (13 residents) and when that happened, she was not able to give Resident #64 a shower because it took two staff to provide the shower. She indicated she gave the Resident a good bed bath instead.
Multiple attempts were made to interview Nurse Aide #1 who worked on 08/26/23 and 09/02/23 but the attempts were unsuccessful.
An interview was conducted with the Director of Nursing on 09/08/23 at 12:22 PM who explained the facility had a shower team in place but ended up having to replace them with people that did not like to give showers all the time, so the decision was made to put them back on the floor and made it the responsibility of the hall staff to provide the showers. Nevertheless, the showers should be given as the resident preferred for their showers to be given.
b. An interview and observation made with Resident #64 on 09/05/23 at 2:59 PM. The Resident was sitting in her wheelchair and had just returned from an afternoon activity. The Resident explained she liked getting out of the bed on a daily basis because she hurt all the time from her diagnosis, and it helped the pain to change positions. She continued to explain she needed to be up in her wheelchair to relieve the pain she had when she was in the bed all the time and after a while being in her wheelchair, she needed to lie back down to relieve the pain in her legs and ankles from sitting up. The Resident explained she enjoyed the activities provided by the facility. Resident #64 further explained she was not always able to get out of the bed every day because it took two staff to assist her out of the bed with the total lift and there was not always enough staff to assist her.
An observation and interview were made with Resident #64 on 09/06/23 at 2:50 PM. The Resident was lying in the bed and explained she was not gotten out of bed that day because she asked the nurse aide to get her up after breakfast and was told by the nurse aide, they could not get her up because they had to give showers. The Resident stated that was usually the reason why the staff could not get her up when she wanted to get up.
An interview was conducted with Nurse Aide (NA) #2 on 09/06/23 at 3:00 PM who stated she had only been employed by the facility for 6 weeks and confirmed she worked with NA #3 on Resident #64's hall that day, which was her first day on Resident #64's hall. NA #2 explained she did not know why Resident #64 did not get out of bed that day but knew that NA #3 had make up showers to give for 09/05/23 and did not have time to get Resident #64 up.
During an interview with Nurse Aide #3 on 09/06/23 at 3:14 PM the NA acknowledged she worked Resident #64's hall that day and had NA #2 to assist her who was fairly new and had never worked Resident #64's hall. NA #3 explained the Resident asked to get up after breakfast, but she told the Resident she had some make up showers from the day before to give and would not have time to get her up.
On 09/08/23 at 12:03 AM an interview and observation were made of Resident #64 who was lying in the bed. The Resident explained she asked her nurse aide who was NA #10 to get her up after breakfast and the NA told her she would get her up around 11:00 AM then when 11:00 came and went the NA told her she would get her up after lunch in time for the afternoon activity. The Resident stated the NA informed her that she had too much to do to get her up before lunch.
An interview was conducted with Nurse Aide #10 on 09/08/23 at 2:16 PM who confirmed she worked Resident #64's hall on 09/08/23 first shift. The NA explained Resident #64 requested to get out of bed after breakfast that morning and it was her intention to get her up then, but she was the only nurse aide scheduled for the entire hall for 13 residents and ran out of time. The NA continued to explain she got Resident #64 out of bed after lunch in time for the afternoon activity.
During an interview with the Director of Nursing (DON) on 09/08/23 at 2:30 PM the DON indicated Resident #64 was alert and could voice her wants and needs. The DON indicated it was not unreasonable for the Resident to be gotten out of bed to attend the leisure activities of her choice.
Based on observations, record review, resident, and staff interviews the facility failed to honor resident request for two showers per week (Resident #23, Resident #39, Resident #60, and Resident #64) and the facility also failed to honor a resident's request to get out of bed (Resident #64) this affected 4 of 6 residents reviewed for choices.
The findings included:
1. Resident #23 was admitted to the facility on [DATE] with diagnoses that included: weakness, end stage renal disease, and above the knee amputation of the left leg.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact and required extensive assistance of one staff member for bathing.
Review of the facility's shower schedule revealed Resident #23 was due a shower on Tuesday and Friday on first shift.
Review of the facility's shower documentation from 08/08/23 to 09/06/23 revealed Resident #23 had received a shower on 08/24/23 and 08/26/23. The documentation further revealed no showers were documented as given on 08/04/23, 08/08/23, 08/11/23, 08/15/23, 08/22/23, 08/25/23, 08/29/23, 09/01/23, and 09/05/23.
An observation and interview were conducted with Resident #23 on 09/05/23 at 11:26 AM. Resident #23 was resting in bed dressed in a hospital gown. She stated that she was supposed to get two showers a week on Tuesday and Friday and that was fine with her except she rarely got the two showers. Resident #23 stated it had been over a week since her last shower, and she could not recall exactly when her last shower was. Resident #23 stated the facility used to have a shower team that gave the showers but now the Nurse Aides (NA) on the hall had to give all the showers.
NA #4 was interviewed on 09/07/23 at 11:50 AM and confirmed she worked with Resident #23 on 08/04/23, which was one of the days Resident #23 was scheduled for a shower. She stated she only worked at the facility three days a week and was not there every day to get information about showers or shower schedules. NA #4 stated one week they had a shower team to complete the showers and the next week they didn't, but it was never communicated to the direct care staff. NA #4 confirmed she had cared for Resident #23 but also confirmed she had never showered her. NA #4 stated she had not completed any showers recently because she did not know if there was or was not a shower team to do them.
NA #2 was interviewed on 09/07/23 at 12:21 PM and confirmed she had worked with Resident #23 on 08/08/23 and 09/05/23, which were two of the days Resident #23 was scheduled for showers. NA #2 stated each day when she reported to work, she would check the shower schedule in the back of the assignment book and that would tell her which residents were due a shower on that day. NA #2 stated normally the facility had a shower team that completed all the showers and so she did not have to do them. However, NA #2 stated if there was no shower team then the NAs on the hall were expected to complete the showers due on that day. There were days NA #2 reported she was unable to complete her assigned showers. She explained it depended on which hall she was on, as some residents required more extensive care than others and she would get caught up in doing things for those residents and would not be able to complete the assigned showers for the day. NA #2 added if she was not able to complete a shower, she would complete a bed bath and document that in the facility electronic record. NA #2 confirmed that she had never showered Resident #23.
Review of the facility schedule for 08/11/23 revealed no documentation of a staff member who was assigned to care for Resident #23 on first shift that day.
NA #5 was interviewed via phone on 09/07/23 at 12:30 PM. NA #5 confirmed she cared for Resident #23 on 08/15/23, one of the days Resident #23 was scheduled for a shower and confirmed she had never showered Resident #23. NA #5 stated she really did not know which residents were supposed to get showers or when. She explained the facility had a shower team up until about two months ago then the staff that was on the shower team quit. After that nothing was said to the NAs about completing showers, but the residents started complaining about not getting their showers. NA #5 stated at one point the nurses would give us a list of the showers that were due that day, but it would be halfway through the shift and the residents would already be up for the day. NA #5 stated if she gave a shower, she documented it in the computer system and if the resident refused the nurse would be made aware.
NA #8 was interviewed via phone on 09/07/23 at 2:09 PM. NA #8 confirmed she cared for Resident #23 on 08/29/23 one of the days Resident #23 was scheduled to receive a shower and confirmed she had never showered Resident #23. She explained that recently the NAs on the hall were told they had to complete the showers, prior to that they had a shower team that completed all the showers. NA #8 stated she was not able to complete her showers due to lack of staffing. She stated a lot of times there were call outs and a lot of residents required two-person assistance with the mechanical lift and could not be transferred to the shower chair by herself.
NA #6 was interviewed via phone on 09/07/23 at 2:25 PM who confirmed she worked wherever the facility needed her to and confirmed she had taken care of Resident #23 on 08/22/23, one of the days Resident #23 was scheduled to receive a shower. NA #6 confirmed she had never showered Resident #23. NA #6 stated she was not clear on showers within the facility. She explained a couple of weeks ago they told us the NAs would have to start completing their own showers, we used to have a shower team. NA #6 stated the shower team always got pulled to the floor to cover the call outs. She added when she worked on F hall (not the hall that Resident #23 resided on) she was able to complete her showers as scheduled but could not explain why she had not showered Resident #23 on 08/22/23.
NA #7 was interviewed via phone on 09/07/23 at 2:58 PM who confirmed she worked at the facility as needed, but when she did work, she usually worked on E hall (where Resident #23 resided) and confirmed she cared for Resident #23 on 08/25/23, one of the days one of the days Resident #23 was scheduled for a shower. NA #7 explained there was a shower schedule at the nursing station that told which residents were due a shower each day. Previously the facility had a shower team and about two weeks the management told the NAs they would have to start completing their own showers. NA #7 stated she had showered Resident #23 once in the last month and may have forgotten to document it but stated a lot of times there was not enough staff to complete the showers. NA #7 explained on E hall they only staffed one NA on the unit so if the NA had a resident in the shower that left no one on the hall to supervise the other residents. Furthermore NA #7 stated most residents required two persons assistance with transfers to/from the shower chair it was difficult to get someone from another hall to help out.
The Unit Manager (UM) was interviewed on 09/07/23 at 4:01 PM. The UM stated the facility no longer had a shower team and the NAs on the hall were expected to check the shower schedule and complete the showers for their shift. She added the nurse were expected to sign off on the shower sheets indicating the shower had or had not been completed. The UM stated she had been pulled to work the hall and had not had the time to follow up on the shower schedule to ensure the showers were done as scheduled.
NA #9 was interviewed via phone on 09/07/23 at 4:09 PM. NA #9 stated she typically worked the weekends in the facility on third shift but picked up extra shifts from time to time. She confirmed that she cared for Resident #23 on 09/01/23, one of the days Resident #23 was scheduled for a shower and confirmed that she had not completed any showers in the facility in the last month. She explained her usual shift was night shift and typically there were no showers scheduled during those times.
The Director of Nursing (DON) was interviewed on 09/08/22 at 12:22 PM. The DON explained the facility had a shower team they put in place and those staff members left the facility. They had two other employees that wanted to do the showers, so they put them on the shower team, and they did not like it. Around the same time staffing became an issue so they had to put the shower team back on the floor. The DON explained that in the last 3-4 weeks they have had the NAs on the halls start completing the showers for their assigned residents. She added she had been working the floor on night shift a lot and really had not gotten a lot of feedback from the residents. The DON stated showers should be completed as scheduled, per the resident's preference, and were being monitored by the Assistant Director of Nursing (ADON) who had since left the facility and the UM who had been working the hall a lot recently. The DON added she recently hired several nurses to cover the night shift which would help free up her time to monitor the shower schedule to ensure they were being completed as they should be.
2. Resident #39 was admitted to the facility on [DATE] with diagnoses that included quadriplegia.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact and required total assistance of two staff members with bathing. No behaviors or rejection of care were noted during the assessment reference period.
Review of the facility's shower schedule revealed Resident #39 was due a shower on Tuesday and Friday on first shift.
Review of the facility's shower documentation from 08/08/23 to 09/06/23 revealed Resident #39 had received a shower on 08/18/23 and 08/29/23. The documentation further revealed no showers were documented as given on 08/4/23, 08/08/23, 08/11/23, 08/15/23, 08/22/23, 08/25/23, 09/01/23, and 09/05/23.
An observation and interview were conducted with Resident #39 on 09/05/23 at 10:15 AM. Resident #39 was resting in bed dressed in a hospital gown. He stated he was supposed to get two showers a week on Tuesday and Friday and that was fine with him except he went months without showers. Resident #39 could not recall when his last shower was but stated it had been a while.
Nurse Aide (NA) #4 was interviewed on 09/07/23 at 11:50 AM and confirmed she worked with Resident #39 on 08/04/23, which was one of the days Resident #39 was scheduled for a shower. She stated she only worked at the facility three days a week and was not there every day to get information about showers or shower schedules. NA #4 stated one week they had a shower team to complete the showers and the next week they didn't, but it was never communicated to the direct care staff. NA #4 confirmed she had cared for Resident #39 but also confirmed she had never showered him. NA #4 stated she had not completed any showers recently because she did not know if there was or was not a shower team to do them.
NA #2 was interviewed on 09/07/23 at 12:21 PM and confirmed she had worked with Resident #39 on 08/08/23 and 09/05/23, which were two of the days Resident #39 was scheduled for showers. NA #2 stated each day when she reported to work, she would check the shower schedule in the back of the assignment book and that would tell her which residents were due a shower on that day. NA #2 stated normally the facility had a shower team that completed all the showers and so she did not have to do them. However, NA #2 stated if there was no shower team then the NAs on the hall were expected to complete the showers due on that day. There were days NA #2 reported she was unable to complete her assigned showers. She explained it depended on which hall she was on, as some residents required more extensive care than others and she would get caught up in doing things for those residents and would not be able to complete the assigned showers for the day. NA #2 added if she was not able to complete a shower, she would complete a bed bath and document that in the facility electronic record. NA #2 confirmed that she had never showered Resident #39.
Review of the facility schedule for 08/11/23 revealed no documented staff member who was assigned to care for Resident #39 on first shift that day.
NA #5 was interviewed via phone on 09/07/23 at 12:30 PM. NA #5 confirmed she cared for Resident #39 on 08/15/23, one of the days Resident #39 was scheduled for a shower and confirmed she had never showered Resident #39. NA #5 stated she really did not know which residents were supposed to get showers or when. She explained the facility had a shower team up until about two months ago then the staff that was on the shower team quit. After that nothing was said to the NAs about completing showers, but the residents started complaining about not getting their showers. NA #5 stated at one point the nurses would give us a list of the showers that were due that day, but it would be halfway through the shift and the residents would already be up for the day. NA #5 stated if she gave a shower, she documented it in the computer system and if the resident refused the nurse would be made aware.
NA #6 was interviewed via phone on 09/07/23 at 2:25 PM who confirmed she worked wherever the facility needed her to and confirmed she had taken care of Resident #39 on 08/22/23, one of the days Resident #39 was scheduled to receive a shower. NA #6 confirmed she had never showered Resident #39. NA #6 stated she was not clear on showers within the facility. She explained a couple of weeks ago they told us the NAs would have to start completing their own showers, we used to have a shower team. NA #6 stated the shower team always got pulled to the floor to cover the call outs. She added when she worked on F hall (not the hall that Resident #39 resided on) she was able to complete her showers as scheduled but could not explain why she had not showered Resident #39 on 08/22/23.
NA #7 was interviewed via phone on 09/07/23 at 2:58 PM who confirmed she worked at the facility as needed, but when she did work, she usually worked on E hall (where Resident #39 resided) and confirmed she cared for Resident #39 on 08/25/23, one of the days one of the days Resident #39 was scheduled for a shower. NA #7 explained there was a shower schedule at the nursing station that told which residents were due a shower each day. Previously the facility had a shower team and about two weeks the management told the NAs they would have to start completing their own showers. NA #7 stated that she had not showered Resident #39 in the last month and explained that a lot of times there was not enough staff to complete the showers. NA #7 explained on E hall they only staffed one NA on the unit so if the NA had a resident in the shower that left no one on the hall to supervise the other residents. Furthermore NA #7 stated most residents required two persons assistance with transfers to/from the shower chair it was difficult to get someone from another hall to help out.
The Unit Manager (UM) was interviewed on 09/07/23 at 4:01 PM. The UM stated the facility no longer had a shower team and the NAs on the hall were expected to check the shower schedule and complete the showers for their shift. She added the nurses were expected to sign off on the shower sheets indicating the shower had or had not been completed. The UM stated she had been pulled to work the hall and had not had the time to follow up on the shower schedule to ensure the showers were done as scheduled.
NA #9 was interviewed via phone on 09/07/23 at 4:09 PM. NA #9 stated she typically worked the weekends in the facility on third shift but picked up extra shifts from time to time. She confirmed she cared for Resident #39 on 09/01/23, one of the days Resident #39 was scheduled for a shower and confirmed she had not completed any showers in the facility in the last month. She explained her usual shift was night shift and typically there were no showers scheduled during those times.
The Director of Nursing (DON) was interviewed on 09/08/22 at 12:22 PM. The DON explained the facility had a shower team they put in place and those staff members left the facility. They had two other employees that wanted to do the showers, so they put them on the shower team, and they did not like it. Around the same time staffing became an issue so they had to put the shower team back on the floor. The DON explained in the last 3-4 weeks they have had the NAs on the halls start completing the showers for their assigned residents. She added she had been working the floor on night shift a lot and really had not gotten a lot of feedback from the residents. The DON stated showers should be completed as scheduled, per the resident's preference, and were being monitored by the Assistant Director of Nursing (ADON) who had since left the facility and the UM who had been working the hall a lot recently. The DON added she recently hired several nurses to cover the night shift which would help free up her time to monitor the shower schedule to ensure they were being completed as they should be.
3. Resident #60 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, chronic pain, and weakness.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was cognitively intact and required extensive assistance of one staff member for bathing. No behaviors or rejection of care were noted during the assessment reference period.
Review of a nurses note dated 02/14/23 written by the Director of Nursing (DON) read; Resident verbalized he does not want showers on his dialysis days. He stated that he preferred showers on Tuesday and Thursday.
Review of the facility's shower schedule revealed Resident #60 was due a shower on Tuesday and Thursday on first shift.
Review of the facility's shower documentation from 08/08/23 to 09/06/23 revealed Resident #60 had received a shower on 08/24/23. The documentation further revealed no showers were documented as given on 08/03/23, 08/08/23, 08/10/23, 08/15/23, 08/17/23, 08/22/23, 08/29/23, 08/31/23, and 09/05/23.
An observation and interview were conducted with Resident #60 on 09/05/23 at 10:30 AM. Resident #60 was sitting up in his wheelchair at bedside and was dressed in pair of shorts and a t-shirt. He stated if he was lucky, he would get one shower a month at the facility. He stated he did not want showers on his dialysis days which were Monday, Wednesday, and Friday and preferred his showers to be on Tuesday and Thursday. Resident #60 stated that he was independent enough that he could go into the bathroom and wash up, but nothing really took the place of good shower.
Nurse Aide (NA) #4 was interviewed on 09/07/23 at 11:50 AM and confirmed she worked with Resident #60 on 08/10/23, one of the days Resident #60 was scheduled to receive a shower. She stated she only worked at the facility three days a week and was not here every day to get information about showers or shower schedule. NA #4 stated one week they had a shower team to complete the showers and the next week they didn't, but it was never communicated to the direct care staff. NA #4 confirmed she had cared for Resident #60 but also confirmed she had never showered him. She stated he was very independent but most days that she worked Resident #60 was at dialysis. NA #4 stated she had not completed any showers recently because she did not know if there was or was not a shower team to do them.
NA #2 was interviewed on 09/07/23 at 12:21 PM and confirmed she had worked with Resident #60 on 08/08/23 and 09/05/23, two of the days that Resident #60 was scheduled to receive a shower. NA #2 stated each day when she reported to work, she would check the shower schedule in the back of the assignment book and that would tell her which residents were due a shower on that day. NA #2 stated normally the facility had a shower team that completed all the showers and so she did not have to do them. However, NA #2 stated if there was no shower team then the NAs on the hall were expected to complete the showers due on that day. There were days NA #2 reported she was unable to complete her assigned showers. She explained it depended on which hall she was on, as some residents required more extensive care than others and she would get caught up in doing things for those residents and would not be able to complete the assigned showers for the day. NA #2 added if she was not able to complete a shower, she would complete a bed bath and document that in the facility electronic record. NA #2 confirmed she had never showered Resident #60, she stated he was fairly independent but was not sure if he could shower himself for not.
NA #5 was interviewed via phone on 09/07/23 at 12:30 PM. NA #5 confirmed she cared for Resident #60 on 08/15/23, one of the days Resident #60 was scheduled to receive a shower. NA #5 confirmed she had never showered Resident #60. NA #5 stated she really did not know which residents were supposed to get showers or when. She explained the facility had a shower team up until about two months ago then the staff that was on the shower team quit. After that nothing was said to the NAs about completing showers, but the residents started complaining about not getting their showers. NA #5 stated that at one point the nurses would give us a list of the showers that were due that day, but it would be halfway through the shift and the residents would already be up for the day. NA #5 stated if she gave a shower, she documented it in the computer system and if the resident refused the nurse would be made aware.
NA #6 was interviewed via phone on 09/07/23 at 2:25 PM who confirmed she worked wherever the facility needed her to and confirmed that she had taken care of Resident #60 on 08/17/23 and 08/22/23, two of the days Resident #60 was scheduled to receive a shower. NA #6 confirmed she had never showered Resident #60 because she was not allowed to go into Resident #60's room so she was not sure who would have showered him on those days. NA #6 stated she was not clear on showers within the facility. She explained a couple of weeks ago they told us the NAs would have to start completing their own showers, we used to have a shower team. NA #6 stated the shower team always got pulled to the floor to cover the call outs.
The Unit Manager (UM) was interviewed on 09/07/23 at 4:01 PM. The UM stated the facility no longer had a shower team and the NAs on the hall were expected to check the shower schedule and complete the showers for their shift. She added the nurse were expected to sign off on the shower sheets indicating the shower had or had not been completed. The UM stated she had been pulled to work the hall and had not had the time to follow up on the shower schedule to ensure the showers were done as scheduled.
The Director of Nursing (DON) was interviewed on 09/08/22 at 12:22 PM. The DON explained the facility had a shower team they put in place and those staff members left the facility. They had two other employees that wanted to do the showers, so they put them on the shower team, and they did not like it. Around the same time staffing became an issue so they had to put the shower team back on the floor. The DON explained in the last 3-4 weeks they have had the NAs on the halls start completing the showers for their assigned residents. She added she had been working the floor on night shift a lot and really had not gotten a lot of feedback from the residents. The DON stated showers should be completed as scheduled, per the resident's preference, and were being monitored by the Assistant Director of Nursing (ADON) who had since left the facility and the UM who had been working the hall a lot recently. The DON added she recently hired several nurses to cover the night shift which would help free up her time to monitor the shower schedule to ensure they were being completed as they should be.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ed on record review, family, staff, and Nurse Practitioner interviews the facility failed to change Resident #82's advance directive (code status) as directed by his power of attorney (POA) for 1 of 1 resident reviewed for advance directives.
The findings included:
Resident #82 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dementia, Alzheimer's Disease, and others.
Review of a facility document titled; Advance Directive Discussion Document dated [DATE] indicated Resident #82 wished for cardiopulmonary resuscitation (CPR). The form was signed by Resident #82.
Review of a Medical Order for Scope of Treatment (MOST) form dated [DATE] indicated that Resident #82 was to receive full scope of treatment which included the use of intubation, advanced airway interventions, mechanical ventilation, cardioversion as indicated, medical treatment, intravenous fluid, etc. also provide comfort measures. Transfer to hospital. The form was signed by the Nurse Practitioner (NP) and by Resident #82's power of attorney.
Review of physician order dated [DATE] read: Full Code.
Review of a care plan initiated on [DATE] read in part, Resident #82 had chosen to be a full code.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #83 was severely cognitively impaired.
Review of a physician order dated [DATE]: Hospice referral.
Review of an admission Comprehensive Assessment from Hospice completed on [DATE] by Hospice Nurse #2 read in part, Resident #82 wished for full resuscitation.
Review of a Psychosocial admission Assessment completed on [DATE] by the Hospice Social Worker read in part, family (POA) desired for Resident #82 to be a full code until she and her family can discuss patients code status.
Resident #82's family member was interviewed via phone on [DATE] at 11:04 AM. The family member confirmed that she was Resident #82's POA and confirmed that when Resident #82 was admitted to hospice she was not ready to make him a DNR (Do Not Resuscitate) but about a week before he passed away, she talked to the Social Worker (SW) about changing him to a DNR. The family member stated she went to the nurse's station and asked who she needed to talk to about changing Resident #82 to a DNR, the UM walked the family member to the SW office. The family member stated that while she was standing in the SW office, she filled out the yellow paper and other form and she signed what she needed to and told the SW that the Medical Doctor (MD) was at the desk if you want to get his signature but could not say which MD and did not know his name. The family member stated that the SW took the forms and left the office headed to the nurse's station and she believed she had gotten them signed to make it official that Resident #82 was a DNR. The family member stated that at the time of Resident #82's death she did not wish for CPR and assumed that the DNR paperwork was completed as she had requested.
The SW was interviewed on [DATE] at 10:04 AM who stated that she really did not have much to do with the code statuses in the facility, unless someone wished to change their code status then she would get the appropriate paperwork filled out and give to the NP for signature. The SW stated she would also complete the golden rod and most form. The SW stated that she was not sure what Resident #82's code status was, she would assume he was a DNR. She added that Resident #82's family had never approached her about changing his code status
Review of an electronic note in Resident #82's medical record dated [DATE] read; Patient passed away at 9:00 PM, Hospice Nurse #3 and family at bedside at time of death. On call provider notified via voicemail. Patient cleaned by staff. Family currently in facility. The note was signed by Nurse #3.
The Unit Manager (UM) was interviewed on [DATE] at 9:44 AM who confirmed she was working in the facility on [DATE] when Resident #82 passed away but was not on his hall, Nurse #3 was caring for Resident #82 that night. She explained that it was not until later that night when they were completing paperwork that they discovered Resident #82 was a full code. The UM stated that she never questioned his code status for several reasons the first being that maybe a week prior to Resident #82's death his family (POA) had approached her about how to change his code status to DNR. The UM stated she referred her to the facility SW to get the appropriate paperwork completed. Second the UM explained that at the time of Resident #82's death Hospice Nurse #3 and his family (POA) were at bedside and never said anything about his code status or that they wished for us to start CPR. The UM stated that normally if a resident was a full code and their heart stopped breathing they would begin CPR and call EMS but again the UM stated I did not even think to look at his code status because the hospice nurse was there as was his family.
The Director of Nursing (DON) was interviewed on [DATE] at 3:02 PM who stated that Resident #82 admitted to hospice as a full code and the plan was to work towards making him a DNR. She stated that was notified of his passing but was not notified of his code status and would have to look into the issue.
A follow up interview was conducted with the DON on [DATE] at 3:37 PM. The DON stated that at the time of Resident #82's passing his family (POA) was at bedside and did not elect to perform CPR and the staff honored those wishes. She was unaware that the family had spoken to the SW earlier about changing Resident #82's code status. She confirmed that they had looked in the electronic medical record and facility and could not find the paperwork making Resident #82 a DNR.
The NP was interviewed on [DATE] at 2:52 PM who stated she did not recall having any conversation with Resident #82's family regarding his code status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to change a soiled privacy curtain for 1 of 8 rooms on E hall (room [ROOM NUMBER]) reviewed for homelike environment.
The finding included:
Resident #23 was admitted to the facility on [DATE].
The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #23 was cognitively intact.
On 09/05/23 at 11:29 AM an observation of Resident #23's privacy curtain revealed an egg sized brown stained area on the inner side of the curtain.
Subsequent observations of the privacy curtain in room [ROOM NUMBER] on 09/06/23 at 9:42 AM remained unchanged.
An interview was conducted with the Housekeeping Supervisor on 09/07/23 at 10:13 AM. The Supervisor explained that she staffed the facility with 3 housekeepers a day during the week and two housekeepers a day on the weekends. She continued to explain that along with cleaning the residents' rooms the housekeepers were responsible to check the window curtains and privacy curtains for cleanliness.
An observation made of the privacy curtain in room [ROOM NUMBER] on 09/07/23 4:07 PM remained unchanged.
A subsequent observation was made of the privacy curtain in room [ROOM NUMBER] on 09/08/23 at 12:35 PM. The curtain remained unchanged.
A second interview was conducted with the Housekeeping Supervisor on 09/08/23 at 12:36 PM. The Supervisor explained that the housekeeper assigned to room [ROOM NUMBER] on 09/07/23 and 09/08/23 had a work coach and the Supervisor was responsible for monitoring his work every day. She explained that she would go behind the housekeeper to make sure he had completed his assignment satisfactorily, but she did not look at the privacy curtain in room [ROOM NUMBER]. Accompanied the Supervisor to room [ROOM NUMBER] to observe the privacy curtain and the Supervisor stated it was unacceptable for the privacy curtain to be in that condition and the curtain should have been changed before then.
An interview was conducted with Resident #23 on 09/08/23 at 2:10 PM who explained that she was not aware of the brown stain on her privacy curtain and stated it was nasty and she appreciated getting a new one.
During an interview with the Director of Nursing (DON) on 09/08/23 at 3:04 PM the DON remarked she was made aware of the dirty privacy curtain and stated the curtain should not have been left like that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #57 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, dementia without behaviors, major depressive disorder and history of stroke.
A review of Resident #57's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #57 to be cognitively intact with no psychosis, behaviors, rejection of care, or instances of wandering. Resident #57 was coded as receiving antipsychotics 1 of 7 days during the lookback period but was coded as not receiving antipsychotics since her admission or entry to the facility or since the prior Minimum Data Set assessment.
A review of Resident #57's physician orders revealed no current, completed, or discontinued orders for the use of an antipsychotic.
A review of Resident #57's August Medication Administration record revealed no antipsychotics were provided to Resident #57 in the Month of August.
An interview with MDS Nurse #1 on 09/07/23 at 3:42 PM revealed she completed Resident #57's quarterly Minimum Data Set assessment dated [DATE]. She reported she recently had lost the other MDS Nurse who was helping her, and she was now responsible for completing all of the Minimum Data Set assessments for the building. She reported she was working about 70 hours a week and had even resorted to completing assessments at home. MDS Nurse #1 verified that Resident #57 had not received any antipsychotics during the lookback period for the Minimum Data Set assessment dated [DATE] and that it was not accurately reflected on the assessment. She reported she would complete a modification and resubmit the assessment, so it accurately reflected Resident #57's lack of antipsychotic use.
During an interview with the Director of Nursing on 09/08/23 at 4:17 PM she reported she expected Minimum Data Set assessments to accurately reflect the care and needs of individual residents. She indicated Resident #57 had not received antipsychotic medications and it should have been coded as such on her Minimum Data Set assessment dated [DATE].
3. Resident #16 was admitted to the facility on [DATE] with diagnoses that included Schizophrenia.
A review of Resident #16's physician orders dated 05/10/23 revealed an order for Abilify (an antipsychotic) 2 milligrams (mg) tablet, give 2 tablets by mouth once a day for Schizophrenia.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 received 7 days of antipsychotic medication during the 7 days look back period. Under antipsychotic medication review the Resident was coded as No, antipsychotics were not received since admission/entry or reentry or the prior assessment whichever is more recent.
A review of Resident #16's Medication Administration Record for 07/2023 revealed the Resident was administered Abilify 2 mg tablet give 2 tablets by mouth once a day every day of the month.
An interview was conducted with the MDS Coordinator on 09/07/23 at 4:11 PM. The MDS Nurse explained Resident #16's MDS was completed by a temporary MDS nurse and coded the MDS wrong. The MDS Nurse stated Resident #16's MDS should have been coded as Yes, the Resident did receive antipsychotics on a routine basis.
On 09/08/23 at 3:08 PM during an interview with the Director of Nursing (DON) remarked the facility had a MDS nurse who did not work out and stated regardless Resident #16's MDS should have been coded correctly.
Based on observations, record review, resident, and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of limb prosthesis (Resident #8), the area of hospice (Resident #60), and the use of antipsychotic medication (Resident #57 and Resident #16) for 4 of 22 MDS assessments reviewed.
The finding included:
1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, and others.
Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #8 was severely cognitively impaired for daily decision making. The MDS further revealed that Resident #8 used a wheelchair for mobility and had a limb prosthesis and received hospice services.
An observation of Resident #8 was made on 09/05/23 at 1:13 PM. Resident #8 was in the dining room with her lunch tray in front of her. She was feeding herself bites of her food. No upper or lower limb prosthesis was noted.
Additional observation of Resident #8 was made on 09/05/23 at 2:47 PM. Resident #8 was using her upper and lower extremities to propel herself all over the facility. No limb prosthesis was noted.
Hospice Nurse #1 was interviewed via phone on 09/06/23 at 12:18 PM who confirmed that she visited with Resident #8 weekly. The nurse stated that generally she has to chase Resident #8 around the facility in her wheelchair. Hospice Nurse #1 stated that she completed a full skin assessment weekly on Resident #8 and confirmed that she did not have a limb prosthesis.
The MDS Nurse was interviewed on 09/06/23 at 5:00 PM and confirmed that Resident #8 did not have a limb prosthesis. She stated, that was an oops on my part and stated she would do a correction right away.
The Director of Nursing (DON) was interviewed on 09/08/23 at 12:13 PM who stated that she expected the MDS to be accurately coded. She explained that the facility had a second MDS nurse and she recently quite leaving only MDS Nurse and maybe that caused the errors to occur.
2. Resident #60 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease.
Review of a care plan initiated on 06/04/22 indicated that Resident #8 received palliative care services.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #60 was cognitively intact and received hospice care.
During an interview with Resident #60 on 09/05/23 at 10:30 AM he stated that he did not receive any hospice or palliative care services.
An interview with the palliative care provider was conducted via phone on 09/06/23 at 12:58 PM and revealed that they had discontinued Resident #60's palliative care services on 03/15/23.
An interview was conducted with the MDS Nurse on 09/06/23 at 4:52 PM who stated that Resident #60 received palliative care and had for a while now. She stated that she had not received any communication from the palliative care provider notifying her that Resident #60 was no longer receiving palliative care services. She stated that was a mistake and that she would correct the issue right away.
The Director of Nursing (DON) was interviewed on 09/08/23 at 12:13 PM who stated that she expected the MDSs to be accurately coded. She explained that the facility had a second MDS nurse and she recently quite leaving only MDS Nurse and maybe that caused the errors to occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop a comprehensive care plan within 7 days of the completion of a resident's admission Minimum Data Set assessment (Resident #83) for 1 of 2 residents reviewed for discharge.
The findings included:
Resident #83 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, muscle weakness, age related physical debility, type II diabetes mellitus, and hypertension.
A review of Resident #83's admission Minimum Data Set assessment dated [DATE] revealed he was cognitively intact with no psychosis, behaviors, rejection of care, or instances of wandering. Resident was coded as requiring supervision with bed mobility, toilet use, and personal hygiene. Resident #83 required limited assistance with transfers, walk in the room and corridor, locomotion on and off the unit, and dressing.
Resident #83 was independent with eating and needed extensive assistance with bathing.
Review of Resident #83's medical record revealed the facility developed a baseline care plan 24 hours after Resident #83 admitted to the facility. Resident #83's admission Minimum Data Set assessment was completed on 07/13/23 with the following areas triggered for care plan development: Activities of Daily Living functional abilities, Fall Risk, Nutrition, Potential Pressure Ulcer or Injury Development, and Pain.
During an interview with MDS Nurse #1 on 09/08/23 at 3:49 PM, she reported comprehensive care plans were to be developed no later than 7 days after the completion of the admission Minimum Data Set assessment. She verified she would have been the staff member responsible for completing Resident #83's comprehensive care plan and stated with Resident #83 discharging on 07/24/23, she must have miscalculated when his comprehensive care plan was due to be completed. She reported it would have been due on 07/21/23.
An interview with the Director of Nursing on 09/08/23 at 4:12 PM, she reported care plans should be developed and implemented within the required timeframes and that Resident #83 should have had a comprehensive care plan developed on 07/21/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interviews the facility failed to invite 2 of 2 residents to a care plan meeting (Resident #39 and Resident #60) that were reviewed for care plans.
The findings included:
1. Resident #39 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, weakness, chronic pain, and others.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #39 was cognitively intact.
Review of Resident #39's medical record revealed no evidence of a care plan meeting being held with Resident #39 or his family.
An interview was conducted with Resident #39 on 09/05/23 at 10:15 AM, Resident #39 stated that he had been at the facility for over two years, and he did not recall ever being invited to a care plan meeting about his stay in the facility or any discharge plan that may or may not be in place. Resident #39 stated that he would be eager to participate in the care plan meeting if he would have known about it.
The Social Worker was interviewed on 09/07/23 at 10:08 AM who stated that she had been at the facility for a year. She stated that she had not yet been trained on the care plan process, she indicated she was supposed to go a sister facility for additional training within the next month. The Social Worker stated in the meantime she did care plan meetings every three to four months and she basically just jotted down any questions or concerns the resident or family had and if it was a big concern, she would write it up on a grievance form. She added that she did not select the residents for care plan off the MDS assessment schedule, but she just selected a group of residents to conduct care plan meetings with and then would reschedule them in three months. She indicated that she was also scheduling care plan meetings around her (the social worker) school schedule and it could be difficult to get to all the residents. The Social Worker confirmed that in the year that she had been at the facility she had not had the opportunity to have a care plan meeting with Resident #39. She stated that she needed to call his family and arrange one.
The Director of Nursing (DON) was interviewed on 09/08/23 at 12:16 PM who stated that to her knowledge the family and residents should be invited to regular care plan meetings every quarter. The DON stated she did not regularly attend the care plan meeting unless requested by the resident or family. She added that the Social Worker should be sending out invitations to the resident and family quarterly that coincide with the MDS assessment schedule.
2. Resident #60 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, diabetes, and other.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #60 was cognitively intact.
Review of Resident #60's medical record revealed the last care plan meeting that was held with Resident #60 was 04/28/21.
An interview was conducted with Resident #60 on 09/05/23 at 10:36 AM who stated that he had not been offered or invited to a care plan meeting in years. Resident #60 stated he vaguely remembered being invited to a care plan meeting shortly after his admission to the facility but nothing recent. Resident #60 stated he would like to regularly discuss his discharge plans as he still wishes to discharge to the community.
The Social Worker was interviewed on 09/07/23 at 10:08 AM who stated that she had been at the facility for a year. She stated that she had not yet been trained on the care plan process, she indicated she was supposed to go a sister facility for additional training within the next month. The Social Worker stated in the meantime she did care plan meetings every three to four months and she basically just jotted down any questions or concerns the resident or family had and if it was a big concern, she would write it up on a grievance form. She added that she did not select the residents for care plan off the MDS assessment schedule, but she just selected a group of residents to conduct care plan meetings with and then would reschedule them in three months. She indicated that she was also scheduled care plan meetings around her (the social worker) school schedule and it could be difficult to get to all the residents. The Social Worker confirmed that in the year that she had been at the facility she had not had the opportunity to have a care plan meeting with Resident #60 because most of the time he was at dialysis during the time that she could schedule care plan meetings.
The Director of Nursing (DON) was interviewed on 09/08/23 at 12:16 PM who stated that to her knowledge the family and residents should be invited to regular care plan meetings every quarter. The DON stated she did not regularly attend the care plan meeting unless requested by the resident or family. She added that the Social Worker should be sending out invitations to the resident and family quarterly that coincide with the MDS assessment schedule.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident and staff interviews, the facility failed to provide nail care to a dependent resident for 1 of 2 residents reviewed for providing activities of daily living (Resident #36).
The findings included:
Resident #36 was admitted to the facility on [DATE] with diagnoses that included chronic pain.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was cognitively intact and required extensive assistance for personal hygiene and was dependent for bathing. It further indicated no rejection of care or behaviors.
Review of the nurse's progress notes from 8/21/23 through 9/8/23 revealed no notes regarding Resident #36 refusing showers or personal hygiene care. Review of the Nurse Aide (NA's) documentation of the same period revealed no indication Resident #36 refused nail care.
An observation and interview with Resident #36 on 9/5/23 at 11:41 AM revealed Resident #36 lying in bed with fingernails on both hands that extended out past the end of her fingertips approximately one-half inch in length with chipped burgundy nail polish. Some nails were jagged on the end. Resident #36 indicated she had not received nail care in a month.
An observation and interview with Resident #36 on 9/7/23 at 2:44 PM revealed Resident #36 lying in bed and her fingernails remained long with chipped burgundy nail polish. Some nails were jagged on the end. Resident #36 indicated she did not receive nail care in a month, and she did not like her nails to be this long and preferred to have her nails trimmed and manicured.
A review of the undated shower schedule revealed Resident #36 was to receive bathing and personal hygiene twice weekly on Monday and Thursdays during day shift (7AM- 3PM).
An interview with NA #11 on 9/7/23 at 2:44 PM revealed she had been assigned to Resident #36 on 9/7/23 on day shift (7A-3P) and had not provided nail care due to not knowing Resident #36's assigned bath days and did not have enough assistance to get nail care completed in the last several weeks. NA #11 acknowledged Resident #36's nails were long and jagged and nail polish was chipped.
An interview with NA #12 on 9/7/23 at 2:44 PM revealed she had been assigned to Resident #36 on 9/7/23 on evening shift (3PM -11 PM) and had not provided nail care due to not knowing Resident #36's assigned bath days, she did not work the day shift, and did not have enough assistance to get nail care completed in the last couple of weeks. NA #11 acknowledged Resident #36's nails were long and jagged and nail polish was chipped.
An interview with the Director of Nursing on 9/8/23 at 4:30 PM revealed she expected all residents to receive nail care on bath days by nurse aides and activity department during manicure activities as allowed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, and staff interviews the facility failed to ensure that oxygen was delivered at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Resident #13).
The findings included:
Resident #13 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease.
Review of a physician order dated 10/13/21 read; oxygen continuous at 3 liters.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #13 was cognitively intact and used oxygen during the look back period. The MDS also revealed Resident #13 had no shortness of breath during the look back period.
An observation of Resident #13 was made on 09/05/23 at 11:41 AM, she was resting in bed with her eyes closed. Resident #13 had an oxygen canula in her nose with oxygen being delivered at 5 liters per minute. Resident #13 appeared to be in no respiratory distress.
An observation of Resident #13 was made on 09/06/23 at 9:47 AM. Resident #13 was resting in bed with her breakfast tray in front of her. She wore an oxygen canula in her nose that was delivering oxygen at 5 liters per minute. Resident #13 appeared to be in no respiratory distress.
An interview was conducted with Medication Aide (MA) # 1 on 09/06/23 at 3:48 PM who confirmed she was caring for Resident #13. MA #1 stated that Resident #13 was supposed to be on 3 liters of oxygen, and she checked the oxygen rate each time she went into the resident's room. MA #1 accompanied the State Surveyor to Resident #13's room and confirmed the oxygen concentrator was set to deliver 4 to 5 liters of oxygen. Resident #13 was asked if she had changed the rate and she replied, no I can't even reach it and she was asked if she had asked anyone to change it and she again stated no. MA #1 stated she had checked Resident #13's oxygen rate earlier during the shift and had pulled the concentrator out away from the wall so that it would not get to hot. She added that she was going to report the oxygen level to Nurse #2 who could adjust the oxygen rate to the correct level.
Nurse #2 was interviewed on 09/06/23 at 3:54 PM who confirmed that Resident #13 was supposed to be on 3 liters of oxygen. She stated she would go and correct the issue immediately.
The Director of Nursing (DON) was interviewed on 09/08/23 at 12:49 PM who stated that oxygen levels were supposed to be checked at least once a shift to ensure the correct amount of oxygen was being delivered. She added that they may have to increase the frequency of those checks to ensure the resident was receiving the correct amount of oxygen.

Based on record reviews and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions for Notification of Changes (F-580), which were put into place during the complaint investigation survey of 09/07/21 and on the current compliant investigation survey of 06/01/23. The continued failure of the facility during the two federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program.
The finding included:
The tag is cross referenced to:
F-580: Based on record review, family and staff interviews, the facility failed to notify the Responsible Party (RP) of a change in condition when the residents COVID-19 test result was positive for 4 of 5 residents reviewed for notification of change (Resident #1, Resident #2, Resident #3, and Resident #4). In addition, the facility failed to notify Resident #2's RPs of a need for evaluation at the hospital after a fall.
During the complaint investigation survey of 09/07/21, the facility failed to notify the Nurse Practitioner when a resident with a diet order to receive nothing by mouth was suspected to consume food and fluids which resulted in a delay in the identification and treatment for pneumonia for 1 of 3 residents reviewed for accidents.
During a telephone interview conducted with the Administrator on 06/01/23 at 11:10 AM the Administrator explained that he was not employed by the facility during the 09/07/21 complaint survey but he knew that the facility had underwent many changes in administration as well as turnover in the direct care staff since that survey which resulted in a lack of consistency and accountability in the QAPI program that was put into place based on the failure of the facility to notify the Nurse Practitioner of a resident's change in condition. He continued to explain that the facility should have educated new staff to maintain compliance obtained from the 09/07/21 complaint survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to complete a comprehensive discharge summary that included a recapitulation of stay for 2 of 3 residents reviewed for discharge (Resident #5 and Resident #6).
The Findings Included:
1. Resident #5 was admitted to the facility on [DATE].
A review of Resident #5's admission Minimum Data Set assessment dated [DATE] revealed Resident #5 to be cognitively intact.
A review of Resident #5's electronic medical record revealed a discharge summary document dated 03/01/23 and titled Discharge Plan and Instructions that did not include a recapitulation of stay,
Resident #5 was discharged to his home from the facility on 03/01/23.
During an interview with the Social Worker on 05/31/23 at 1:51 PM she reported she was only responsible for completing certain sections within the discharge summary. She stated those sections did not include the recapitulation of stay and that section was supposed to be completed by the nursing department. She stated she was unsure who in nursing was responsible for completing the recapitulation of stay.
During an interview with the Director of Nursing on 05/31/23 at 3:36 PM, she reported section 3 of the discharge summary, which included the recapitulation of stay was to be completed by the unit manager at the time of discharge.
An interview with Unit Manager #1 on 05/31/23 at 4:13 PM revealed when she worked, she was responsible for completing the discharge summary and recapitulation of stay. She then reported on 03/01/23 she was not working. Unit Manager #1 reported on days she did not work; it would be the responsibility of the hall nurse to complete the discharge summary and recapitulation of stay.
Review of facility provided staffing schedule from 03/01/23 revealed no unit manager scheduled for that day. Additional review of the staffing schedule from 03/01/23 revealed Nurse #1 was Resident #5's hall nurse the day he was discharged from the facility.
An interview with Nurse #1 on 05/31/23 at 4:18 PM revealed she had never been told or asked to complete a discharge summary. She reported she was aware of the discharge summary but stated it was something that the unit manager or the Director of Nursing would complete. She further stated she did not believe she had the ability to access discharge summaries through the electronic medical record.
A follow up interview with the Director of Nursing on 05/31/23 at 4:28 PM revealed when the unit manager was not in the facility, the responsibility of completing the recapitulation of stay would fall to the nurse who was working on the hall. She further stated the hall nurses should have access to discharge summaries on the electronic medical record. She reported Resident #5's discharge summary was not complete and was not an accurate representation of Resident #5's condition and abilities at the time of his discharge. She stated discharge summaries should be completed thoroughly and be an accurate representation of the resident at the time of discharge.
2. Resident #6 was admitted to the facility on [DATE].
A review of Resident #6's admission Minimum Data Set assessment dated [DATE] revealed her to be moderately impaired.
A review of Resident #6's electronic medical record revealed a discharge summary document dated 03/01/23 and titled Discharge Plan and Instructions that did not include a recapitulation of stay,
Resident #6 was discharged to her home from the facility on 03/02/23.
During an interview with the Social Worker on 05/31/23 at 1:51 PM she reported she was only responsible for completing certain sections within the discharge summary. She stated those sections did not include the recapitulation of stay and that section was supposed to be completed by the nursing department. She stated she was unsure who in nursing was responsible for completing the recapitulation of stay.
During an interview with the Director of Nursing on 05/31/23 at 3:36 PM, she reported section 3 of the discharge summary, which included the recapitulation of stay was to be completed by the unit manager at the time of discharge.
An interview with Unit Manager #1 on 05/31/23 at 4:13 PM revealed when she worked, she was responsible for completing the discharge summary and recapitulation of stay. She then reported on 03/01/23 she was not working. Unit Manager #1 reported on days she did not work; it would be the responsibility of the hall nurse to complete the discharge summary and recapitulation of stay.
Review of facility provided staffing schedule from 03/01/23 revealed no unit manager scheduled for that day. Additional review of the staffing schedule from 03/01/23 revealed Nurse #2 was Resident #6's hall nurse the day he discharged from the facility.
An interview with Nurse #2 on 05/31/23 at 4:25 PM revealed he worked the day that Resident #6 was discharged . He reported he had never been asked to complete a discharge summary or a recapitulation of stay.
A follow up interview with the Director of Nursing on 05/31/23 at 4:28 PM revealed when the unit manager was not in the facility, the responsibility of completing the recapitulation of stay would fall to the nurse who was working on the hall. She further stated the hall nurses should have access to discharge summaries on the electronic medical record. She reported Resident #6's discharge summary was not complete and was not an accurate representation of Resident #6's condition and abilities at the time of his discharge. She stated discharge summaries should be completed thoroughly and be an accurate representation of the resident at the time of discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, the facility failed to notify the Responsible Party (RP) of a change in condition when the residents COVID-19 test result was positive for 4 of 5 residents reviewed for notification of change (Resident #1, Resident #2, Resident #3, and Resident #4). In addition, the facility failed to notify Resident #2's RPs of a need for evaluation at the hospital after a fall.
Findings included:
1a. Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included dementia.
A review of the face sheet revealed Family Member #1 was Resident #1's guardian (RP).
A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was rarely/never understood with short and long-term memory impairment.
A form provided by the facility titled, Resident/Staff Contracted COVID-19/SARS COVID-19 Test dated 2/22/23 and signed by Director of Nursing (DON) revealed Resident #1 had a positive test result.
A review of the progress notes from February to March 2023 revealed on 2/22/23 at 9:56 AM, Resident #1 was discussed related to testing positive for COVID-19 and revealed the hospice and medical provider were made aware of the results but did not include notification of the RP. It further revealed Resident #1 was symptomatic with a cough.
An interview with Family Member #1 was conducted on 6/1/23 at 12:37 PM revealed she had not been made aware of Resident #1's COVID-19 on 2/22/23. She did not learn of Resident #1's COVID-19 status until several days after she was diagnosed when staff contacted her about an unrelated issue.
b. Resident #2 was admitted to the facility on [DATE] with diagnosis that included a cerebral infarction, chronic obstructive pulmonary disease, and vascular dementia.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact.
A form provided by the facility titled, Resident/Staff Contracted COVID-19/SARS COVID-19 Test dated 3/1/23 and signed by Director of Nursing (DON) revealed Resident #2 had a positive test result.
A review of the progress notes from February to March 2023 revealed on 3/1/23 at 4:30 AM, Resident #2 tested positive for COVID-19.
Additional progress notes dated 3/1/23 at 10:21 AM was discussed related to testing positive for COVID-19. It further indicated the facility was awaiting notification of the provider of the results during a visit in the facility on that date and that Resident #2 had experienced a fall on 2/28/23 and had a Computerized Tomography (CT). It did not include notification of the RP but revealed Resident #2 was currently asymptomatic.
An interview with Family Member #2 was conducted on 5/30/23 at 4:37 PM revealed he was Resident #2's dual RP and had not been made aware of Resident #2's diagnosis of COVID-19 until he arrived on 3/4/23 to visit. Family Member #2 stated he arrived at the facility and could not locate his father in his usual room and therefore asked where Resident #2 could be located and was directed to a new location. Family Member #2 stated upon arrival to Resident #2's room he proceeded in the room and began visiting with his father. Family Member #2 indicated he received the blanket call that the facility had a COVID outbreak; however, the recording indicated if Family Member #2's family member was diagnosed he would be contacted individually, and he was never contacted about Resident #2. Family Member #2 stated he was contacted by the facility to notify him that Resident #2 had a fall and would need radiological studies performed but did not notify him the facility would be sending Resident #2 to the hospital to obtain the studies.
An interview with Family Member #3 was conducted on 5/31/23 at 8:42 AM which revealed she was Resident 2's dual RP and had not been made aware of his diagnosis of COVID-19 until Family Member #3 arrived at the facility on 3/4/23 when he learned of the new diagnosis because he had been exposed. Family Member #3 stated she was not called about Resident #2's fall or the need to be sent to the hospital for radiological studies.
c. Resident #3 was re-admitted to the facility on [DATE] with diagnosis that included a disorder which affects a person's ability to move and maintain balance and respiratory failure with hypoxia or hypercapnia.
An annual Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact.
A form provided by the facility titled, Resident/Staff Contracted COVID-19/SARS COVID-19 Test dated 2/22/23 and signed by Director of Nursing (DON) revealed Resident #3 had a positive test result.
A review of the progress notes from February 2023 revealed on 2/22/23 at 10:00 AM, Resident #3 was discussed related to testing positive for COVID-19 and revealed the medical provider was made aware of the results but did not include notification of the RP. It further revealed Resident #3 was symptomatic with a non-productive cough.
An interview with Family Member #4 was conducted on 5/31/23 at 10:38 AM revealed he was not made aware of Resident #3's diagnosis of COVID-19 until he arrived at the facility a few days after she had been diagnosed. Family Member #4 indicated he received the blanket call that the facility had a COVID outbreak; however, the recording indicated if Family Member #4's family member was diagnosed he would be contacted individually, and he was never contacted about Resident #4.
d. Resident #4 was admitted to the facility on [DATE] with diagnosis that included Parkinson's Disease and dementia.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely cognitively impaired.
A form provided by the facility titled, Resident/Staff Contracted COVID-19/SARS COVID-19 Test dated 2/22/23 and signed by Director of Nursing (DON) revealed Resident #3 had a positive test result.
A review of the progress notes from February 2023 revealed on 2/22/23 at 9:55 AM, Resident #4 was discussed related to testing positive for COVID-19 and revealed the medical provider was made aware of the results but did not include notification of the RP. It further revealed Resident #3 was symptomatic with a non-productive cough and congestion.
An interview with Family Member #5 was conducted on 5/31/23 at 1:04 PM revealed she was Resident #4's RP and was not notified Resident #4 had been diagnosed with COVID-19 on 2/22/23 and did not learn he was COVID-19 positive until she was called to notify her that Resident #4 was being moved to a room at the end of his isolation around the first week of March 2023.
An interview with the current Unit Manager on 5/31/23 at 9:45 AM revealed she performed most of the COVID-19 routine testing in the facility; however, she had not contacted any family members to make them aware then their relative tested positive for COVID-19. The Unit Manager indicated she provided the list of positive tests to the Director of Nursing each week. She stated if she performed a test for a symptomatic resident outside of the entire facility's routine testing, she would call the resident's RP and document it under the progress notes in the medical record, but she had not notified the RP for Resident #1, Resident #2, Resident #3, or Resident #4 testing positive for COVID-19. The UM indicated families were to be notified of all changes of medical condition and was unsure who was responsible for contacting Resident #2's family regarding the need to send him to the hospital for radiological studies.
An interview with the Infection Control Preventionist on 5/31/23 at 9:30 AM revealed she was new to the facility and had only been in her role approximately a month. The Infection Control Preventionist stated she had not performed testing on Resident #1, Resident #2, Resident #3, or Resident #4 and was unable to locate any documentation in the medical record to reflect notification of the responsible party of the change in condition of their family member. She stated staff were to document they contacted and change of condition for each resident. The Infection Control Preventionist stated she was new to her role and was not sure who had been responsible to contact the families during February and March 2023 to notify them of changes in medical conditions.
An interview with the former Infection Control Preventionist/Unit Manager on 5/31/23 at 11:17 AM revealed she was aware Resident #1, Resident #2, Resident #3, and Resident #4 had been diagnosed with COVID-19 during 2023. She stated she had made the DON and Corporate Nurses aware that procedures were not being followed when a resident tested positive, but nothing was done about it. She further indicated whatever nurse completed the testing for that week was assigned to notify the RP and if they were unable, they were to pass along that information to the DON to make contact. The former Infection Control Preventionist/Unit Manager said she had not been asked to contact any RPs for Resident #1, Resident #2, Resident #3 or Resident #4 and was unable to verify who was responsible for contacting the family during the February and March 2023. The UM indicated families were to be notified of all changes of medical condition and was unsure who was responsible for contacting Resident #2's family regarding the need to send him to the hospital for radiological studies.
An interview with the Director of Nursing at 10:00 AM revealed she was aware when each resident had been positive for COVID-19 and completed the documentation for the positive test for each of the resident (Resident #1, Resident #2, Resident #3, and Resident #4). The DON stated it was not the responsibility of the nursing department to notify the RP of the change of condition when a resident was diagnosed with COVID-19. The Director of Nursing explained the Social Services Department was responsible for notifying the RP when they called to notify the family of a room change to isolation. The DON reviewed the medical records for Resident #1, Resident #2, Resident #3, and Resident #4 and was unable to locate any documentation to reflect the RP was notified of COVID positive status.
Attempts to contact the former Social Worker were unsuccessful.
An interview with the Administrator on 5/31/23 at 4:40 PM revealed RPs were to be notified with each change of condition in a resident's medical condition by the nursing department.