Every finding on record at Aviata at the Sea - Harbor Beach

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions, and to prevent foodborne illnesses, during 2 of 2 tours in the central kitchen. The findings included: A review of the Food Safety Guide dated September 19, 2023, showed that raw chicken should be in the refrigerator for 1 to 2 days https://www.foodsafety.gov/food-safety-charts/cold-food-storage-charts.In a tour of the central kitchen conducted on 09/08/2025 at 9:08 AM, accompanied by the food service manager, the following issues were noted:The reach in freezer was noted with a pack of frozen meat patties that were not labeled and did not have the date of when the frozen meat patties were placed in the freezer, nor did they have an expiration date.The reach in freezer was noted with a bag of frozen turkey patties that was labeled but did not have the date of when the turkey patties were placed in the freezer, nor did it have an expiration date.The reach-in freezer was noted with three large pieces of raw chicken that were labeled but did not have the date of when the chicken pieces were placed in the freezer and did not have an expiration date.The reach-in freezer was noted with a bag of unidentified frozen raw meat that was not labeled and did not have an expiration date or the date that the frozen meat was placed in the reach-in freezer. The reach-in freezer was noted to contain a bag of 6 large pieces of raw chicken that was open and unlabeled. The bag did not have the date that the chicken pieces were placed in the freezer and did not have an expiration date. The reach-in freezer was noted with a large bag of unidentified frozen meat that was not labeled and did not have an expiration date or the date that the frozen meat was placed in the reach-in freezer.The reach in freezer was noted with a bag of frozen raw pork that was labeled but did not have the date when the pork meat was placed in the freezer and did not have an expiration date.The walk-in refrigerator was noted with a large box of raw chicken that was not labeled or dated. When asked when it was placed in the walk-in refrigerator, the kitchen manager said that he had put the chicken last Thursday, on 09/04/2025. He further said that it was used for Sunday's meal and that it was going to be used for tonight's meal.The walk-in refrigerator was noted with 10 pounds of pork loin, but it did not have an expiration date or the date that the raw meat was placed in the walk-in refrigerator. A Hydrion meter was used to check the sanitation solution in one red bucket, which showed that it was between 400 and 500 parts per million. This showed too much sanitation solution, with normal ranges between 150 and 400. The hot temperature dishwasher machine showed that the rinse cycle reached between 170- and 175-degrees Fahrenheit (F), and not the necessary 180 degrees or above. In an interview conducted on 09/08/2025 at 2:00 PM with the Kitchen Manager, he stated that he was told that the dishwasher needs to run a few times to reach 180 degrees and above before using it for dishes.In an observation conducted on 09/10/25 at 11:45 AM, Staff P, Cook, was noted in the food production area with no facial hairnet. He placed a facial hairnet during this observation, which covered his beard but not his mustache. In a second tour of the kitchen conducted on 09/11/2025 at 11:35 AM during the lunch tray line, the following were noted:A chocolate cream pie noted with an internal temperature of 50 degrees Fahrenheit (F) and another chocolate cream pie noted with an internal temperature of 50 degrees F. The remaining chocolate cream pies were placed on the individual's lunch trays. This was not at the appropriate temperatures of 40 degrees F and below. A steam table quarter-size pan of chopped pork loin was noted with an internal temperature of 125 degrees F, and not the necessary 155 degrees F and above for hot food. In this observation, the Kitchen Manager reheated the chopped pork loin and rechecked the internal temperature, which showed 158 degrees F and not the necessary internal temperature of 165 degrees F when reheating cooked pork loin that was cooked and cooled. The temperature of a cooked breaded chicken sandwich was taken using a facility-calibrated thermometer, showing an internal temperature of 85 degrees F. In this observation, the Kitchen Manager reheated the breaded chicken and checked the internal temperature. Further observation showed that the breaded chicken had an internal temperature of 115 degrees F after reheating, and not the necessary 165 degrees F or above. A pureed chocolate pudding was noted at 53 degrees F, and not the necessary 40 degrees F or below. In an interview conducted on September 11, 2025, at 3:00 PM with the facility's Administrator, he was informed of the findings.

Based on observation, interviews, and records review, the facility failed to ensure call lights were within reach for 3 of 25 sample residents (Resident #1, Resident #17 and Resident #22).The findings included:1. On 09/08/2025 at 10:48 AM, it was observed that a call light in the resident's room was attached to the back of Resident #22's bed's headboard. The observation prompted an interview with Resident #22 who reported through gestural confirmation, because of his tracheostomy, that he wanted to use the call light, but he could not reach it. Resident #22 affirmatively nodded, it was not the first time this situation occurred, when asked if that was the first time it had happened. To ensure that Resident #22 could use his hands, the Assistant Nurse Manager was immediately called to the room and was asked to hand the call light to Resident #22 and to have him press on it to activate it. Resident #22 successfully activated the call light.Resident #22 was admitted to the facility on [DATE] and was diagnosed with: Anoxic Brain Damage, Not Elsewhere Classified; Quadriplegia; Tracheostomy Status.Section GG of the MDS dated [DATE] documented Resident #22 had no impairment in range of motion for both upper and lower extremities. Section C was not assessed. Review of the Care Plan documented Resident #22 was at risk for falls. As preventive measures the CP outlined that staff would minimize risk of minor injury through the next review date. Also, the facility will make sure the resident's call light is within reach and will encourage the resident to use it for assistance as needed. At about 3:45 PM, on 9/10/2025, Staff N (registered nurse) was asked to come to the room to verify the position of the call light. Staff N acknowledged that the call light should not have been hanging by the bedside. She said the call light was not where it was supposed to be. Staff N also added that Resident #22 was totally dependent. Staff N said that Resident #22 could only use his call light, when it is reachable. Resident #22 could not roll from side to side. Therefore Resident #22's needs had to be anticipated. Staff N also said, they checked on Resident #22 every two hours. Staff N alleged that she saw Resident #22 about 20 minutes prior to the interview with her. Staff concluded when the call light is not within reach Resident #22 asked for it.2. On 09/09/2025 at 9:42 AM, an observation conducted in the resident's room revealed Resident #17's call light was on the floor. The call light was not within reach. The Resident said occasionally, when she requested her call light, they did not give it to her. During the interview, it was noted that Resident #17 could not see anything at all.During a follow-up visit to the Resident's room on 09/10/2025 at 3:45 PM, Resident #17's call light was again found on the floor. The resident was in bed sleeping.Resident #17 was admitted to the facility on [DATE]. Resident #17's diagnoses included Atherosclerosis; Mild Cognitive Impairment of uncertain or unknown etiology; Schizophrenia, Unspecified; Legal Blindness; Muscle Weakness (Generalized). The minimum data set (MDS) dated [DATE], section C revealed a score of 12/15 on the Brief Interview for Mental Status (BIMS). Section GG0115 of the MDS titled Functional Limitation in Range of Motion documented Resident #17 had No upper extremities impairments. The Care Plan (CP) dated 8/6/2025 documented Resident #17 was at risk for falls related to confusion, Gait/balance problems, periods of Incontinence, Psychoactive/ antidepressant drug use, Vision problems. The goals were to minimize the risk of falls through next review date; Minimize risk of minor injury through the next review date. As intervention staff would make sure Resident #17's call light was within reach and she would be encouraged to use it for assistance, as needed. 3. On 09/08/2025 at 11:01 AM, in the resident's room, Resident #1's call light was observed in a nightstand drawer. Resident #1 could not reach the call light due to physical limitations and contractures in both hands. Resident #1 said that the call light did not work the day before, Resident #1 said he had been trying to get someone to come to his room to lower the head of his bed, but he did not see, nor could he reach the call light. The bed control was also observed on the floor away from Resident #1. On 09/09/2025 at 11:24 AM, Resident #1's call light was observed attached to his bed and was also replaced by a softer touch call light instead of the push-button call light Resident #1 previously had.Review of the MDS revealed a significant change was processed on 8/4/2025. Section C of the MDS revealed Resident #1 obtained a score of 12/15 on the BIMS. In section GG0130 titled self-care documented Resident #1 had bilateral hands impairment. The CP dated 3/11/25 outlined Resident #1 was at risk for falls related to: Gait/balance problems and Incontinence. The goal was to minimize risk of minor injury through the next review date. To do so, Staff would make sure the resident's call light was placed within reach and Resident #1 would be encouraged to use it for assistance, as needed.The findings were reported to the Director of Nursing, the Corporate Nurse, and the Administrator during the initial observation and at the end of the survey on 9/13/2025.

Based on observations, interviews and record reviews, the facility failed to follow their own policy regarding grooming for Activities of Daily Living (ADL) for 1 of 21 sampled residents (Resident #40). The findings included: A review of the facility's policy titled, Grooming Activities, revised on 03/19/19, documented the following:o Grooming activities are provided to assist residents in meeting their physical needs as well as self-esteem needs.o Grooming activities shall be offered daily.o Grooming activities shall include, but not limited to: Shaving Combing hair Nail careA record review documented Resident # 40 was admitted to the facility on [DATE] with diagnoses that included Displaced Intertrochanteric Fracture of the Left Femur, and Muscle Weakness.An electronic record review of the annual Minimum Data Set (MDS) assessment, under Section C of the Brief Interview for Mental Status (BIMS), revealed a score of 13 indicating Resident #40 had no cognitive impairment.A review of the nursing care plan dated 09/06/24 revealed a focus noting Resident #40 had an ADL self-care performance deficit related to impaired balance, left hip/pelvis fracture and weakness.The nursing care plan interventions included bathing /showering: provide sponge bath when a full bath or shower cannot be tolerated; skin inspection: the resident requires skin inspection. In an interview conducted with Staff D, Certified Nursing Assistant (CNA), on 09/08/25 at 11:09 AM, who stated she has been working in the facility for 3 years. She stated she usually brings the shaving supplies inside the residents' rooms. She also brings whatever they need. She takes the supplies from the central storage rooms. She added that she uses a different blade for each resident, she puts them in plastic trash after usage. When she was asked if she offered to shave a resident assigned to her, she responded, No resident asked her for a shave.During an observation conducted on 09/08/25 at 2:14 PM, Resident #40 stated he requested facial shaving from a staff, but staff did not respond, did not provide him with shaving supplies or offered to shave him. An observation of the assignment board dated 09/08/25 revealed Staff E, Certified Nursing Assistant (CNA) was assigned to Resident #40.In another interview conducted with Resident #40 on 09/09/25 at 9:17 AM, he stated he is still waiting for a shave. He added that he asked the staff again, but staff did not respond or offered to shave him. When he was asked about the name of the staff, he responded, he does not know because she would not tell him her name.A review of the assignment board for 09/09/25 revealed that Staff D, CNA, was assigned to Resident #40.During another observation conducted on 09/09/25 at 12:19 PM, Resident #40 still had long facial hair around his mouth and chin. He added that no staff offered to shave him.In an interview conducted with Staff C, CNA on 09/09/25 at 3:36 PM, who stated she has been working in the facility for 20 years. When she was asked how she would know a resident needs shaving, she responded, By looking at the resident's face, I will know if he needs shaving.She added that when a resident refused to shave, she would try and asked the resident again at a later time. Sometimes a resident would ask her to stop shaving halfway, so she would listen to the resident.She added that she provides the shaving supplies, and she would do the shaving too, if the resident is not able to shave by himself.In an interview conducted with Staff B, CNA on 09/09/2025 at 4:40 PM, who stated she has been working in the facility for 4 years.When she was asked if she ever offered to shave Resident #40, she responded, she never had a chance to ask him. She added that she asked this resident before, but he refused to shave. She would ask him again today. During an observation conducted on 09/09/25 at 4:50 PM, Resident #40's face still had approximately 2 inches long whitish hair around his mouth and below his chin.In an interview conducted with Staff E, CNA, on 09/10/2025 10:23 AM, when she was asked why she provided facial shave to this resident, she responded, I saw his facial hair was about 2 inches long and asked the resident if he would like a shave, and the resident, responded, yes. She added that the 3:00 PM to 11:00 PM shifts staff are the ones responsible for providing showers, but because she saw the resident with long facial hair, she decided to give him a shower. She added that this resident also asked for a shave today. When she was asked what other personal care was provided to Resident #40, she responded, I gave him a shower today. When she was asked what shower includes, she responded, The staff washes from top to bottom. The hair is shampooed; the nails are cleaned including both fingernails and toenails.When she was asked if she was the staff assigned to Resident #40 on Monday, 09/09/25, she responded that she does not remember. When she was asked if Resident #40 requested a shave on Monday, she responded that she does not remember.

Based on observations, interviews, and record review, the facility failed to follow fall interventions and failed to complete a post-fall assessment for 1 of 5 sampled residents (Resident #23).The findings included:A record review revealed that Resident #23 was readmitted to the facility on [DATE] with diagnoses of Anemia and Muscle Weakness. The Quarterly Minimum Data Set, dated [DATE] revealed Resident #23 had a Brief Interview Mental Status (BIMS) score of 04, which indicated severe cognitive impairment. An order dated 09/02/2025 for bilateral floor mats for safety.A review of the facility's policy titled Fall Management dated 07/29/2019 showed the following: the purpose of this policy is to identify residents at risk for falls and to establish and modify interventions to decrease the risk of future falls and minimize the potential for a resulting injury. Initiate post-fall documentation every shift for 72 hours. In an observation conducted on 09/08/25 at 11:00 AM, Resident #23 was noted in the bed with a fall mat folded on the right side of the bed and a fully opened mat on the left side of the bed. Further observation did not show that the bed was in the lowest position. In an observation conducted on 09/08/25 at 3:15 PM, Resident #23 was not in the room. The two floor mats were folded on each side of the bed. Further observation did not show that the bed was in the lowest position.In an observation conducted on 09/11/2025 at 9:55 AM, Resident #23 was noted in the bed with a fall mat folded on the right side of the bed and a fully opened mat on the left side of the bed. The Care plan revealed the following: Resident #23 has had an actual fall on 02/08/2025, 03/29/2025, and on 07/22/2025, with the following interventions in place: bed in low position initiated on 02/11/2025, bilateral floor mats placed for safety initiated on 07/22/2025 and determine and address causative factors of the fall. Further record review showed that post-fall assessments were conducted on 07/28/2025, which was 6 days after the actual fall on 07/22/2025.In an interview conducted on 09/10/2025 at 12:53 PM with the facility's Director of Nursing, she reported that after a fall, they need to assess the residents and ensure no injuries. They need to notify the family and the doctor and update the care plans for interventions. She further said that they complete a post-fall assessment every shift for 72 hours. In an interview conducted on 09/10/25 at 2:47 PM with Staff A, a Certified Nursing Assistant, she stated that Resident #23 was a fall risk and there are interventions in place. The bed needs to be in the lowest position, fall mats on both sides of the bed, and ensure the call lights are within reach and close to the Resident.

Based on observations, interviews, and record review the facility failed to attain weekly weights and identify significant weight loss in a timely manner for 1 of 3 sampled residents (Resident #55). The findings included:A review of the facility's policy titled Weighing the Resident, revised on 10/04/2021, showed the following: When there is a significant variance from the previous recorded weight, the scale should be rebalanced and the resident reweighted, and a licensed nurse should validate. It further showed to record the weight and alert the nurse to any significant change. A chart review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses of Anemia, Dementia, and Dysphagia. The annual Minimum Data Set (MDS) dated [DATE] showed Resident #55 with a Brief Interview of Mental Status (BIMS) score of 12, which is low to moderate cognitive impairment. In an observation conducted on 09/08/2025 at 12:13 PM in the main dining area, Resident #55 was eating her lunch meal. Further observation showed that she ate above 75% of her meal.A review of the weight history for Resident #55 showed the following:07/07/2025, weighing 162 pounds.08/05/2025 with a weight of 153 pounds.08/11/2025, weighing 150 pounds.08/11/2025, with a weight of 167 pounds, which was mismarked.09/05/2025 with a weight of 145.8 pounds.The above shows that Resident #55 experienced a significant weight loss of 5.5% in one month. The above shows that Resident #55 experienced a significant weight loss of 10% in approximately 2 months.The nutrition care plan revealed that Resident #55 was at risk for malnutrition related to advanced age and medical conditions. The resident will maintain adequate nutritional status as evidenced by maintaining weight, with no signs and symptoms of malnutrition, and consuming at least 75% of her meals. Monitor/record/report any significant weight loss: >5% in 1 month, >7.5% in 3 months, and >10% in 6 months.A review of the Nutrition assessment dated [DATE] revealed Resident #55 had a significant weight loss-a current body weight of 153 pounds, with a usual body weight of 160 to 165 pounds. To begin weekly weights for monitoring, and to start Med Pass (nutritional supplement) once a day, providing an additional 240 calories and 10 grams of protein.A follow-up nutrition note dated 08/12/25 revealed Resident #55 was on a weekly weight regimen due to significant weight loss, and the current body weight was noted at 167 pounds. In this note, the facility's Dietitian pointed out that the weight of 153 pounds on 08/05/2025 was erroneous and to continue weekly weight with Med Pass once a day. In this note, the Dietitian did not request a reweight to check the validity of the weight of 167 pounds and assumed the weight of 153 pounds was not correct.Further review of the weights for Resident #55 showed that no weekly weights were completed from 08/11/25 to 09/05/2025.A review of the Dietary progress note dated 09/09/2025 showed Resident #55 has a significant unplanned weight loss with suboptimal meal intake. Recommend starting Med Pass two times a day to provide an extra 480 calories and 20 grams of protein. It was again recommended to begin weekly weights for weight monitoring. In this note, The Dietitian reported that Resident #55 was tolerating her diet well and accepted the nutritional supplement well in the past. In an interview conducted on 09/10/25 at 9:43 AM with the facility's Dietitian, he stated that he puts the weekly weights in an internal sheet that gets adjusted periodically. This sheet is then given to the Director of Nursing (DON), and the nursing team takes the weights, and the weights are recorded in the electronic system. For any missing weekly weights, he will ask the nursing team. He further acknowledged that Resident #55 had a significant weight loss and was not sure as to why they did not have weekly weights in the system. According to the Dietitian, he assumed that the weight of 167 pounds was accurate for Resident #55 and that the weight of 153 pounds could not have been correct. Since Resident #55 was on weekly weights, he could see any weight loss trend if it happened.In an interview conducted on 09/10/25, at 10:15 AM with Staff A, a Certified Nursing Assistant (CNA) stated that Resident #55 requires assistance with all meals, specifically eating 75% of her meals for breakfast and 100% of her meals for lunch.In an interview conducted on 09/10/25 at 10:20 AM with the DON, she said that the Dietitian gives her and the Assistant Director of Nursing (ADON) a list of any residents who need weekly weights, and she splits the assignments between the nursing staff. There are no specific staff members who take the weekly weights. In the past two months, the weekly weights were given to the ADON, and she was in charge of putting the weights in the electronic system. In an interview conducted on 09/10/25 at 10:30 AM, with the ADON, she said that the weekly weights are given to any of the nursing staff or the DON. The Dietitian may ask for specific weights if needed, but she does not put the weekly weights in the computer system. She may remind the nursing staff that the weekly weights need to be done, but she does not oversee the weekly weights.

Based on observations, interviews, and record reviews, the facility failed to follow the professional standards for gastrotomy tube (G-tube) care and management for 2 out of 2 sampled residents (Resident #22 and Resident #52). The findings included: A review of a facility's policy titled, Medication Administration via Enteral Tube, with a revision date of 03/06/19, documented the following: Place disposable under pad or towel around the area of tube to limit spillage. Check for residual. Check for placement. Aspirate gently by pulling back on plunger of syringe plunger to check for stomach contents.1) Resident #22 was admitted to the facility on [DATE] with diagnoses that included Anoxic Brain Damage, Candidiasis, and Quadriplegia.A review of the recent Minimum Data Set (MDS) assessment dated [DATE], under section C of the Brief Interview for Mental Status (BIMS), documented that it was disabled.An electronic review of physician orders dated 08/19/25 revealed the following: Enteral feed every shift. Check for placement every shift. Enteral stoma care every shift. Check residual every shift and notify MD, if greater than 60 ml every shift.A record review of nursing care plan interventions documented to provide local care to G-tube site as ordered and monitor for signs and symptoms of infection.During observation of gastrostomy care on 09/09/25 at 10:25 AM with Staff G, RN on 09/09/2025 at 10:25 AM, she did not place a barrier after disconnecting the feeding tube from the end port of the G-tube, resulting in spillage on resident's right upper thigh. Staff failed to aspirate for residual, and failed to check the G-tube placement. Staff also failed to clean the G-tube tip and the area around the G-tube before putting back the resident's gown and bed cover. It was observed that the G-tube end tip did not have a cap.2) Resident #52 was admitted to the facility on [DATE] with diagnoses that included Cachexia, Muscle Weakness, Contracture of the Right Hand.An electronic review of MDS assessment dated [DATE], documented under Section C that Resident #52 had a BIMS score of 13 indicating she had no cognitive impairment.An electronic record review of physician order dated 06/30/25 documented for enteral, check residual every shift and notify MD if greater than 60 cc every shift.An additional review of a physician order documented Oxycodone 10 mg tablet, to give via PEG tube every 6 hours for chronic pain.During a medication administration observation on 09/10/2025 at 12:37 PM which was performed by Staff I, RN, the following were observed:Staff I, RN, crushed the medication tablet, then poured it into a medication cup. She prepared a cup of water and stated she needed to dilute the medication. She placed them on a Styrofoam tray. Staff entered the resident's room and stated she would perform hand washing.Staff I, RN did not clean the resident's meal table where she placed the Styrofoam tray. Staff donned gloves, but not Personal Protective PPE) gown. The resident raised her head up using the bed remote. Staff placed a syringe contained inside a plastic bag on top of the meal table. She pulled up the resident's gown, exposed the G-tube end tip and removed the detachable cap cover at the end of G-tube.She started to pour water into the G- tube opening without first performing aspiration to check for stomach contents.Staff I, RN did not verify the G-tube placement. She mixed the crushed medication pill with some water and poured the mixed solution by gravity into the resident's G tube using a syringe. When the medication solution was all in, Staff I, RN put the G- tube cap back. She wrapped the G-tube tip with a cotton towel found below the resident's abdomen, lowered the resident's gown, and covered the resident with a blanket. Staff I, RN threw out the Styrofoam tray and the cups used during the medication administration and returned the syringe inside a plastic bag. She removed her gloves and performed hand washing. Staff left the resident's room at 12:45 PM. When she was asked why she did not check the residual, she responded that she checked the residual during 9:00 AM medication administration. She added that checking for residual and G-tube placement is only done in the morning. A review of Resident #52's electronic Medication Administration Record (MAR) revealed there was no documentation of G-tube residual check at 9:00 AM.A further review of MAR revealed a check mark and 2 initials across enteral residual check at 12:00 PM, indicating Staff I, RN performed this process as ordered, but it was not observed during this medication administration. Staff stated that this was the only medication administered at 12:00 PM.In an interview with the Director of Nursing (DON) on 09/0925 at 3:13 PM when she was asked about the process of giving medications through the G-tube, she responded to wash hands, look at the physician order, apply barrier to cover resident, check the placement, pop a plunger from the syringe barrel. She added that the facility's policy for G-tube noted that the Staff must aspirate for stomach contents first and if more than 60 ml was obtained, do not flush the G-tube. She added that the gastric strip is not used in the facility, and the G-tube flushes are accomplished using gravity, The staff change the syringes for flushes every night, the cap is inside the package, and the Staff use them to cap the flushing syringe. She added that the facility staff use whatever G-tube end port cap that came in the package. She added that G- tube end port must be capped at all times.

Based on observations, interviews and record reviews, the facility failed to follow the professional standards of tracheostomy care and management for 1 of 1 sampled resident (Resident # 22). The findings included:A record review of the facility's policy titled, Tracheostomy Care, with a revision date of 08/2013, documented the following:Assess respiratory distress.a. Measure resident's oxygen saturation with pulse oximeter.b. Listen to lung sounds with stethoscope.c. Observe for asymmetrical chest expansion.A record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses that included Anoxic Brain Damage, Candidiasis, Quadriplegia and Chronic Respiratory Failure with Hypoxia and Hypercapnia.An electronic review of recent Minimum Data Set (MDS) assessment dated [DATE] under Section C, revealed that the Brief Interview for Mental Status (BIMS) score was disabled.A tracheostomy care observation was conducted on [DATE] at 10:10 AM with Staff I, Registered Nurse (RN) and Staff J, Licensed Practical Nurse (LPN).Both Staff donned on personal protective equipment (PPE) gown and gloves and performed hand hygiene either with hand sanitizer and with soap and water. Staff I, RN stated that the tracheostomy supplies she will be using are not expired. She added she would be using these supplies and dressings, sterile saline plastic containers, sterile T- drain sponges, inner tracheostomy cannula, and tracheostomy care kit. Both Staff had to be reminded to oxygenate the resident before the tracheostomy care. Staff did not apply the oximeter until they were reminded. Staff I, RN stated the oxygen saturation was at 95 %, 5 minutes before the tracheostomy care. Staff did not assess Resident #22's respiratory status by listening to lung sounds and did not observe for chest expansion. Staff did not set up supplies on the sterile field, Both Staff used clean technique in opening supplies like gauze, normal saline and tracheostomy care kit.Staff I, RN picked up the sterile gloves from the tracheostomy kit and donned them. She put a protective chuck over Resident #22's chest and put a T-drain gauze onto resident's neck. She changed the tracheostomy collar and washed her hands. Staff I, RN put on regular gloves and stated she would change the inner cannula. With regular clean gloves, she picked up a square box from the tracheostomy care kit and asked Staff J, LPN to pour normal saline solution into the box.She then placed the box with normal saline solution on top of the table (not a sterile field). Staff J, LPN opened the inner cannula box and put it on the table. The flap of the box went back to its closing position, indicating the sterility of the inner cannula was not maintained. Staff J, LPN did not keep the flap open for Staff I to pick it up using aseptic technique. Staff I, RN picked up the inner cannula using clean gloves (not sterile gloves). She then inserted the inner cannula into the tracheostomy site.Staff I, RN opened the suction tubing kit using clean gloves and picked up the sterile suction tubing. She dipped the tip of the suction tubing into the box with normal saline. She was asked if she will need to use sterile gloves.Staff I, RN opened another package of suction tubing on top of resident's abdomen. The suction kit came with only one sterile glove, so she asked Staff J, LPN to give her another kit. Staff I, RN opened another suction kit on top of resident's abdomen. She had a hard time donning the sterile gloves stating they are too small. The resident had a big cough, and productive light-yellow colored secretions came out and down the gauze pad.Staff I, RN inserted the suction tip inside the inner cannula tube using her right hand (she used the normal saline solution which was opened onto unsterile field). She stated she would keep the right hand sterile, and the left hand clean. There were more secretions that came out and Staff I, RN used the suction tip to suck the outside sections but inserted the suction tip inside the tracheotomy tube again. She was reminded not to do that. Staff J, LPN was reminded to oxygenate the resident. Staff I was reminded to check the oxygen saturation.

Based on observations, interviews and record reviews, the facility also failed to follow a physician order for a seizure medication and failed to follow the professional standards of nursing practice related to the rights of medication administration: the right time for 1 of 25 sampled residents (Resident # 26). The findings included: A review of the facility's policy titled, Oral Administration of Medication, with a revision date of 08/15/19, documented to review Physician's order (1).According to National Institute of Health, Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. In upholding patient safety, the 'five R's' of medication administration are followed.A guiding principle for one of the five rights is of the right time. The right time is ensuring that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms. https://www.ncbi.nlm.nih.gov/books/NBK560654/Based on multiple clinical studies, including those funded by the National Institutes of Health, levetiracetam (Keppra) and lacosamide (Vimpat) have shown comparable efficacy for treating focal-onset seizures. Key differences lie in their side effect profiles, mechanisms of action, and controlled substance status. Levetiracetam is not a controlled substance while Lacosamide is a schedule V controlled substance indicating a potential for misuse and dependence. It can also cause abnormal heart rhythms. https://pubmed.ncbi.nlm.nih.gov/40119876/1) A record review documented Resident #26 was admitted to the facility on [DATE] with diagnoses that included Seizure, and Cerebral Infarction due to unspecified Occlusion or Stenosis of the Right Anterior Cerebral Artery.An electronic review of the recent Minimum Data Set (MDS) assessment dated [DATE], under Section C of the Brief Interview for Mental Status (BIMS), revealed a score of 13, indicating Resident #26 had no cognitive impairment.An additional review revealed that on 09/10/25 at 11:07 AM, a physician order for Lacosamide oral tablet 50 mg by mouth, two times a day for seizures. An additional review of physician order dated 01/24/25 revealed Lacosamide oral tablet 50 mg by mouth, two times a day for seizures.During a medication administration observation with Staff G, RN on 09/09/25 at 9:44 AM, she stated that she would administer Lacosamide 50 mg for seizure. She added it is scheduled twice daily.A further record review of a paper documentation called Medication Monitoring Control Record (MMCR) for Lacosamide administration during the month of September, it revealed that it was administered with only a 4-hour interval on the following dates: On 09/03/25, 1 (one) pill was administered at 12:35 PM with the second pill administered at 4:32 PM, both by Staff K, LPN, indicating only a 4-hour interval between administrations.On 09/06/25, 1 pill was administered at11:03 AM, and the second pill at 4:00 PM, indicating only a 5-hour interval between administrations, with both pills administered by Staff I, RN.In a telephone interview conducted with Staff K, Licensed Practical Nurse (LPN) on 09/10/25 at 10:55 AM, she stated that she knew this resident, and is familiar with the anti-seizure medication Lacosamide. When she was asked what time she usually gives a medication that is scheduled twice daily, she responded, I work from 7 AM to 7 PM, so I would give 1 (one) in the morning, and the next dose would be given by the next shift nurses at night. She added that a medication scheduled to be given twice daily must have an 8-to-12-hour time interval. When she was asked about her process of documenting in the Medication Monitoring Control Record (MMCR), she responded that once she took a pill from the locked medication box, she would sign it out from the MMCR and would immediately administer it to the resident. When she was asked if she verifies the physician order for any anti-seizure medications, she responded, I check the orders, When she was asked why she gave Lacosamide for seizure on 09/03/25 at 12:35 PM and at 4:32 PM with only 4-hour interval between administrations, she responded that she did not know she did that. She added that the second dose should have been given by the night nurse after 8 to 12 hours from the first dose at 12:35 PM. In an interview conducted with Staff I, RN on 09/10/25 at 3:45 PM, she stated that she gave Lacosamide on 09/06/25 both at 11:03 AM and at 3:04 PM, indicating only a 4-hour interval between administrations. She acknowledged that the interval must be between 8 to 12 hours for a BID, or a twice daily scheduled medication. She added that she would pay more attention to physician orders and administer medications on the right time following the physician ordered interval. When she was asked if she reads and verifies the physician orders for medications, she responded, Yes.

Based on observations, interviews and record reviews, the facility failed to follow the professional standards of practice related to keeping the medication storage room free of facility staff's personal belongings. The facility also failed to ensure medications and supplies are properly stored for 1 of 21 sampled residents (Resident #53). The findings included:A review of facility's policy titled, Medication Supply Storage and Medication Disposal, with an effective date of 11/30/14, documented the following (ff): Central storage of medications is required for prescriptions, prescribed over -the counter medications and complementary and alternative medicine (CAM). Will be kept in a locked area, in their original labeled container and may not be removed more than 2 hours prior to scheduled administration. 1) During a tour of the medication storage room with Staff G, Registered Nurse (RN) on 09/09/25 at 10:06 AM, it revealed a big black unzipped purse sitting on the counter next to bags of residents' antibiotics. When Staff G, RN was asked why the big black purse was kept inside a medication storage room, she stated that facility staff leave personal items like lunch boxes, and purses inside the medication storage room. She added that staff do not have an area where they can keep their personal items because the facility is very small. The only place where they can keep their purses is inside the medication storage room. In an interview conducted with the Director of Nursing (DON) on 09/09/25 at 10:44 AM, she stated that facility staff are not allowed to keep personal belongings inside the medication storage room. 2) A record review revealed Resident # 53 was admitted to the facility on [DATE] with diagnoses that included Acute Osteomyelitis of the Left Ankle and Foot, Local Infection of the Skin and Subcutaneous Tissue, and Von Willebrand Disease. An electronic record review of the recent Minimum Data Set (MDS) under Section C of the Brief Interview for Mental Status (BIMS) revealed a score of 15 indicating Resident #26 had no cognitive impairment. A review of physician orders dated 09/02/25, documented to: cleanse left posterior-lateral leg with normal saline; apply Calcium Alginate, and abdominal pad; wrap with kerlix and secure with tape 3x a week, prn (as needed), every night shift, every Tuesday, Thursday, and Saturday for wound management. A review of nursing care plan revealed a focus that Resident #53 requires Enhanced Barrier Precautions related to venous wound requiring a dressing/covering and is at risk for Center for Disease Control and Prevention (CDC), Multiple Drug-Resistant Organism (MDRO). During an observation conducted on 09/08/25 at 9:49 AM, Resident #53 was sitting at the edge of his bed. He had a bulky wrapped dressing on his left foot. On the top left side of his meal table together with drinks and food packages was a big plastic bag of dressing supplies. The plastic bag was observed with pink containers of 15 ml normal saline solution, kerlix dressings, abdominal pads, and Vitamin D ointment in sachets. When Resident #53 was asked about the plastic bag of dressing supplies on top of his food, he responded that facility staff leave them there. He added that these dressing supplies are left over from the past dressing changes, and the staff will reuse them on the next scheduled dressing changes of his left foot. In an interview conducted with Staff I, RN, when asked if she keeps dressing supplies and medications at bedside, she responded, No, staff are not permitted to leave any unused dressing supplies and medications at resident's bedside. When she was asked if a resident is allowed to keep dressings and supplies in his room, she responded, No, no resident is allowed to keep dressing supplies and medications in his room. In an interview conducted with Staff J, Licensed Practical Nurse (LPN) on 09/11/2025 at 12:50 PM, she stated that she has been working in the facility for a long time. She stated that the only dressing supplies allowed inside a resident's room are the tracheostomy care supplies. She added that residents are not allowed to keep any medication and dressing supplies inside their rooms. In another interview with Staff J, LPN on 09/11/25 at 11:30 AM, when she was asked about a process the facility follows for a resident with foot dressing changes and with left over dressing supplies, she responded, The dressing supplies which are not used during the dressing changes are discarded, they are not put back in the dressing storage carts and are not kept in the resident's room.

Based on observations, interviews, and record reviews, the facility failed to follow the menus and preferences of 3 out of 3 residents observed during dining observations (Resident #34, Resident #1, and Resident #10). The findings included:1. A chart review revealed that Resident #34 was admitted on [DATE] with diagnoses of dysphagia and anemia. Magic cup (nutritional supplements) two times a day for lunch and dinner was ordered on 05/22/2025.The nutrition assessment dated [DATE] showed the following: Resident #34's Body Mass Index (BMI) was low for age at 16.8, and that weight gain was beneficial to the Resident. Recommendations were made for a large portion of protein with all meals and Magic cup supplements twice a day.In an observation conducted on 09/08/25 at 12:18 PM in the main dining room, Resident #34 was eating the lunch meal. Resident #34's meal ticket showed the following: a pureed diet, large entree portions, pureed broccoli florets, pureed dinner roll, pureed sour cream, orange cake, and a Magic cup supplement. Further observation of the lunch meal showed that the Magic cup was not provided, and only one scoop of the protein was provided on the plate, which was not a large portion. 2. Resident #1 was admitted to the facility on [DATE] with diagnoses of dysphagia, anemia, and parkinsonism. An order noted for regular diet dysphagia, mechanical soft large portions of proteins for lunch and dinner, dated 07/17/2025. In an observation conducted on 09/09/2025 at 12:13 PM in the main dining room, Resident #1 was eating his lunch meal. The lunch meal ticket was noted to have large portions of protein and ground baked ham. The meal plate was noted with only one scoop of meat and not the large portions of protein as ordered. 3. Resident #10 was admitted to the facility on [DATE] with diagnoses of anemia and dementia. An order was noted for dysphagia, advanced texture, regular/thin liquid consistency, and large entree portions with all meals, dated 3/17/2023. The nutrition assessment dated [DATE] showed that Resident #10 is at risk for malnutrition-related dementia, advanced age, limited mobility, chronic disease process, and comorbidities.In an observation conducted on 09/09/2025 at 12:14 PM, Resident #10 was in the dining room eating his lunch meal. The meal ticket was noted with dysphagia, advanced diet with a large entree. The lunch meal was noted with one serving of ground ham, 1/2 cup serving of baked sweet potato, and 1/2 cup of seasoned green beans. The meal plate did not provide the large entree as ordered by the Physician. In an interview conducted on 09/10/25 at 3:30 PM with the kitchen Manager, he stated that the diet aids on the tray line observe to make sure that the correct food items and portions are placed on the meal trays to match the diets on the meal tickets. It is also his responsibility to ensure that the correct items are on the meal trays. When asked about the double portion of meat, they will place two scoops of the meat (3 ounces each) on the meal plates. When the order calls for a large entree, they will provide significant portions of the meat, starch, and vegetables.

Based on observations, interviews, and chart review, the facility failed to provide food in a form to meet the needs of 2 of 2 residents on the Dysphagia advanced diet (Resident #55 and Resident #10). This has the potential to affect three residents on a Dysphagia advanced diet.The findings included:A review of the National Dysphagia Diet Levels was provided by the Kitchen Manager. The following was noted: Level 3 Dysphagia advance is characterized by a mechanical soft texture, such as moistened ground meats and fork-mashable fruits and vegetables. A chart review revealed that Resident #55 was admitted to the facility on [DATE] with diagnoses of Dementia and Dysphagia following a Cerebrovascular Disease. In an observation conducted on 09/08/2025 at 12:13 PM in the main dining area, Resident #55 was eating her lunch meal. The meal ticket was noted as follows: Dysphagia advanced diet, chopped roasted broccoli florets, chopped ground bruschetta chicken, parmesan noodles, dinner roll, sour cream, orange cake, and tea of choice. The meal plate was noted with ground chicken and two large broccoli florets, 2-3 inches in size, that were not fork-mashable. A chart review revealed that Resident #10 was readmitted to the facility on [DATE] with diagnoses of Alzheimer's Disease and Unspecified Dementia. In an observation conducted on 09/08/2025 at 12:20 PM, in the main dining room, Resident #10 was eating his lunch meal. The meal ticket was noted with the following: Dysphagia advanced diet, chopped roasted broccoli florets, ground bruschetta chicken, parmesan noodles, dinner roll, snickerdoodle cookie, 6 ounces of coffee, and 4 ounces of iced tea. The meal plate was noted with ground chicken and two large broccoli florets, 2-3 inches in size, that were not fork-mashable. In an interview conducted on 09/10/2025 at 3:30 PM with the Kitchen Manager, he stated that on the Dysphagia advanced diet, the meat is ground, and the broccoli needs to be chopped because of its texture. This diet is usually for residents who have problems with swallowing. He further said the only way to provide broccoli on this diet is to overcook it, which they do not. The diets are generated by their computer system, and the meal tickets will be printed with the specific diet consistency for each food item. In an interview conducted on 09/10/2025 with Staff M, Speech Language Pathologist, she said that for the Dysphagia advanced diet, the food needs to be chopped up and recognizable. The vegetables need to be cut into bite-sized pieces, and the broccoli needs to be in smaller florets with no stems.

Based on observation, interview, and record review, it was determined that the facility failed to dispose of garbage and refuse properly in 2 of 2 observations. The findings included: A review of the facility's policy titled Solid Waste Management dated 11/30/2014 showed the following: solid waste shall be handled and disposed of in a manner that shall ensure a safe and sanitary facility environment. An observation was conducted on 09/08/25 at 8:39 AM outside the main dumpster. Two large blue dumpsters were partially open, with numerous bags of garbage/trash broken open and spilling their contents outside the dumpsters. Further observation showed garbage, trash, medication containers, and medical waste products on top of the blue dumpsters. Further observations showed protective Equipment, gloves, and surgical masks were noted all around the garbage area. On 09/09/25 at 8:45 AM, an observation was conducted in the outside dumpster area, where one blue dumpster was found to be unsealed and contained garbage bags, food boxes, disposable plates, and other trash. The area around the blue dumpster was noted with dirty gloves and other trash. In an interview conducted on 09/10/25 with the Kitchen Manager at 2:30 PM, he stated that he oversees the garbage dumpster area and cleans around the area. When asked how often they empty the blue dumpster outside, he did not know.

Based on observations, interviews and record reviews, the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBP) for 2 of 15 EBP residents (Resident #4 and Resident #22). The findings included: According to the Center for Disease Control and Prevention (CDC), Enhanced Barrier Precautions sign post included the following: Everyone must clean their hands, including when both entering and leaving the room: Providers and Staff must also wear gloves and a gown for the following: high-contact care resident care activities, dressing, bathing-showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting: Device care or use; central line, urinary catheter, feeding tube, tracheostomy: Wound care with any skin opening requiring a dressing. https://www.cdc.gov/long-term-care facilities/media/pdfs/ 1) A record review documented Resident #4 was admitted to the facility on [DATE] with diagnoses that included Displaced Fracture of Medial Malleolus of Left Tibia, Gastrostomy Status, and Dysphagia, Oropharyngeal Phase. An electronic review of the most recent Minimum Data Set (MDS) assessment, under Section C of the Brief Interview for Mental Status (BIMS), documented a score of 7, indicating Resident #4 had severe cognitive impairment. An electronic review of physician orders dated 09/01/25, documented EBP related to percutaneous endoscopic gastrostomy (PEG) Tube. A further review of the nursing care plan dated 08/06/25, documented a focus on alteration in usual functional performance in mobility/transfer status, related to weakness. One of the interventions was to use a mechanical lift as a transfer device. During an observation conducted on 09/08/25 at 10:48 AM, two staff were not wearing personal protective equipment (PPE) gowns during a resident's mechanical lift transfer. Both exited Resident #4's room, with one staff member pushing the Hoyer lift out and with the other staff who went out with the resident. The Hoyer lift that used during the resident transfer stayed on the hall for the entire time without disinfection during the morning observation. In an interview conducted with Staff F, a Certified Nursing Assistant (CNA) on 09/10/25 at 4:02 PM, when asked why she did not don gown and gloves during the Hoyer lift transfer of Resident#4, she responded that EBP is followed only for residents with PEG tube and ostomy. She added that she did not remember to use gown and gloves during the transfer, but she performed hand hygiene before and after the transfer. When asked if she disinfected the Hoyer lift after resident's use, she responded, No one told me to disinfect the Hoyer lift after resident's use. She added that she has been working in the facility for 1(one) year and she had never disinfected a Hoyer lift or any machine after each resident's use. 2) Review of the facility policy titled Infection Prevention and Control Program provided by the Director of Nursing (DON) revised October 2018 documented in the Policy Statement: An Infection Prevention and Control Program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.The program is based on accepted national infection prevention and control standards. Review of the facility policy titled Dressings, Dry/Clean provided by the DON revised September 2013 documented in the Policy Statement: Purpose---of this procedure is to provide guidelines for the application of dry, clean dressings.Steps in the Procedure.2. Arrange the supplies so they can be easily reached.6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag.18. Discard disposable items into the designated container. Resident #22 was re-admitted to the facility on [DATE] with diagnoses which included Un-stageable Pressure Ulcer of the Sacral Region, Anoxic Brain Damage, Chronic Respiratory Failure, Quadriplegia, Tracheostomy Status, Gastrostomy Status and Hypertension. He had Mental Status indicative of----severe impairment. On 09/10/25 at 9:36 AM an un-stageable Sacral Wound Care dressing change, present upon admission to the facility on [DATE], was observed for Resident # 22 by Staff D, the assigned Licensed Practical Nurse. Staff D, was assisted with the wound care by Staff J, LPN/Unit Manager (UM). Both Staff D and Staff J were observed retrieving personal protective equipment (PPE) from the supply caddy hanging outside door of the resident's room in order to perform this procedure. During the Sacral Wound Care procedure, Staff D was first observed placing the resident's soiled wound care dressing that she had removed from his person and then placing it in the resident's regular trash can, which did not contain a red bag. Next, Staff D was then observed using her soiled gloves from the dressing change, in order to touch the outside and then reach inside in order to retrieve a 4 x 4 gauze pad pack from the clean dressing supply cart, located in the resident's room, without first removing the soiled gloves. On 09/02/25 the Physician's Order documented, Wound Care Procedure read as follows: Cleanse the sacrum with normal saline (NS), apply Collagen wound filler and cover with a dry dressing daily and as needed (PRN) and every other night shift for Wound Management. An interview was conducted with Staff D on 09/10/25 at 10:10 AM, regarding the fact that she was observed placing the resident's soiled wound care dressing that she had removed from his person and then placing it in the resident's regular trash can, which did not contain a red bag. And, the assigned nurse was then observed using her soiled gloves from the dressing change, in order to touch the outside and then reach inside in order to retrieve a 4 x 4 gauze pad pack from the clean dressing supply cart, located in the resident's room, without first removing the soiled gloves and Staff D, acknowledged that she should not have placed the soiled wound dressing in the regular, trash bag and that she should not have touched the clean resident room's dressing supply bin with her used soiled gloved hand. During an interview conducted with Staff J, on 09/10/25 at 10:21 AM regarding her having placed the regular, trash bag, with the soiled dressing, in the regular, trash can, instead of in the Biohazard bin and she acknowledged that she should have placed the soiled dressing, which was in the regular trash bag, into the Biohazard bin. Record review of the Resident #22's Enhanced Barrier Precautions (EBP) Care plan initiated 09/08/25 and revised 09/08/25 indicated Focus: Resident requires EBP related to the use of Indwelling device Tracheostomy, is at risk for a Centers for Disease Control (CDC) Multi-drug Resistant Organism (MDRO) infection with a dressing in place.Interventions:.Monitor for any signs or symptoms of infection. Goal: Resident #22 will have a reduced risk of obtaining/transmitting a CDC MDRO during review period. Record review of the Resident #22's Pressure Injury Care plan initiated 06/30/25 and revised 06/30/25 indicated Focus: Resident has pressure injury to the Sacrum related to History of Ulcers, Immobility.Interventions:.Administer treatments as ordered and monitor for effectiveness.Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Goal: Resident #22's pressure injury will show signs of healing and have minimal risk of infection by/through review date. The DON further recognized and acknowledged on 09/10/25 at 11:03 AM, that the soiled wound dressing should not have been placed in the regular, trash bag, the assigned nurse should not have touched the clean resident room's dressing supply bin. And, that the regular trash bag with the resident's soiled wound dressing should not have been placed in the regular trash bin the soiled utility room. But, placed in the Biohazard bin.

Based on review of policy and procedure, record review and interview, the facility failed to ensure that it followed physician's order for Intravenous (IV) antibiotic administration for 1 of 3 sampled residents observed, Resident #1. The findings included: Record review of the facility policy and procedure titled Physician's Orders provided by the Director of Nursing (DON) revised 03/03/21 documented in the Policy Statement: The center will ensure that Physician's orders are appropriately and timely documented in the medical record. Procedure: Admission Orders: Information received from the referring facility or agency to be reviewed, verified with the physician and transcribed to the electronic medical record .Routine Orders: A nurse may accept a telephone order from the Physician, Physician Assistant or Nurse Practitioner .For pharmacy orders, the nurse will notify the pharmacy per pharmacy policy by telephoning, faxing or completing the order electronically .to maintain an accurate medical record. Record review of the facility policy and procedure titled Administering Medications provided by the Director of Nursing (DON) revised April 2019 documented in the Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so .4. Medications are administered in accordance with prescriber orders, including any required time frame 7. Medications administered within one (1) hour of their prescribed time, unless otherwise specified 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending physician or the facility's Medical Director to discuss the concerns 21. If a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR) space provided for that drug and dose. Resident #1 was admitted to the facility on [DATE] with diagnoses which included Osteomyelitis---left ankle and foot, Anemia, Peripheral Vascular Disease (PVD), Infection of Multiple Drug Resistant Organism (MDRO)---Methicillin Resistant Staphylococcus Aureus (MRSA), Septicemia---Severe Sepsis without Septic Shock, Diabetes Mellitus Type II with Diabetic Polyneuropathy, Morbid Obesity, Gastroesophageal Reflux Disease (GERD), Neuralgia and Neuritis, Acidosis, Overactive Bladder, Rash/skin eruption, and Acute Respiratory Failure. On 10/10/29 the Patient Hospital Transfer Form documented, primary diagnosis: Severe Sepsis. Osteomyelitis needs IV antibiotics .Methicillin Resistant Staphylococcus Aureus (MRSA) of lower extremities .Contact Isolation Medication due near time of transfer/list last time administered Antibiotics date 10/10/24 time 1 PM pain level 7/10 on 10/10/24 at 12:40 PM .Skin condition: leg wounds A side-by-side record review of the Resident #1's Physician's Order Sheet for October 2024 was conducted with the Director of Nursing (DON) in which the following three IV antibiotics had been ordered by the Physician: 1) Originally, on 10/10/24 Cefiderocol Sulfate Tosylate (Fetroja) IV solution use 1.5 gm IV every eight hours for Sepsis administer over three hours; 2) On 10/13/24 Doxycycline Hyclate IV solution reconstituted 100mg use 100ml/hr. IV every twelve hours for Sepsis until 12/08/24---(substituted for Minocycline, per the DON); And, 3) originally on 10/10/24 Minocycline HCL IV solution reconstituted 100mg use 100 ml/hr. IV every twelve hours for Sepsis for four weeks---(substituted by Doxycycline, per the DON). Record review of the Nursing Progress Notes dated 10/13/24 by the DON, subsequently revealed the following: follow-up done on IV medication with pharmacy. Per Pharmacist they're out of Minocycline. Call placed to MD waiting on medication. Record review of the Resident #1's Base line Care plan initiated 10/10/24 indicated the following for Resident #1: Isolation for MRSA (wound) IV antibiotics Minocycline and Fetroja. Goals included: Infection will resolve .Medication and/or treatments as ordered and monitor for signs/symptoms or worsening of infection . However, further record review of Resident #1's Medication Administration Record (MAR) dated October 2024 did not document that any of the above IV antibiotic medications had been checked off, nor initialed/signed off to signify that any of the IV medications had been administered to Resident #1, as ordered by the physician, during the resident's three day facility stay, prior to her discharge from the facility. The only documentation recorded for any of these three IV medications was as: Other/See Nurse Notes---medication on order per pharmacy; with no further detailed information or explanation. Record review revealed that Resident #1 had the following abnormal lab work results dated 10/11/24, Complete Blood Count (CBC) with Differential---White Blood Cell (WBC) 17.2 High, Red Blood Cells (RBC) 2.89 low, Hemoglobin 8.3 low, Hematocrit 26.7 low, Mean Cell Hemoglobin count (MCHC) 31.2 low, Red cell distribution width (RDW) 17.7 high, Neutrophil % 82.1 high, Lymphocyte % 8.4 low, Neutrophil # 14.1 high, Monocyte # 1.2 high, Comprehensive Panel---Glucose serum 51 low, Blood Urea Nitrogen (BUN) 41 high, Chloride 111 high, Osmolality calculated 305.5 high, Calcium total 7.33 low, Total Protein Serum 5.0 low, Albumin Serum 2.3 low, Albumin/Globulin (A/G) Ratio 0.9 low, Alkaline Phosphatase 129 high and C-Reactive Protein (CRP) Quantitative 5.3 high. An interview was conducted with Staff A, a Licensed Practical Nurse, (LPN) on 12/02/24 at 10:31 AM, regarding Resident #1's ordered IV antibiotic medications that were not received for administration to the resident, and he acknowledged that the resident had at least two IV antibiotics ordered by her physician. However, he stated that despite two attempts to contact the facility's pharmacy to have the medications delivered, the IV antibiotic medications, had still not been delivered to the facility for administration to the resident, during his work shift. He also added that he had not notified the ADON nor the DON regarding the fact that the IV antibiotics had not yet been delivered to the facility from the pharmacy. During a telephone interview conducted with Staff B, an LPN, on 12/03/24 at 10:53 AM regarding Resident #1's ordered IV antibiotic medications that were not received for administration to the resident, she also acknowledged that the resident had at least two IV antibiotics ordered by his physician. And, she stated that she, too, contacted the facility's pharmacy to have the medications delivered. However, the medications had still not been delivered to the facility for administration to the resident, during her work shift. She added that she did not document any notification of the ADON or DON anywhere in the resident's record, and she ended by saying that she had no explanation as to why she did not follow-through with trying to obtain Resident#1's IV antibiotic medications for administration. During an interview conducted on 12/03/24 at 11:13 AM with the ADON, she stated that the facility's Admission's Department requested that she contact the facility's pharmacy, to see if the IV antibiotics (Minocycline and the Fetroja) were in stock, prior to the resident's admission to the facility. And, the ADON added that she was told by the pharmacy that they both were in-stock, but high cost. The ADON indicated that she relayed this message back to the Admissions Department, prompting the resident's admission to the facility. However, the ADON did acknowledged that, according to the October 2024 MAR, none of Resident#1's IV antibiotic medications had been administered to her, for the three day facility stay period. An interview was conducted with Staff D, facility Pharmacist, on 12/03/24 at 12:58 PM regarding Resident #1's ordered IV antibiotic medications that were not delivered to the facility for administration, she explained, in detail, by saying that the order for high-cost Fetroja 1.5 gm IV every eight (8) hours for Sepsis over 3 hours was sent to them via electronic order via Point-Click-Care (PCC) on 10/10/24 at 11:37 PM. Subsequently, she stated that the pharmacy received a cancellation order for the Fetroja by 10/11/24 at 5:54 PM, and another order was entered again and updated, due to non-delivery. The pharmacist stated that this medication was a high cost medication, and she went on to say that the pharmacy did send out the high-cost limit form via fax to the facility on [DATE]. However, she acknowledged that there was no specific staff attention noted on it; only a fax confirmation was received back to the pharmacy, that it was sent. The pharmacist stated that if this form is not completed and signed by the facility, and returned back to the pharmacy, then the pharmacy cannot send the medication to the facility. The high-cost authorization signed form was not e-mailed to the pharmacy, from the facility until the resident's last day in the facility on 10/13/24, by the facility's DON, as verbally corroborated by her, as well. The pharmacist stated that it learned that the Minocycline medication was not made available for the pharmacy. And, as result of this, the pharmacy recommended for the physician to switch to Doxycycline, which was not delivered to the facility until after the resident had already been discharged from the facility, according to the pharmacist. The pharmacist ended by saying that, she was not aware of any of the above until today. An interview was conducted on 12/03/24 at 1:15 PM with the facility's Medical Director and Attending Physician for Resident #1 regarding Resident #1's ordered IV antibiotic medications that were not delivered by the pharmacy and received into the facility for administration to the resident. The Medical Director stated that he didn't receive notification from the DON until 10/13/24, the third day of the resident's facility stay, in which he said that he was told that they were having difficulty getting the medication from the pharmacy. The Medical Director went on to say that he learned from the facility that the IV antibiotic had never arrived at the facility even after he switched the antibiotic. The Medical Director acknowledged that no IV antibiotic therapy treatment was administered by the facility to this resident. There was no detailed documentation in the facility's notes to indicate exactly why Resident #1's ordered IV antibiotics were not delivered and administered during her three day facility stay. The DON further recognized and acknowledged on 12/03/24 at 2:45 PM that none of Resident #1's IV antibiotic medications had been administered to Resident #1, as per the physician's orders; when they should have been.

Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 16 of 28 resident rooms, 1 of 2 community shower rooms, main dining room, ice machine room, and 1 of 1 clean linen storage rooms. The findings included: 1) During the observation of the commercial ice machine room which is located in a room just off the main dining room on 05/07/24 at 1 PM accompanied with the Corporate Housekeeping Director (CHD). The floor of the entire room was heavily soiled and stained black in color. Further noted the floor area was missing around the commercial ice machine and there was a large gap under the exit door to the outside that could potentially allow entrance of pests into the facility. Photographic Evidence Obtained. 2) During the observation of the facility's laundry room department on 05/07/24 at 2 PM and on 05/08/24 at 2 PM, accompanied with the facility's Corporate Director of Housekeeping (CDH), the following were noted: * Upon entering it was noted that the door (barrier) between the soiled room and the wash room was wide open. The CDH stated that the air-conditioning stopped working in the laundry department a few days ago and the door is left open for circulation for the employees working within the laundry areas. The CDH stated that the door is required to be closed at all times as a infection control barrier between the soiled and clean area. * The entire floor area of the soiled/sorting room was noted to be heavily soiled, large black stains, and areas of peeling paint. It was discussed with the CDH that the floor is not being properly cleaned on a daily basis. * The exterior of the large ceiling vent in air-intake vent located in the middle of the soiled room were noted to be heavily soiled and rust laden. * Washing chemicals were noted to be stored on wood and paper shelving and it was noted that the wood was covered in a black mold type matter. The floor area underneath the shelving was noted to have a heavy build-up of dirt and dust. It was discussed with the CHD that shelving should not be porous wood and should be metal or hard plastics. Further stated that the floor underneath the shelving is not being properly cleaned on a regular basis. * The walls and window of the soiled room was noted to be dust and dirt laden. * The floor and walls of the washing machine room was noted to be soiled and covered with a black substance. The floor area in front of the washing machine was noted to have a large area of peeling paint. The area behind the washing machines was heavily soiled with dust and dirt and is not being cleaned on a regular basis. Interview with the CHD noted 1 of the 2 washing machines has not been operational in the last 3 months. They stated administration is aware, however there has been no resolution. * The floor of the clean drying/folding room was heavily soiled and large areas of peeling paint. It was discussed with the CHD that the floor is not being maintained and cleaned on a regular basis. * Interview with the CHD noted that 1 of the 2 commercial dryers has not been operational since October 2023. They stated that the facility administration is aware but no attempt made to resolve the dryer issue. The lint vent of the operational dryer had a heavy build-up of dirt and dust and was not being cleaned per the facility policy of cleaning the lint vent every 2 hours. * The ceiling vent located above the clean linen folding table was soiled and build-up of black mold type matter. It was discussed with the CHD that the vent could contaminate clean clothes located below the vent. * Photographic Evidence Obtained. 3) During the observation of the Main Dining Room conducted on 05/08/24 at 11 AM and accompanied with the Administrator, the following were noted: * The ceiling frame located on the 2 long sides of the Dining Room were noted to have a build-up of yellow/brown matter. The administrator stated that it was old tape from an activity conducted in the dining room. * One of the ceiling light covers located over a dining room table was noted to have a large crack and piece missing. It was discussed with the administrator that the pieces of the cover could potentially fall onto the residents and their food while eating. * One of 5 ceiling light covers was noted to have a build-up of dried dead insects. * Photographic Evidence Obtained. 4) During the resident screening conducted by the surveyors on 05/06/24 and the Environment Tour conducted with the Administrator on 05/08/24 at 11 AM and accompanied with the Administrator the following were noted: * Clean Linen Room: Unlocked and not secured, 4 disposable razors stored on shelving, 12 ounce bottle of Hydrogen Peroxide located on shelf, room floor and walls (4) heavily soiled and stained. Interview with the Administrator at the time of the observation noted that the room is not being properly cleaned or secured on a regular basis. * room [ROOM NUMBER]: Exterior of over-bed tables (2) noted to be soiled and areas of peeling paint, room floors and walls soiled and in disrepair, and disposable razor on floor. * room [ROOM NUMBER]: Exterior of over-bed tables (2) noted to be soiled and areas of peeling paint, heavily rusted bed frame (Bed-2), Electric Bed not working (Bed-1), and room walls scuffed and in disrepair. * room [ROOM NUMBER]: Room floor and wall base boards soiled, stained, and in disrepair. room [ROOM NUMBER]: Large area room wall damage, IV pole and base heavily soiled and rust laden, privacy curtains (2) areas of dried brown matter, bathroom floor soiled and stained black, bathroom emergency call light activation cord wrapped around the wall hand rail. room [ROOM NUMBER]: Exterior of bed frame rust laden (Bed-1) , exterior of over-bed tables (2) soiled and areas of peeling paint, room walls and floors heavily stained and soiled. room [ROOM NUMBER]: Room baseboards missing, large hole in room walls, room floor and walls soiled and in disrepair. room [ROOM NUMBER]: Bathroom emergency call pull cord wrapped around bathroom hand rails, exterior of over-bed tables soiled and areas of peeling paint, bathroom noted offensive urine odor. room [ROOM NUMBER]: Bathroom toilet continuously running, bathroom toilet paper holder broken off of wall, exterior of over-bed tables soiled and areas of peeling paint, bedside table missing bottom drawer (Bed -1). Community Shower: Three of 4 ceiling lights not working. Biohazard Room: Internal cavity of specimen refrigerator had a heavy ice build-up. room [ROOM NUMBER]: Exterior of bathroom door damaged and in disrepair, bathroom emergency call light cord wrapped around handrail, exterior of over-bed tables (2) soiled and areas of peeling paint. room [ROOM NUMBER]: Walls soiled, damaged, and in disrepair. room [ROOM NUMBER]: Walls soiled, damaged, and in disrepair, room closet wardrobe closet missing door opening knobs,(Bed-1), pull chain for over-bed light missing (Bed-1). room [ROOM NUMBER]: Privacy curtains (2) soiled with dried brown matter, and room walls soiled, damaged, and in disrepair. room [ROOM NUMBER]: Offensive urine odor coming from room into resident hallway, and room walls soiled, damaged, and in disrepair. room [ROOM NUMBER]: Room walls soiled, damaged, and in disrepair, and bathroom toilet noted to be black stained and requires re-caulking to the floor, room [ROOM NUMBER]: Two large holes in room wall, bathroom door opening handle broken, bathroom walls and tiles stained black, and exteriors over-bed tables (2) soiled and areas of peeling paint. room [ROOM NUMBER]: Poor TV reception (Bed-2) , room walls soiled, damaged, and in disrepair, and exterior of over-bed tables soiled and areas of peeling paint. Outdoor Patio: Numerous (5) large potted plants noted to be dead, entire floor area noted to have peeling paint, and rust laden wall fan, large hole at the entrance exit door (12 inches across by 3/4 inch deep - trip/fall hazard). Following the 05/08/24 Environment Tour the findings were again reviewed and confirmed with the Administrator, and were also discussed with the facility's Corporate District Manager. It was discussed that the facility does have a computerized TELS system for reporting of housekeeping and maintenance issues , however staff require retraining of the system. It was also noted that there is a Housekeeping/Maintenance Log located at the Nurses Station for staff to report issues. Further stated staff are not reporting and documenting housekeeping and maintenance requests.

Based on observations and interviews, 5 of 14 sampled residents (Resident #4, Resident #14, Resident #19, Resident # 30, and Resident # 33) were noted to be treated in an undignified manner by the facility. The findings included: 1) On 05/06/24 at 1:44 PM, Resident #14 was observed sitting in a wheelchair appropriately dressed in his personal attire. Resident #14's feeding formula was infusing via a tube. The privacy curtain dividing Resident #14 from his roommate, who also was observed in bed eating lunch, was fully opened. Resident #14 could easily see Resident #33's meal and did see Resident #33 eating his lunch. Resident #14 was admitted to the facility on [DATE]. Resident #14 diagnoses included: Cerebral Infarction and Flaccid Hemiplegia affecting right non-dominant side. Resident #14 is fed via peg tube. He is non-verbal and communicates using facial gestures, his hands, and head (nodding yes or no). Resident #14 gestured his displeasure on 05/06/24 at 1:47 PM to question, how do you feel watching your roommate eating? He used his hand to express his emotional feeling gesturing the cutthroat sign. To be sure, the Surveyor asked Resident #14 to gesture like or dislike by head movement. When asked if he liked seeing his roommate eating, he gestured no with head movement, and made a grimacing look of disapproval. He was asked if he would like the curtain closed, he gestured yes with head movement. Review of the physician orders for the month of May 2024 confirmed orders for enteral feeding for Resident #14. The Nursing Care Plan dated 3/21/24 documented that Resident#14 depended on staff for meeting his emotional, intellectual, physical and social needs. 2) On 05/06/24 at 1:19 PM, Resident #33 was observed in bed lying on his back and wearing an institutional or a facility's gown. With the Resident's permission, the Surveyor observed that Resident #33 had personal clothes in his closet. Resident #33 was noted to be non-verbal. He smiled when spoken to but quickly presented a flat affect or non-expressive facial appearance. On 05/06/24 at 1:44 PM during lunch, Resident #33 was observed in bed in a seating position eating but wearing the same gown. Meanwhile, his roommate was observed appropriately dressed and seating in a wheelchair while his meal was being infused. On 05/07/24 at 2:21 PM, Resident #33 was observed lying in bed wearing a green institutional gown. Resident #33's body rested in a supine position or on his back with his head slightly elevated and watching television. On 05/08/24 at 1:12 PM, Resident #33 was observed wearing a green institutional gown in bed in the same position as previously noted. On 05/09/24 at 1:44 PM, Resident #33 was observed in bed wearing an orange color shirt and laying in bed watching Television. Resident #33 was admitted on [DATE] and his diagnoses included: Cerebral infarction; Flaccid Hemiplegia affecting right nondominant side; Adjustment Disorder; Generalized Anxiety Disorder; Major Depressive Disorder. The Care Plan dated 3/21/2024 showed that Resident #33 depended on staff for meeting emotional, intellectual, physical, and social needs related to disease process. Resident #33 had communication problems related to stroke, he rarely responds verbally. Staff will anticipate his needs and be conscious of the resident's needs. On 05/08/24 at 3:45 PM, an interview with Employee A, a Certified Nursing Assistant (CNA) revealed that she has been working at this facility for two years. She said that they usually float or rotate throughout the facility. She said that Resident #33 has his own clothes. The CNAs who works in the are supposed to dress the patients and when she comes in the afternoon, she would undress the patients and put night gown on them. She said that Resident #33 can eat by himself, but he is not able to turn or transition from lying down to sitting by himself. He cannot speak. Resident #33 tries at times to say some words, but he is not clear. Employee A said that as a CNA they must anticipate Resident #33's needs. 01948 3) During the observation of the lunch meal conducted in the main dining room on 05/06/24 at 12:15 PM, it was noted that Resident #4 was seated at a dining room table with another resident, and also noted that 17 residents were in attendance in the dining room for the lunch meal. Further observation of Resident #4 noted that the resident was served a Consistent Carbohydrate Diet/No Added Salt Diet with Large Portions. Further observation noted that the staff (Staff E) set the meal tray in front of the resident and left to attend to other residents. It was noted that the resident was alert with confusion and begin to eat the entire meal with her bare hands that included Cheesy Ham & Macaroni Casserole , Sauteed Spinach Carrots, and Pineapple Crisp. Further observation noted that there were 4 other staff in the dining area serving and assisting other residents, however no attempt was made by facility staff to intervene and try to supervise the resident utilizing silverware provided on the meal tray. During the meal it was noted the food covered the resident's face, front of chest, table, and floor with spilled foods from eating with bare hands. It was noted that several residents seated near the resident during the meal and complained to staff concerning Resident #4, however no staff responded to the resident's request. During the observation of the lunch meal on 05/08/24, it was again noted that Resident #4 ate the entire meal without staff intervention. Also noted that several residents complained concerning Resident #4, however staff did not respond. Resident was noted to eat Pork Chop, Rice, and Corn with bare hands. Resident again noted to cover face with foods, front of body, table, and floor with spilled foods from eating with bare hands. A review of the clinical record of Resident #4 noted the following: < Date Of Admission: 5/18/21 < Diagnoses: Schizophrenia, Bipolar Disorder, Diabetes Type 2 < Current Physician Orders: * 9/27/21 - CCD/NAS/Large Entree 11/29/21 - Scoop Plate with all meals * Current MDS: 1/27/24 Section B : Usually understood & understands Section C: BIMS = 6 (cognitive impairment) Sec GG: Eat = Set Up Sec K : 67/165# Therapeutic Diet * Weight History: 4/16 = 161 2/6 = 165 1/4 = 171 BMI= 25.2 Ht = 67 Care Plan Review: 3/21/24 * * Assistance Daily Living: scoop plate, *Provide Food from mug or cup - resident refuses or difficulty eating solid foods with solid foods 4) During the observation of the lunch meal in the main dining room of 05/06/24 at 12:15 PM, it was noted that Residents #19 and #30 were served a Pureed Diet by the LPN (Staff D). Further observation noted that the pureed foods were thin, watery, and running over the edge of the entree plate. Further observation noted that the CNA (Staff E) mixed both resident's pureed meal (entree, vegetable, and starch) in a brown slurry mix. The appearance and acceptability of the meal was poor. Further observation noted that Staff D turned to the surveyor and stated aloud in front of Residents #19 and #30 and the rest of the residents I don't know how anyone can eat that crap'. The residents were noted to eat less than 25% of the lunch pureed meal.

Based on records review and interviews, the facility failed to investigate an incident in which 1 of 1 sampled resident (Resident #15) sustained injuries of unknown origin. The findings included: Resident #15's electronic clinical record revealed he was readmitted to the facility on [DATE] and an initial admitted [DATE]. Resident #15 diagnoses included: Dislocation of left shoulder joint; Anxiety Disorder; Atherosclerotic Heart Disease; Type 2 Diabetes Mellitus; Osteoarthritis; Muscle weakness; Cognitive communication deficit; Difficulty walking; Convulsion; Depression; Localized swelling to left upper limb; History of falling. The Nurses' Progress Notes (NP's) dated 4/14/2024 at 7:07 AM, noted that Resident #15 was complaining of left-hand pain and swelling. the MD was notified, and an X-Ray was ordered. Another NP's notes dated 4/15/2024 documented that order received to send the resident to hospital for higher level of care and altered mental status. The 4/16/2024 NP's notes revealed that Resident #15 was hospitalized . None of the NPs' notes documented that Resident #15 had a fall injury. In fact, the NPs report did not document how the fall occurred. There was no indication of a comprehensive nursing assessment detailing Resident #15's pain level or injuries. Review of the SNF to Hospital transfer form dated 04/15/2024 revealed that Resident #15 had a fall on 4/13/2024. Staff documented bilateral shoulder pain to identify pain location. During an interview with the Regional Minimum Data Set (MDS) Coordinator on 05/09/24 at 10:03 AM, she reported that an X-ray was ordered on 4/14/2024 for Resident #15. She provided the evidence which outlined Resident #15's possible pain level. Review of the Radiology Results Report dated 4/14/2024 revealed an order to have 2-views of Resident #15's left elbow. The report further revealed that due to Resident #15's level of pain only a single frontal view of the left elbow could be performed. The single frontal view of the left elbow X-Ray showed no abnormalities. Recommendation was made to have additional views to better assess the resident's physical condition when Resident #15 could tolerate a lateral positioning of the arm. The hospital record dated 4/20/2024 documented that Resident #15 sustained a shoulder dislocation as per diagnoses listed in the record which included: Generalized weakness; Fall; Shoulder dislocation. Also, the record noted that Resident #15 had left shoulder dislocation reduced in ED (emergency department) on 04/16/2024, the exact date Resident #15 was transferred to the hospital. As per Orthopedic, Resident #15 was non-weight bearing on the left upper extremity. During an interview with the Director of Nursing (DON) on 05/09/24 at 11:45 AM, she said that she did not have any record of the resident injuring his shoulder while at the facility. she only had record of Resident #15's fall which occurred on March 6, 2024 which was a fall resulting in no injuries. When questioned further, the DON said that she did not conduct an investigation on the cause of Resident #15's transfer to the hospital. During an interview with the Social Service Director (SSD) on 05/09/24 at 1:32 PM, she reported that Resident #15's brother had planned for the resident to be discharged home on 4/11/2024. The SSD said that she had to inform Resident #15's brother, when she returned to the facility on [DATE] that Resident #15 had a fall and was sent to the hospital. The SSD said that one of the nurses had reported the incident to her. On 05/09/24 at 3:06 PM, an interview with Staff B, a Licensed Practical Nurse (LPN) who completed the SNF-to hospital transfer from and assessment confirmed that Resident #15 had a fall at the facility and was injured. Staff B said that during the assessment, Resident #15 guarded his shoulder and complained of severe pain. Staff B said that he spoke with Resident #15's brother and informed him that resident was sent to the hospital for altered mental status. Staff B added that Resident #15 wandered at times and said inappropriate things. Staff B was not sure how Resident #15's injuries occurred. Staff B said contrary to what he erroneously documented, Resident #15's pain level was not zero. Staff B said that he had reported the transfer and injuries to the facility's DON. The DON had inquired about Resident #15's vitals signs and who Staff B had notified.

Based on observation, interview, and record review, it was determined that the facility failed to provide assistance and supervision to maintain independent eating abilities for 2 (Resident #5 and #13) of 6 sampled residents reviewed for nutrition. The findings included: 1) During the observation of the breakfast meal of 05/08/24 at 8:30 AM, it was noted that the meal tray was observed to be delivered to the room of Resident #5. Continued observation noted that the resident was visually impaired but alert. Continued observation noted that the Certified Nursing Assistant (CNA- Staff E) set the tray on the resident's overbed table in front of the resident who was noted to be in a reclining position in the bed. The CNA failed to speak with the resident concerning where foods could be located on the meal tray or reposition the resident into an upright eating position in the bed. Further observation noted the CNA to leave the room and not return to give the resident supervision or assistance with the meal. The resident was noted to struggle to find foods on the meal tray and would utilize bare hands with pureed hot and cold tray foods. The resident was noted to get increasingly agitated and yelling out for assistance with eating. At 9 AM the CNA returned to the resident's room and took the meal tray away with the resident consuming less than 25% of the meal. A second observation conducted on 05/08/24 at 12:30 PM, and again noted the pureed meal served to the room of Resident #5. Continued observation again noted the meal tray was set up on the overbed table in front of resident and the CNA left the room. Continued observation for the next 30 minutes noted no nursing staff entering the room to supervise or assist the resident with the lunch meal. Resident noted to be eating pureed foods with bare hands resulting in spilling pureed foods on body, bed, and floor. At one point during the observation the straw provided in the cold beverage became lodged into the resident's mouth and was noted to struggle to remove. The surveyor intervened and helped remove the straw to prevent choking. It was again noted that the CNA removed the tray with the resident consuming less than 25% of the lunch meal. Review of the clinical record of Resident #5 noted the following: * Date of Admission: 4/23/21 * Re-admission: 3/19/24 * Diagnoses: Legal Blindness, Post Traumatic Stress Disorder, Gastrostomy Disorder * Current Physician Orders: 5/7/24 - Osmolyte @75 ml/hr X 20 hours - on at 2 PM - off @10 AM 5/7/24 @ 8 AM - Osmylyte 75 ml/hr running 5/7/24 - Flush water @ 25 ml /hr X 20 hr 4/27/24 = Dysphagia Pureed Diet * Current MDS: 3/24/24 < Section B: Understood & Understands < Section C: BIMS = 13 (alert & oriented < Section D: No Mood Issues < Section GG: Supervision & Assistance < Section J : 67/170# < Feeding Tube/Mechanically Altered Diet * Review of current Care Plan : 03/24/24 < Requires Tube Feeding < Nutritional Problem - Risk For Malnutrition * NO interventions for assistance with independent with eating < Visual Impairment * No interventions for eating * Weight History : < 4/11/24 = 160# < 3/28/24 = 165.5# < 02/23/24 = 170# < 9/8/23 = 172# < 8/11/23 = 174 2) During the observation of the breakfast meal of 05/08/24 at 8:35 AM, it was noted the meal tray was served to the room of Resident #13. It was also noted that Resident #13 resides in the same room as Resident #5 and was also noted to be visually impaired and alert. Continued observation noted the resident to struggle finding foods located on the tray and ate with hands/fingers. The resident was noted to request assistance but the room door was shut and no staff were noted to assist or supervise the resident with the breakfast meal. The meal was taken away approximately 30 minutes later and it was noted the resident to consume less than 50% of the breakfast meal . A second observation conducted for the lunch meal of 05/08/24 at 12:30 PM noted the Consistent Carbohydrate/No Added Salt diet meal tray was already served to the room of Resident #13. The observation noted that the tray was set up on the resident's overbed table, however the resident was laying flat in the bed and was naked from the waist down. The resident was noted to be visually impaired and was reaching up from the bed over the overbed table and into the meal tray. The resident was noted to grab whatever foods she could and drop foods into her mouth. Spilled foods were noted all over the resident's face, body, and bed. At this time, the surveyor summoned the Director of Nursing (DON) to the resident's room to view the surveyor's observations. The DON confirmed the surveyor's findings and stated that all nursing staff would require in-service training on providing Resident #5 and #13 with assistance and supervision with all meals. During the review of the clinical record of Resident #13, the following were noted: * Date of Admission: 4/9/21 * Re-Admission: 8/15/21 * Diagnoses: Legal Blindness /Glaucoma * Current Physician Orders: < 10/1/21 - Carbohydrate Controlled Diet/ No Added Salt Diet < 3/24/23 - Fortified Food at Lunch < 12/13/21 - Scoop Plate < 10/1/21 - HS Snack < 9/19/23 - Dietary Counseling/Surveillance * MDS: 3/20/24 Section B : Understood & Understands Section C : BIMS = 13 (some cognitive impairment) Section D: Depressed Mood/Sec GG: Set Up - Assistance Section K: No Swallow Disorder 67/137# Weight History: 4/26/24 = 137# 1/3/24 = 139# 10/25/23 = 143# 9/8/23 = 150# Ht = 67 BMI = 21.5 Care Plan Review : 1/13/23 * Nutritional Problem-Resident is Legally Blind * No documented intervention of maintaining independence of eating with blindness. * Self Care ADL Deficit: * Able to feed with set up and assistance , requires scoop plate. * Requires and provide food from mug - difficulty with solid food. Following the Care Plan review with the Director of Nursing on 05/08/24, it was noted that the dietary and nursing staff were unaware of the care plan intervention to provide all foods in mugs to maintain independence with eating. Also discussed no interventions of assistance with eating during meals with diagnoses of blindness.

36734 Based on observation, interview, and record review, the facility failed to identify and treat a resident with Diabetes for 1 of 1 resident reviewed for insulin (Resident #17). The findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus Type 2 and a Diabetic foot ulcer. A comprehensive assessment dated [DATE] documented the resident was cognitively intact (15/15 Brief Interview for Mental Status), and required partial/moderate assist for activities of daily living. The assessment further documented Resident #17 had not received any injections (insulin) since admission to the facility. Record review revealed Resident #17 was care planned for Diabetes, with an intervention to medicate as ordered. A review of Resident #17's orders on 05/08/24 revealed Resident #17 did not have any medications for Diabetes, nor any fingersticks or lab results indicating the resident's blood sugar levels. An interview was conducted with Resident #17 on 05/08/24 at 11:00 AM. The resident was observed ambulating to her room. Resident #17 stated she was concerned because she was not receiving any insulin, or getting her blood glucose levels checked. The resident stated she was a Diabetic, and had received insulin while in the hospital prior to admission to the facility. Resident #17 further stated she had brought it up to staff/nurses, and was told they needed an order to check the resident's blood sugar. An interview was conducted with the Director of Nursing (DON) on 05/08/24 at 11:20 AM. The DON confirmed Resident #17 had a diagnosis of Diabetes. The DON further confirmed the resident did not have any orders for fingersticks or labs to monitor the resident's blood glucose, nor any medication to treat the resident's Diabetes. A progress note dated 05/08/24 at 12:10 PM by the DON documented: Spoke with MD in regard to patient concern with BS levels, lab, and diagnosis. Orders received for stat labs, Lispro (insulin), Lantus orders (insulin), Metformin (diabetic medicine), and blood sugar checks daily. An interview was conducted with Resident #17 on 05/08/24 at 12:30 PM. The resident stated they checked her blood sugar and it was 446 (normal is 74-109). An interview was conducted with the DON on 05/08/24 at 1:00 PM. The DON confirmed Resident #17's blood sugar was 446, the resident received insulin and the physician had ordered diabetes medication and stat labs. An interview was conducted with the Medical Director of the facility, who was also the Resident #17's Primary Care Physician (PCP) while at the facility, on 05/08/24 at 2:30 PM. The PCP stated, It's very horrible that the resident fell through the cracks. The PCP stated the resident refused labs at one time, but he did not follow up with it. The PCP stated the resident did not refuse accuchecks/fingersticks, as none were ordered. The PCP stated nothing was communicated to him about the resident requiring or asking for her blood sugar to be checked. All the staff had to do was call him. The PCP stated, We'll take care of her now. An interview was conducted with Staff F, a Licensed Practical Nurse, on 05/08/24 at 2:35 PM. Staff F stated he was Resident #17's primary nurse, and had cared for the resident before. When questioned by the surveyor if he knew the resident was a Diabetic, he stated, No, because the resident did not have any medications ordered for Diabetes. Staff F further stated Resident #17 did not ask him to check her blood glucose level.

Based on observations, records review, and interviews, the facility failed to provide physician's ordered left hand splint to 1 of 1 sampled resident (Resident #14). The findings included: On 05/06/24 at 12:48 PM Resident #14 was observed in bed lying in supine position with contracted left hand and having no splint on. Resident #14 was alert, aware, but non-verbal. Review of the physician's orders dated 12/17/2022 revealed the following order: left hand splint to be worn up to 6 hours, 7 days a week. Apply left elbow splint up to 6 hours 7 days a week. Another order noted: Left Elbow Splint as tolerated, may remove for ADL care or skin checks. Also, Resident #14 to wear Carrot on left hand at all times except for hand hygiene and bathing. Resident #14's diagnoses included, Hemiplegia and hemiparesis following Cerebral Infarction Affecting left non-dominant side; Muscle weakness generalized; Amyotrophic lateral sclerosis; Contracture left ankle; Anxiety Disorder; Ankylosis left wrist; Mild Cognitive impairment of unknown etiology; Ataxia; Irritant Contact Dermatitis; Progressive Bulbar Palsy; Foot Drop left foot; Dysarthria and Anarthria. Review of the Care Plan dated 1/25/2024 documented that Resident #14 continues to wear adaptive devices related to contracture treatments prevention. Patient has a Left Lower Extremity brace. Patient has a Left upper extremity slim grip to the left wrist. Patient continues to wear adaptive devices related to contracture, treatment/prevention. Resident wears a splint on the left upper extremities. The Minimum Data Set (MDS) section C documented Resident #14 obtained a score of 11/15 on the brief interview for mental status (BIMS). Resident #14 nodded when interviewed on 05/07/24 at 3:00 PM that they did not put the splints on for him on 5/6/24. He gestured and also pointed out to where the splints were. The location Resident #14 pointed to was the dresser. On 05/08/24 at 12:39 PM Resident #14 was observed sitting in his wheelchair appropriately dressed wearing a left elbow splint and ankle brace, but Resident #14 had no wrist splint on. Resident #14 affirmed with a negative head nod that they do not put the wrist splint on for him. On 05/08/24 at 2:44 PM Resident #14's Power of Attorney (POA) informed that Resident #14 has been ill since 2013 and has resided at this facility since 2016. The POA said not all staff are as attentive to Resident #14's health needs as they should have been. The POA stated some of the staff put the splint on some do not. The POA also said that Resident #14 is very alert and his mind is very sharp. Resident #14 understands everything, but he is just a little forgetful, at times. On 05/08/24 at 3:54 PM, Staff A said that she has been working at this facility for two years. She said that they usually float and rotate throughout the facility. Staff A works 3-11 PM shift. She said that Resident #14 is on tube-feeding, he wears a splint; he is totally dependent for his care. She said that the splints are used to prevent contractures. Staff A said that Resident #14 has an elbow splint on the left arm and one ankle splint. He does not have any other splint. When questioned about the hand/wrist splint. Staff A said that Resident #14 used to have a hand splint but they do not use it anymore. Staff A added that sometimes they put it, sometimes, they do not. Staff A said that she does not put the wrist splint for Resident #14. The Certified Nursing Assistant (CNA) who works in the morning usually does it. Lastly, Staff A said that the facility used to have a restorative nurse responsible for that assignment, but that responsibility was now assigned to the CNAs.

Based on interviews, observations, record reviews and policy review, the facility failed to prevent neglect by failing to appropriately assess a resident as an elopement risk for 3 of 5 sampled residents reviewed for elopements (Residents #1, Resident #39, and Resident #6). Additionally the facility failed to implement facility Elopement Risk Evaluation/Assessment at the time of admission, facility failed to provide staff with instructions/policy procedure to communicate increase exit seeking behavior to identify need to increase supervision, failed to administer [CONDITION(S)] medications as ordered, failed to instruct staff on what to do if a resident exits the 8 doors in the facility, and failed to do elopement drills. These failures allowed Resident #1 to elope from the facility undetected on 10/12/21 between 7:00 AM and 7:05 AM. The findings included: The facility's Policies and Procedures titled Elopement/Wandering Risk Guideline effective date 09/21/2016 and revised on 08/01/2020 has an Overview To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. Process: Patient/Residents to be evaluated on admission, re-admission, 7 days post-admission, quarterly, with a significant change in condition, and elopement event using the risk tool. It further showed that if a patient/resident is identified as being at risk for elopement, the following steps are needed: complete an Elopement risk Alert and obtain a photograph, initiate individualized interventions based on Patient/Residents' risk, and document individualized interventions in the patient/resident Care plan and Kardex. If a wander monitoring system device is utilized, check the placement of the device every shift and functionality every day. The staff will need to maintain the Elopement Risk Alerts in an easily accessible location and complete routine elopement drills monthly and review in QAPI meetings. Record review revealed Resident #1 was admitted to the facility from an acute care hospital on 07/08/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident's Minimum Data Set (MDS) Comprehensive assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status of 11, which indicates moderate loss in cognitive ability and can be associated with poor decision-making skills. In Section E of the MDS, Resident #1 was assessed not to have wandering behaviors. In Section G of the MDS under Functional Status, Resident #1 needs supervision with walking in her room, corridor, and locomotion on and off the unit. Under Section N- medications, Resident #1 was assessed to take antipsychotic medication for the past 7 days, antianxiety medications for the past 7 days, and antidepressant medication for the past 7 days. Under Section P-restraints and alarms, the wander/elopement alarm was coded as not used. Another BIMS test was conducted on 10/13/21, which showed a new score of 13 out of 15, indicating intact cognition. Record review revealed a skilled nursing note dated 07/09/21 showed that Resident #1 was identified as an elopement risk. An elopement risk evaluation was conducted on 10/12/21, the day of the elopement incident, which was not done prior to that. The assessment showed a score of 4, which indicates that Resident #1 is at risk for elopement. Record review revealed Resident #1 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication [MEDICATION(S)] had blanks for the dates of 10/1, 10/2, 10/6, 10/7, 10/10, 10/11 at bedtime. The medication [MEDICATION(S)] 0.25mg had blanks for the dates of 10/1, 10/2, 10/6, 10/7, 10/10, 10/11 at 5:00 PM. [MEDICATION(S)] 100mg had blanks for 10/1, 10/2, 10/6, 10/7 for the bedtime doses. The medication [MEDICATION(S)] had blanks for 10/1, 10/2, 10/6, 10/7, 10/10, and 10/11/21 for the 5:00 PM doses. A review of the Elopement drills that were provided by the facility showed no indication that Wandering and Elopement in-services were given in September as listed on the Education Calendar for 2021. This surveyor was provided education in-service attendance reports for abuse/mistreatment dated 08/21/21 and Missing Resident/Elopement/Abuse dated 10/12/21. The facility also conducted elopement drills on 10/13/21 and 10/14/21 after the incident on 10/12/21. A closer review of the Elopement drills after 10/12/21 did not show an education that included: an outside search that needs to be done outside the facility as far as the eye distance from the alarming exit door as a point of reference. An interview was conducted on 11/4/21 at 2:00 PM with the facility's Director of Nursing, who was asked why there were blank spaces when the nurse's initials should be there, and she was unable to provide a reason why. Resident #1's care plan reveals a focus of Resident has potential for drug-seeking type behaviors. History of drug abuse and drug-seeking since admission. Date initiated 07/16/21. Interventions include Anticipate and meet resident's needs (dated 07/16/21), Educate resident on successful coping and interaction strategies (dated 07/16/21), and resident will not wander out of facility (dated 07/16/21). An additional focus of the care plan includes a focus of the resident is an elopement risk/wanderer related to impaired safety awareness (date initiated 07/15/21) with interventions that include actual elopement on 10/12/21 (dated 10/12/21), assess for elopement risk (date initiated 07/15/21) electronic monitoring to place on the resident (dated 07/15/21). In an interview conducted with Staff H, CNA, via telephone on 11/01/21 at 11:59 AM, she was asked about the incident on October 12, 2021. Staff H stated that she was leaving the facility when Staff G, a Licensed Practical Nurse (LPN) asked her to look for Resident #1 on her drive home. At approximately 7:15 AM, Staff H located Resident #1 by a Speedway gas station located on US-1 and 16th street. Staff H stated that Resident #1 was about to turn right onto Highway US-1 going North. The Resident was observed wearing sweatpants, a shirt, and sneakers and carrying her purse. Staff H pulled into the gas station and approached the Resident on foot. Resident #1 stated, I do not want to go back to the hospital. Staff H reported that Resident #1 did not recall her name but knew her by face. Resident #1 agreed to get in the car, and Staff H then brought her back to the facility at approximately 7:20 AM. Staff H further stated that Resident #1 was very restless the night before. During the night, she kept coming out of the room and asked to leave, and she had her shoes and purse. She asked to leave multiple times during the night shift and was monitored by staff. According to Staff H, Resident #1 was more anxious than usual. When asked about her cognitive status before leaving the facility, she reported that Resident #1 was confused. She also said that Resident #1 exhibited exit behaviors before her leaving on 10/12/21 but nothing to the extent of her leaving the facility. An interview with Staff E, Certified Occupational Therapy Assistant (COTA), was conducted on 11/01/21 at 12:15 PM. Staff E stated that on 10/12/21, between 7:00 AM and 7:05 AM, she was in the gym working on her notes when she heard an alarm. She walked in the direction of the door that the alarm sounded from and poked her head out of the door but did not step out. The exit door was located between rooms [ROOM NUMBERS]. On her way to the exit door, she stated that the Resident in room [ROOM NUMBER]B told her that the skinny lady in room [ROOM NUMBER] was walking in the hallway toward the exit door earlier, but he did not see her leave. Staff E further stated that she returned to the nurse's station and alerted additional staff to what the Resident in room [ROOM NUMBER]B told her. She then asked Staff F, Certified Nursing Assistant (CNA), to check Resident #1's room to see if she was there. She did not call the police and is unsure if anyone called the police. The Director of Nurses and the Administrator had not arrived at the facility yet. Resident #1 was not located in her room or inside the facility. Staff immediately initiated a search of the grounds, including the parking lot. Staff G, who worked the night shift, went outside looking for Resident #1. In an interview with the Director of Maintenance on 11/01/21 at 4:25 PM it was revealed that the wanderguard will only lock the front door. Last Friday (10/29/21) they changed the whole wanderguard system but the keypads at the 7 other exit doors are not wired yet for the wanderguard system. The wanderguard will lock the door within 3 feet of the door and 15 pounds of pressure will open the door in case of fire. The Director of Maintenance is not sure when all doors will be fully wired for a wanderguard to be working on all 8 doors. In an interview conducted on 11/02/21 at 10:20 AM, with Staff J, Certified Nursing Assistant, she arrived at the facility at 7:00 AM, on the morning of 10/12/21. On her way to the nursing station, she heard from another staff that Resident #1 had escaped and that they listened to the alarm. According to Staff J, Resident #1 always says that she wants to go out and wants to leave and is known to be a little confused. On the morning of the incident, staff started looking for her outside and inside the facility. She was told to look for Resident #1 outside in the front parking lot of the facility. When asked if Resident #1 had a wander guard before she attempted to leave the facility, she said no. She further stated that because she had never left the facility before, she did not need one. According to Staff J, on 10/12/21, they did not have a supervisor in charge because it was too early. She further said that when she was educated on elopement, she was told to first check each room before searching outside the premises. Then you go out to look for the resident. When an elopement happens, they are supposed to tell someone in charge and follow the directions of the supervisor. Staff J stated that she did not participate in any elopement drills after 10/12/21. When asked as to how many exit doors does the facility have, she did not know. In a second interview conducted on 11/02/21 at 11:07 AM with Staff E, she stated that she was educated on elopement twice a year. The drills consisted of a code called BODYBEAR as an indication that a resident was missing. They needed to get to the nurse's station and receive the individual assignment from the supervisor. Once you have your instructions, you follow them and report your findings. On the morning of 10/12/21, she heard the alarm and told the nurses what the Resident in room [ROOM NUMBER] told her. She tried getting the staff around the facility to search for Resident #1, and she even looked outside the front of the facility. After the incident, the facility conducted an in-service on elopement which she did not participate. When she returned, she completed a test on elopement. According to Staff E, nothing new was part of the education, and that they re-educated staff on the same instruction you would follow if an elopement happened again. She did not know if the facility completed another drill after the incident on 10/12/21. When asked by the surveyor if she could see Resident #1 walking away when she peeked outside the door on 10/12/21, she said: I can see a partial view of the street, on both sides but more to the left. She then said Resident #1 must-have walked very fast. In an interview conducted on 11/02/21 at 11:57 AM, Staff K, Housekeeping, stated that on the day of the incident, she passed by room [ROOM NUMBER] to go to the nurses' stations. She is familiar with Resident #1, who usually comes out of her room at around 8:00 AM and goes outside the patio across from her room. On the morning of 10/12/21, she saw Resident #1 walking out of her room and did not think much of it. The next thing she heard was the alarm on the door. She walked in the direction of the sound and was told by Staff E, who was by the exit door, that Resident #1 had already gone and could not see her. She then started looking for Resident #1 around the building. She also reported that by the time she was ready to go into her car and drive around to look for Resident #1, another staff brought Resident #1 back to the facility. She could not remember when the last time was, she participated in elopement drills. When asked if this happened again: she said, they would not have to tell me anything; I would go looking for [Resident #1] right away. In an interview conducted on 11/02/21 at 12:15 PM with the Maintenance Director, he stated he helps with the elopement drills. He noted that elopement drills are conducted once a month for every shift. Before this year, they used to have a dressed-up teddy bear called BODYBEAR, which the facility would hide either inside or outside. Once announced, staff would have to come to the nurse's station to receive their assignments. Now they have changed the drills, they will call the name of the missing resident, and staff will follow the supervisor's instructions. In an interview conducted on 11/03/21 at 2:10 PM, during the Resident Council meeting, Resident #33 stated that when an alarm goes off in one of the 8 exit doors, there is no sense of urgency by staff. He further said that staff would take a long time before addressing the loud noise of the alarm. Resident #9 stated that the last time one of the alarm doors went off, it took staff 15 minutes to come to the door to check as to why the alarm sounded off. Record review of Resident #33 showed that he was initially admitted to the facility on [DATE]. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #33 has a Brief interview of Mental Status (BIMS) score of 15, which is cognitively intact. Record review of Resident #9 showed that he was initially admitted to the facility on [DATE]. A review of the Quarterly MDS showed that Resident #9 is with BIMS score of 15, which is cognitively intact. 2. Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a nursing progress note dated 08/01/21 revealed: patient attempted to go out the door re-oriented patient back to facility patient appeared to be confused. An elopement assessment was not completed on Resident #39 until 10/12/21, when it was determined that the resident was at risk for elopement. An interview with the Director of Nursing (DON) on 11/05/21 at 10:30 AM revealed there are no additional elopement assessments for Resident #39. A review of the resident's care plan for elopement risk initiated 10/12/18 and revised on 07/08/20 revealed the following: a focus of resident is an elopement risk/wanderer .history of attempts to leave the facility unattended .secondary to dementia . Interventions dated 10/12/18 and revised on 07/08/20 include identify a pattern of wandering, and provide electronic monitoring device (wander guard) date initiated 10/12/18 and modified on 10/20/21. An interview was conducted with the Minimum Data Set (MDS) coordinator on 11/05/21 at 11:00 AM, which revealed the original order for the wander guard is uncertain due to medical records dating back to his admission are not in the facility anymore. 3. Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly minimum data set (MDS) dated [DATE] revealed in section C a brief interview of mental status (BIMS) score of 13, indicating an intact cognitive response. A review of nursing progress noted date 08/23/2021 reveals Resident #6 was up and about pacing in the hallway. The resident appeared to be very anxious, screaming and yelling at staff, and very difficult to redirect. A call was placed to (Psychiatrist). New order received for [MEDICATION(S)] 0.25mg q 12 hrs. as needed (PRN) for anxiety. Noted and carried out. An interview with the DON on 11/05/21 at 10:15 AM reveals Resident #6 refused to have the wander guard put on his ankle, so they put it on the walker since he always uses his walker. Questioned the DON on why the wander guard was not put on when exit-seeking behaviors were identified on 08/23/21, and she stated that after he was seen by psych, he didn't have any more exit-seeking behaviors. The first elopement risk evaluation for Resident #6 was done on 10/13/21 and he was identified as at risk for elopement so the wander guard was placed on his walker on 10/13/21. An interview with Resident #6 on 11/05/21 at 10:45 AM revealed a wander guard on his walker. He further stated that he is not going anywhere because his legs are bad, and he would not get that far. Resident #6 also said that he wanted to leave when he was first admitted to the facility. He did not like the condition of the facility, but he knows now that he isn't going anywhere. The facility Immediate Jeopardy Removal Plan included: 1. On 10/12/21 The Director of Clinical Services and designee completed elopement risk assessments on all current residents to identify others that may be at risk. One new resident at risk was identified. 2. On 10/13/21 and 11/4/21 Elopement books were updated. 3. On 11/4/21, the Director of Clinical Services and designees-initiated education for Licensed Nursing Staff on completing the Elopement Risk Evaluation which is to be completed at the time of admission. This consisted of on-site education, phone education when available and education documentation if needed via mail. Education includes 18 licensed nurses. 4. On 11/4/21, the Director of Clinical Services was educated by the Regional Nurse Consultant on conducting New Admission Chart reviews during the clinical meeting. 5. On 11/4/21 The Director of Clinical Services and designee-initiated education for Licensed Nurses and unlicensed staff on Change of Condition policy and reporting to the Director of Clinical Services any event of exit seeking behaviors. Staff included are Therapy (7), Housekeeping/Laundry (5), Dietary (7), CNAs (28), and Nurses (18) Administrative/department heads (12). 6. On11/4/21 The Director of Clinical Services was educated by the Regional Nurse Consultant on initiating interventions related to increasing supervision needs. 7. Licensed staff and unlicensed staff including Therapy (7), Housekeeping/Laundry (5), Dietary (7), CNAs (28), and Nurses (18) Administrative/department heads (12), will be in-serviced on any new resident identified with exit seeking behaviors by the Director of Clinical Services and/or designees. 8. On 11/4/21 Licensed staff and unlicensed staff education were initiated on reporting and communicating resident exit-seeking behaviors to their supervisor. Staff included are Therapy (7), Housekeeping/Laundry (5), Dietary (7), CNAs (28) and Nurses (18) and Administrative/department heads (12). 9. On 11/4/21 - Licensed Nursing Staff education was initiated on the administration of anti-psychotic meds. Education includes 18 Licensed Nursing staff. 10. On 11/4/21 - The Director of Clinical Services/designee will conduct a daily audit of the Electronic Administration Record to ensure resident psych medication is documented as given, and/or documented for refusal. 11. On 11/4/21 The Executive Director and Director of Clinical Services were educated on determining the root causes specific to elopements by the Regional Vice President of Operations. 12. The Executive Director led an additional Quality Assurance and Performance Improvement meeting on 10/13/21 with the Executive Director, Medical Director, Director of Clinical Services, Social Services Director, Plant Operations, Activities, Dietary Supervisor, Housekeeping Supervisor, CNA, Business Office Manager, Therapy Director and Unit Manager present. The Elopement Policy and Procedures were reviewed, and the root cause of elopement was discussed. 13. An additional ad hoc quality assurance performance improvement meeting was held on 11/3/21 with the participation of the Center Medical Director, Executive Director, Director of Clinical Services, Social Services Director, Unit Manager, MDS Coordinator, Plant Operations Manager, Human Resources, Housekeeping Supervisor, Dietary Director, Therapy Director, and Activities Director. The plan along with the root cause for the incident was discussed and approved by the Medical Director. The Facility's policy on Elopement was reviewed during the QAPI meeting. 14. An ad hoc quality assurance performance improvement meeting was held on 11/4/21 with the participation of the Center Medical Director, Executive Director, Director of Clinical Services, Social Services Director, Unit Manager, MDS Coordinator, Plant Operations Manager, Human Resources, Housekeeping Supervisor, Dietary Director, Therapy Director, and Activities Director. The plan along with the root cause for the incident was discussed and approved by the Medical Director. The facility's policy on Abuse and Neglect was reviewed during the QAPI meeting. 15. Plant Operations and or Designee will be responsible for conducting monthly elopement drills. Results will be brought and reviewed during the Quality Assurance Committee meeting. 16. 10/12/21 8:30 am The Plant Operations Manager rounded in the facility to validate all exit doors were secure and alarms functioning properly.

Based on interviews, observations, record reviews and policy review, the facility failed to prevent a vulnerable resident with memory and cognitive deficits from exiting the facility unsupervised. The facility did not provide supervision to prevent an elopement of 1 of 5 sampled residents reviewed for elopement risk (Resident #1). The deficient practice allowed Resident #1 to elope from the facility undetected on [DATE] between 7:00 AM and 7:05 AM. The findings included: The facility's Policies and Procedures titled Missing Patient/Resident effective date [DATE] and revised on [DATE] has an Overview Staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. Procedure: Check Leave of Absence (LOA) book and Medical Record to ensure patient/resident is not on an authorized leave or medical appointment. Announce resident name) please return to your room, over PA system. Repeat three times to alert staff of a missing patient/resident. Assigned staff to search the grounds. If the patient/resident is not located after the initial search the point person will notify the Executive Director and Director of Nurses, Resident Representative, and Physician. The Executive Director and/or Director of Nursing or designee to notify local Law Enforcement. Upon return to the Center a physical evaluation will be completed to determine if further treatment is needed. Document in the Medical Record. Notify Physician, Resident Representative, Executive Director, Director of Nurses and Law Enforcement (if applicable) of patient/resident's return. Review and revise the interventions as indicated related to elopement and wandering risk and update the Care Plan and Kardex. Record review revealed Resident #1 was admitted to the facility from an acute care hospital on [DATE] with diagnoses that include [CONDITION(S)], [CONDITION(S)] Disorder, and Anxiety Disorder. The Resident's Minimum Data Set (MDS) Comprehensive assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicates moderate loss in cognitive ability and can be associated with poor decision-making skills. In Section E of the MDS, Resident #1 was assessed not to have wandering behaviors. In Section G of the MDS under Functional Status, Resident #1 needs supervision with walking in her room, corridor, and locomotion on and off the unit. Under Section N- medications, Resident #1 was assessed to take antipsychotic medication for the past 7 days, antianxiety medications for the past 7 days, and antidepressant medication for the past 7 days. Under Section P-restraints and alarms, the wander/elopement alarm was coded as not used. Another BIMS test was conducted on [DATE], which showed a new score of 13 out of 15, indicating intact cognition. Record review revealed a skilled nursing note dated [DATE] showed that Resident #1 was identified as an elopement risk. An elopement risk evaluation was conducted on [DATE], the day of the elopement incident, which was not done prior to that. The assessment showed a score of 4, which indicates that Resident #1 is at risk for elopement. Resident #1's care plan reveals a focus of Resident has potential for drug-seeking type behaviors. Hx. [History] of drug abuse and drug-seeking since admission. Date initiated [DATE]. Interventions include Anticipate and meet resident's needs (dated [DATE]), Educate resident on successful coping and interaction strategies (dated [DATE]), and resident will not wander out of facility (dated [DATE]). An additional focus of the care plan includes the resident is an elopement risk/wanderer related to impaired safety awareness (date initiated [DATE]) with interventions that include actual elopement on [DATE] (dated [DATE]), assess for elopement risk (date initiated [DATE]) electronic monitoring to place on the resident (dated [DATE]). Record review revealed Resident #1 Physician's orders for [DATE], (prior to the elopement that occurred on [DATE]) included the following: Aspirin 81milligrams (mg) one tablet daily for antiarrhythmic; [MEDICATION(S)] 20mg one tablet daily for hyperlipidemia; [MEDICATION(S)] 20mg one tablet daily for GERD (gastroesophageal reflux disease); [MEDICATION(S)] Sulfate 325mg one tablet daily for a supplement; [MEDICATION(S)] 100mg one tablet daily for hypertension; [MEDICATION(S)] Extended-release 24 hour 60mg one tablet daily for hypertension; [MEDICATION(S)] 20mg one tablet daily for inflammation; [MEDICATION(S)] 20mg one tablet daily for antidepressant; [MEDICATION(S)] 75mg in the morning for depression; Vitamin D3 tablet 5000 units 1 tablet daily for vitamin D deficiency; [MEDICATION(S)] tablet 1 mg every 12 hours for extrapyramidal symptoms; [MEDICATION(S)] tablet 0.25mg one tablet two times a day for schizophrenia; [MEDICATION(S)] tablet 15mg one tablet three times a day for anxiety. During the Medication Administration Record (MAR) review, there were blank sections where the nurses would put their initials indicating if the medication was given or why it was not given. The medication [MEDICATION(S)] had blanks for the dates of ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] at bedtime. The medication [MEDICATION(S)] 0.25mg had blanks for the dates of ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] at 5:00 PM. [MEDICATION(S)] 100mg had blanks for ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] for the bedtime doses. The medication [MEDICATION(S)] had blanks for ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE] for the 5:00 PM doses. An interview was conducted on [DATE] at 2:00 PM with the facility's Director of Nursing, who was asked why there were blank spaces when the nurse's initials should be there, and she was unable to provide a reason why. In an interview conducted on [DATE] at 11:00 AM with the facility's the Director of Rehab, he stated that they use the BCAT (Brief Cognition Assessment Tool) to assess the cognitive level. Residents must be able to meet a specific criterion to be able to perform the test. The social worker will do her BIMS, and the SLP (Speech Language Pathologist) will conduct the BCAT to assess cognitive status. The BIMS is used as a baseline test when residents are admitted . The BCAT is more intensive with specific based questions that have 1 step command and 2 step commands. The test is very standardized and needs to be done by the book. He further stated that the BCAT could show specific goals for needs assessment and 1 to 2 steps goals. It is an excellent tool recognized by the American Speech-Language-Hearing Association ([NAME]). A nursing referral must be sent to have the SLP conduct the BCAT test. The lower the score on the BCAT, the more dependent the residents may be on all their Activities of Daily Living (ADL's). Someone with a low BCAT score will need maximum assistant, supervision, and everything must be structured for them. Someone with a score of 20 and below will have a high risk of getting hurt if they walk outside the facility and start walking, and they will need constant monitoring to avoid any accidents. A resident with a BIMS score higher than the BCAT will have to be reassessed with a new BIMS score. The Director of Rehab stated that cognitive levels could change and fluctuate from one day to another. The BCAT is more standardized, and it is a more accurate test. Resident #1 had a BCAT (Brief Cognitive Assessment Tool) conducted after the incident on [DATE]. The assessment was completed by the facility's Speech-Language Pathologist on [DATE], 3 days after the incident. The BCAT assessment showed a score of 18 out of 50, indicating severe cognitive-linguistic impairment. The Resident presents with severe impairments in sustained attention, auditory comprehension for following basic directions, short-term memory recall, and problem-solving skills. Resident required max verbal cues for redirection to structured tasks throughout the examination. An elopement risk evaluation was conducted on [DATE], the day of the incident, which was not done prior to that. The assessment showed a score of 4, which indicates that Resident #1 is at risk for elopement. In an interview conducted on [DATE] at 11:10 AM with Resident #1, she could not have a conversation with the surveyor and did not provide appropriate responses when answering the surveyor's questions. In an interview conducted with Staff H, CNA, via telephone on [DATE] at 11:59 AM, she was asked about the incident on [DATE]. Staff H stated that she was leaving the facility when Staff G, a Licensed Practical Nurse (LPN) asked her to look for Resident #1 on her drive home. At approximately 7:15 AM, Staff H located Resident #1 by a Speedway gas station located on US-1 and 16th street. Staff H stated that Resident #1 was about to turn right onto Highway US-1 going North. The Resident was observed wearing sweatpants, a shirt, and sneakers and carrying her purse. Staff H pulled into the gas station and approached the Resident on foot. Resident #1 stated, I do not want to go back to the hospital. Staff H reported that Resident #1 did not recall her name but knew her by face. Resident #1 agreed to get in the car, and Staff H then brought her back to the facility at approximately 7:20 AM. Staff H further stated that Resident #1 was very restless the night before. During the night, she kept coming out of the room and asked to leave, and she had her shoes and purse. She asked to leave multiple times during the night shift and was monitored by staff. According to Staff H, Resident #1 was more anxious than usual. When asked about her cognitive status before leaving the facility, she reported that Resident #1 was confused. She also said that Resident #1 exhibited exit behaviors before her leaving on [DATE] but nothing to the extent of her leaving the facility. An interview with Staff E, Certified Occupational Therapy Assistant (COTA), was conducted on [DATE] at 12:15 PM. Staff E stated that on [DATE], between 7:00 AM and 7:05 AM, she was in the gym working on her notes when she heard an alarm. She walked in the direction of the door that the alarm sounded from and poked her head out of the door but did not step out. The exit door was located between rooms 109 and 117. On her way to the exit door, she stated that the Resident in room 111B told her that the skinny lady in room 105 was walking in the hallway toward the exit door earlier, but he did not see her leave. Staff E further stated that she returned to the nurse's station and alerted additional staff to what the Resident in room 111B told her. She then asked Staff F, Certified Nursing Assistant (CNA), to check Resident #1's room to see if she was there. She did not call the police and is unsure if anyone called the police. The Director of Nurses and the Administrator had not arrived at the facility yet. Resident #1 was not located in her room or inside the facility. Staff immediately initiated a search of the grounds, including the parking lot. Staff G, a Licensed Practical Nurse (LPN) who worked the night shift, went outside looking for Resident #1. In a tour conducted on [DATE] at 12:10 PM, surveyors walked the path that Resident #1 walked when she left the faciity on [DATE]. Resident #1 walked out from Harbor Beach Nursing and Rehabilitation Center through the exit door on the North-West side. She walked down the ramp and turned left onto 16th Street, going West towards US-1. The side street (16th Street) did not have any sidewalk on one side of the road and had cracked uneven pavement. Highway US-1 had 6 lane highway, with 3 lanes on each side. Further, observation showed no crossing light/or traffic light at the intersection of US-1 and 16th street. It is unknown what side of the road the Resident walked on or if she walked in the street. The resident could have gotten lost, fallen, or been hit by a car. While Resident #1 was out of the facility unsupervised there was a high likelihood that she could have been seriously injured, seriously harmed, or died (Photographic evidence obtained). In an interview conducted on [DATE] at 12:33 PM with Staff I, Social Services Director, she reported that BIMS scores could vary from one day to the other. If a resident has a Urinary Tract Infection ([CONDITION(S)]), or other comorbidities, their BIMS score might be affected. She may repeat the test for the BIMS depending on the discrepancies after a resident is all better. When asked if she is aware of the BCAT test, she said that SLP does it, but she is not very familiar with it. The BCAT may be done on residents with dementia or Alzheimer's because it is more detailed. Staff said that the BCAT is more accurate than the BIMS because they are going into more details with the questions, and it takes longer to do the test. Staff I, further stated that Resident #1's cognitive level and speech have improved since her admission to the facility. On [DATE], Resident #1's repeated BIMS score was at 13, which is cognitively intact. On [DATE] at 1:00 PM, Staff I indicated a new BIMS test would be completed for Resident #1 . In this test, Resident #1 was only able to answer the present year and scored 3 out of 15, indicating severely cognitively deficit. In a phone interview conducted on [DATE] at 1:48 PM with Resident #1's father, he stated that Resident's #1 communication and cognitive status have worsened since she was admitted to the facility. He further reported that Resident #1 is not able to verbalize her needs to him. A review of the Elopement drills that were provided by the facility showed no indication that Wandering and Elopement in-services were given in September as listed on the Education Calendar for 2021. This surveyor was provided education in-service attendance reports for abuse/mistreatment dated [DATE] and Missing Resident/Elopement/Abuse dated [DATE]. The facility also conducted elopement drills on [DATE] and [DATE] after the incident on [DATE]. A closer review of the Elopement drills after [DATE] did not show an education that included: an outside search that needs to be done outside the facility as far as the eye distance from the alarming exit door as a point of reference. In an interview conducted on [DATE] at 10:20 AM, with Staff J, Certified Nursing Assistant, she arrived at the facility at 7:00 AM, on the morning of [DATE]. On her way to the nursing station, she heard from another staff that Resident #1 had escaped and that they listened to the alarm. According to Staff J, Resident #1 always says that she wants to go out and wants to leave and is known to be a little confused. On the morning of the incident, staff started looking for her outside and inside the facility. She was told to look for Resident #1 outside in the front parking lot of the facility. When asked if Resident #1 had a wander guard before she attempted to leave the facility, she said no. She further stated that because she had never left the facility before, she did not need one. According to Staff J, on [DATE], they did not have a supervisor in charge because it was too early. She further said that when she was educated on elopement, she was told to first check each room before searching outside the premises. Then you go out to look for the resident. When an elopement happens, they are supposed to tell someone in charge and follow the directions of the supervisor. Staff J stated that she did not participate in any elopement drills after [DATE]. When asked as to how many exit doors does the facility has, she did not know. In a second interview conducted on [DATE] at 11:07 AM with Staff E, she stated that she was educated on elopement twice a year. The drills consisted of a code called BODYBEAR as an indication that a resident was missing. They needed to get to the nurse's station and receive the individual assignment from the supervisor. Once you have your instructions, you follow them and report your findings. On the morning of [DATE], she heard the alarm and told the nurses what the Resident in room 111 told her. She tried getting the staff around the facility to search for Resident #1, and she even looked outside the front of the facility. After the incident, the facility conducted an in-service on elopement which she did not participate. When she returned, she completed a test on elopement. According to Staff E, nothing new was part of the education, and that they re-educated staff on the same instruction you would follow if an elopement happened again. She did not know if the facility completed another drill after the incident on [DATE]. When asked by the surveyor if she could see Resident #1 walking away when she peeked outside the door on [DATE], she said: I can see a partial view of the street, on both sides but more to the left. She then said Resident #1 must-have walked very fast. In an interview conducted on [DATE] at 11:57 AM, Staff K, Housekeeping, stated that on the day of the incident, she passed by room 105 to go to the nurses' stations. She is familiar with Resident #1, who usually comes out of her room at around 8:00 AM and goes outside the patio across from her room. On the morning of [DATE], she saw Resident #1 walking out of her room and did not think much of it. The next thing she heard was the alarm on the door. She walked in the direction of the sound and was told by Staff E, who was by the exit door, that Resident #1 had already gone and could not see her. She then started looking for Resident #1 around the building. She also reported that by the time she was ready to go into her car and drive around to look for Resident #1, another staff brought Resident #1 back to the facility. She could not remember when the last time she participated in elopement drills. When asked if this happened again: she said, they would not have to tell me anything; I would go looking for [Resident #1] right away. In an interview conducted on [DATE] at 12:15 PM with the Maintenance Director, he stated he helps with the elopement drills. He noted that elopement drills are conducted once a month for every shift. Before this year, they used to have a dressed-up teddy bear called BODYBEAR, which the facility would hide either inside or outside. Once announced, staff would have to come to the nurse's station to receive their assignments. Now they have changed the drills, they will call the name of the missing resident, and staff will follow the supervisor's instructions. In a tour conducted on [DATE] at 6:00 PM, with the Regional Director of Clinical Services, she was asked to accompany the surveyor to the exit door that Resident #1 escaped from. Surveyor opened the exit door and peeked outside. Surveyor could not see a full view of the street from right to left, and only the ramp to the street was visible from the door (Photographic evidence obtained). The Regional Director of Clinical Services agreed that Staff E, should have stepped outside the door, and walked down the ramp, to have a full view of the street. The facility Immediate Jeopardy Removal Plan included: 1. On [DATE] the Director of Clinical Services and designees initiated education for staff on how to search for a resident who has eloped from an alarming door to include an immediate perimeter area search from the starting point of eye distance. The responder to the alarming door will be assigned to conduct the initial/immediate search. This education consisted of return demonstration to validate knowledge and phone education when available and education documentation if needed. Return education demonstration will continue upon staff return. 2. On [DATE] The Plant Operations Manager was educated by the Senior Maintenance Director on conducting monthly Elopement Drills. 3. The Director of Clinical Services and designee conducted elopement drills on each shift, daily for 3 days starting on [DATE] then weekly through [DATE], drills included post drill education based on response. 4. On [DATE] the Director of Clinical Services and designees initiated staff education on demonstration to follow elopement plan. Education initiated on [DATE]. Staff includes Therapy (7), Housekeeping/Laundry (5), Dietary (7), CNAs (28), Nurses (18), and Administrative/department heads (12). 5. On [DATE] Licensed nursing staff education was initiated to ensure the Elopement Risk evaluation is conducted at the time of admission. Education includes 18 licensed nursing staff. 6. On [DATE] Staff education was initiated on reporting and communicating resident exit-seeking behaviors to their supervisor. The Director of Clinical Services will be notified, and appropriate interventions will be reviewed. Staff Education includes Therapy (7), Housekeeping/Laundry (5), Dietary (7), CNAs (28) Nurses (18), and Administrative/department heads (12). 7. On [DATE] The Executive Director and Director of Clinical Services were educated on determining the root causes specific to elopements by the Regional Vice President of Operations. 8. The Executive Director led an additional Quality Assurance and Performance Improvement meeting on [DATE] with the Medical Director, Director of Clinical Services, Social Services Director, Plant Operations, Activities, Dietary Supervisor, Housekeeping Supervisor, CNA, Business Office. 9. An additional ad hoc quality assurance performance improvement meeting was held on [DATE] with the participation of the Center Medical Director, Executive Director, Director of Clinical Services, Social Services Director, Unit Manager, MDS Coordinator, Plant Operations Manager, Human Resources, Housekeeping Supervisor, Dietary Director, Therapy Director, and Activities Director. The plan along with the root cause for the incident was discussed and approved by the Medical Director. The Facility policies on Elopement were reviewed during the QAPI meeting. 10. An ad hoc quality assurance performance improvement meeting was held on [DATE] with the participation of the Center Medical Director, Executive Director, Director of Clinical Services, Social Services Director, Unit Manager, MDS Coordinator, Plant Operations Manager, Human Resources, Housekeeping Supervisor, Dietary Director, Therapy Director, and Activities Director. The Plan along with the root cause for the incident was discussed and approved by the Medical Director. The Facility policies on Elopement were reviewed during the QAPI meeting.

Based on observation, interview, record review and facility policy review the facility failed to provide the necessary care and services to maintain the highest practicable physical and mental well-being for 2 of 21 sampled residents including 1 of 1 sampled residents for [MEDICAL TREATMENT] as evidenced by Resident # 37 who experienced pain without relief due to lack of pain assessments and pain medication administration and regarding assessment of Resident # 32's shunt and not receiving medications as ordered. Findings include: 1) On 05/04/2011 at 9:36 AM in the hallway outside a resident's room, a resident was overheard loudly crying. In an interview at that time, a nurse reported that Resident #37 was crying because staff were applying the splints. The nurse further reported that the resident was medicated for the pain. Review of Resident # 37's clinical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record contained a physician's order dated 12/18/10 for "[MEDICATION NAME] 325 mg 2 tabs q 4 hours prn pain" ([MEDICATION NAME], every 4 hours as needed for pain). The record recorded the following varying pain assessments: on the 12/18/10 re-admission, the resident was assessed as with "no pain"; the February 2011 clinical review documented that the resident "has pain"; on the 3/11/11 clinical review, in the Pain section was documented, "unable to self report, points to body part (abdomen), pain medications prescribed" and the monthly clinical review on 4/12/11 had no assessment recorded in the pain section. The resident's care plans documented that the resident required splints: "Apply right hand, right elbow and right knee splints as ordered daily." The resident's current care plan for "Potential for alteration in comfort: Multiple joint contractures, impaired mobility" was updated 03/03/11; approaches included "administer medications as ordered, document regarding the effectiveness, assess for location of pain, assess for severity of pain and assist to maintain proper body alignment". The resident's care plan for "Potential for alteration in mood, crying episodes had as approaches, "assess causative and contributing factors, such as new diagnosis, pain..." Review of the resident's Medication Administration Record (MAR) for the previous 3 months revealed: the May 2011 MAR documented the pain medication was given once so far on May 5, 2011; no documentation the resident was given medication for pain in the morning on 5/04/11 when Resident #37 was crying because staff were applying the splints, contrary to what the nurse reported; the April 2011 MAR documented the resident was administered medication for pain once (around 4/21/11, date illegible); the March 2011 MAR documented the medication for pain was given twice, on 3/18 and 3/19. On 5/05/11 at 9:10 am, Resident # 37 was overheard in her room moaning. The Restorative aide exited the resident's room. At that time, in an interview, the aide reported she was applying the splints to the resident. She said the resident has pain and so the aide tells the nurse and the resident is given medication. The nurse's aide who provides care to the resident was interviewed on 05/05/11 at 9:20 am. The nurse's aide said that she does Range of Motion every time she bathes the resident, especially her hand because it is tight. She said that when the Range of Motion is done slowly the resident does not scream. She said the resident has pain in the right shoulder and in the right leg. Review of the facility's Pain policy and Procedure states, "Monitor pain daily and document resident/patient response to pain interventions." On 05/05/11 at 10:45 am in an interview, the resident's nurse for that day (a different nurse than assigned 05/04/11) said she did not work with the resident every day but was familiar with the resident. She said the resident has pain every day but the resident cannot communicate to tell where the pain is located. The nurse said it was generalized pain. She said the resident's pain is assessed daily and the resident was given pain medication today. When asked where is it documentation that the resident's pain was assessed daily, she kept pointed to the one entry on the May 2011 MAR when the resident received the pain medication. There was no documentation in the MAR of a daily pain assessment. In addition, the MAR documented that the pain medication was given at 9:30 a.m. on 5/05/11, after the application of the splints. On 05/05/11 at 2:10 p.m. in an interview, the Director of Nurses (DON) reported that sometimes the resident can tell you when she is experiencing pain and sometimes she denies pain. It was brought to the DON's attention that there was no documentation on the MAR that the resident was medicated for pain on 05/04/11 in the morning, as the resident's nurse had stated to the surveyor. 2) Resident #32 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. After a short hospital stay the resident was readmitted to the facility on [DATE]. Review of hospital physician progress notes [REDACTED]. Review of the physician orders revealed the resident was on daily medications for blood pressure, heart arrhythmias, depression. The resident was receiving Aspirin, [MEDICATION NAME] and [MEDICATION NAME], anticoagulation medications, and renal supplements. All were scheduled for 9:00 am. On 05/04/11 at 2:26 pm, in an interview, Resident #32 stated he goes to [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday and is out of the facility from approximately 4:30 am. until 11:30 am, returning in time for lunch. The resident was wearing a short sleeved shirt and his left arm with the [MEDICAL TREATMENT] shunt had a large bruised area extending up under the [MEDICAL TREATMENT] shunt dressing. During the interview, Resident #32 stated he recently had some work done on the shunt while he was in the hospital. Review of the resident's Medication Administration Records (MAR) revealed the following: On the April 2011 MAR, documentation that the resident was not receiving the 9:00 am medications on the days of [MEDICAL TREATMENT], Tuesday, Thursday and Saturday. Staff documented for the 9:00 am medication administration on [MEDICAL TREATMENT] days, "[MEDICAL TREATMENT]", or initials with a circle around the initials with documentation on the back of the MAR, "medications not given, resident at [MEDICAL TREATMENT]" Medications that were not administered included renal supplements, antiarrhythmic, blood pressure and the anticoagulant medications, Aspirin, [MEDICATION NAME] and [MEDICATION NAME]. The resident's clinical record contained a physician's order dated 4/25/11 to "hold a.m. dose of BP (blood pressure) medications on [MEDICAL TREATMENT] days" Further review of the April MAR revealed after 4/25/11, the blood pressure medications were held on [MEDICAL TREATMENT] days as well as all the other 9:00 am medications including the anticoagulants, Aspirin, [MEDICATION NAME] and [MEDICATION NAME]. On the May 2011 MAR, documentation on 5/3/11 at 9:00 am, the resident "was OOF (out of facility), and at 9:00 am on 5/5/11, initials with a circle around the initial indicating the medication was not given with further documentation on the back of the MAR stating, "All am medications not given, resident out to [MEDICAL TREATMENT]". On 05/05/11 at 10:30 a.m. in an interview, the Registered Nurse (RN) caring for Resident #32 stated she holds all 9:00 am medications on [MEDICAL TREATMENT] days but does give all the medications that are due in the afternoon. Additionally, she stated she does not give the 9:00 am medications when the resident returns to the facility around 12:00 p.m. On 5/5/11 at 1:19 pm in an interview, the Director of Nurses (DON) was made aware the resident's 9:00 am medications were not administered on [MEDICAL TREATMENT] days. She stated they were probably given when the resident returned. The clinical record was reviewed with the DON at that time revealing no evidence of documentation the 9:00 am medications were administered. The DON stated she will contact the physician and advise him of the omissions. On 5/5/11 at 3:38 pm, the DON stated she contacted the physician and received an order to change the time of administration of the 9:00 am medications to reflect the resident going out to [MEDICAL TREATMENT]. On 5/6/11 at 9:17 am, the clinical record was reviewed to reveal a physician order dated 5/5/11 to '"Give all daily medications at 5:00 pm and all TID (3 times daily) medications at 1:00 pm, 5:00 pm and 9:00 pm". Further review of the clinical record revealed a nursing progress note dated 5/5/11 at 2:00 pm documenting, "Call placed to physician regarding meds on a.m. [MEDICAL TREATMENT] days withheld by staff some days. Message left." Documentation in the nursing progress notes dated 5/5/11 at 4:00 pm stated, "Physician called back and was updated on above regarding med held on some [MEDICAL TREATMENT] days. New orders received". Review of nursing progress notes dated 5/6/11 at 1:00 p.m. documented, "Call placed to (name of responsible party) updating her on resident's meds changed and time changed and reason for it related to [MEDICAL TREATMENT] days doses 9:00 am not given."' 3) Further review of the clinical record revealed inconsistent monitoring or assessment of Resident # 32's [MEDICAL TREATMENT] shunt. Review of the physician orders for March, April and May 2011 revealed no order for the assessment of the [MEDICAL TREATMENT] shunt. Review of the MAR and Treatment Administration Record revealed no documentation the [MEDICAL TREATMENT] shunt was being assessed or monitored. On 5/5/11 at 10:30 am, in an interview, the RN caring for Resident #32 stated the [MEDICAL TREATMENT] shunt is assessed every shift. An inquiry was made as to where this was documented and she stated it was on the MAR. Review of the MAR's for March, April and May revealed no documentation regarding the [MEDICAL TREATMENT] shunt. The RN then stated they document every shift in the nursing progress notes. Review of the nursing progress notes revealed documentation the [MEDICAL TREATMENT] shunt was being assessed on the days the resident returned from [MEDICAL TREATMENT], however on 5/2, 5/1, 4/29, 4/25, 4/22, 4/20, 4/13, 4/11, 4/8, 4/7 and 4/2 there was no documentation in the clinical record of the [MEDICAL TREATMENT] shunt being assessed or monitored. On 05/5/505/11 at 1:19 pm in an interview, the DON also stated the [MEDICAL TREATMENT] shunt is assessed by the nurse every shift and documented on the MAR. Review of the MAR with the DON revealed no documentation of assessment of the [MEDICAL TREATMENT] shunt. She further stated the assessment is documented on the nursing progress notes. The nursing progress notes were reviewed with the DON from 3/30/11 through 5/4/11. The DON confirmed the [MEDICAL TREATMENT] shunt was not assessed every day, and usually not on days the resident doesn't go to [MEDICAL TREATMENT]. Review of the facility policy on the Care and Maintenance of an Internal Arteriovenous Access Device states in part ' Evaluate resident daily, upon return from [MEDICAL TREATMENT], and more frequently as indicated. ' Review of care plan for resident #32 dated 03/31/11 documents under Problems/Needs, ' Alteration in renal status as evidenced by receiving [MEDICAL TREATMENT] X 3 weekly. ' Interventions include: ' ' Monitor vascular access site for any abnormalities (i.e. redness, swelling, drainage). Document and report to MD. ' Review of the facility policy on Medication Management states in part, ' Medication schedules are reviewed to maximize the effectiveness of the medication, avoid potential adverse consequences, and recognize resident preference and choice when possible. ' 4) Review of the admission physician orders reveals the resident was ordered Nepro (liquid renal diet supplement) one can daily on 03/30/11. Review of the April MAR reveals a handwritten notation the Nepro was discontinued on 04/13/11. During the interview with resident #32 on 05/04/11 at 2:26 p.m. an observation was made of an uncapped drink box of Nepro sitting on the bedside table. During the interview with resident #32 on 05/4/11 at 2:26 p.m. the resident was asked if the facility provided a breakfast before he leaves as it is so early in the morning and he stated he was going to talk to the facility about this as they do not send him out with any food and he gets hungry. He further stated he only gets water at the [MEDICAL TREATMENT] center and he is hungry when he returns to the facility. Review of the MARs for March and April dietary recommendation documentation states FYI (for your information) the resident is to be on a no concentrated sugar, no added salt, avoid food high in potassium, large protein portion diet, in addition he is to receive a boiled egg on the a.m. of [MEDICAL TREATMENT]. Review of the May MAR does not document the boiled egg on the a.m. of [MEDICAL TREATMENT]. Additionally the April and May MAR documents FYI a 1500 milliliter fluid restriction over 24 hours. Further review of the MARs documents the resident is to receive blood sugar monitoring AC and HS (prior to meals and at bedtime). Review of the clinical record revealed documentation in the nursing progress notes dated 04/12/11 stating resident ' ate early breakfast, off to [MEDICAL TREATMENT]. ' Documentation in the nursing progress notes dated 04/26/11 states ' resident ' s blood sugar low so ate small breakfast. Off to [MEDICAL TREATMENT]. ' Further review of the clinical record reveal no additional documentation the resident was provided with a breakfast prior to [MEDICAL TREATMENT] or a breakfast to take to [MEDICAL TREATMENT]. On 05/05/11 at 10:30 a.m. an interview was conducted with the RN caring for resident #32 who stated the resident is sent to [MEDICAL TREATMENT] with a breakfast bag. The RN was asked how they monitor the resident ' s fluid restriction of 1500 milliliters over 24 hours and she stated it is on the MAR. Review of the MAR documents the fluid restriction FYI with no documentation of how much and when the resident is drinking. Review of a care plan for resident #32 dated 03/31/11 documents under Problems/Needs, ' Alteration in renal status as evidenced by receiving [MEDICAL TREATMENT] X 3 weekly. ' Interventions include: ' Provide therapeutic diet and fluid restriction as ordered. Monitor and document. ' On 05/05/11 at 10:55 a.m. an interview was conducted with the consultant dietician who stated she is not sure why they are not documenting how much fluid the resident consumes throughout the day to equal the 1500 milliliter fluid restriction. When an inquiry was made as to the resident receiving a breakfast prior to or provided with a breakfast to take to [MEDICAL TREATMENT] she stated she was not sure and would have to ask the dietary manager. On 05/05/11 at 11:05 a.m. an interview was conducted with the consultant dietician and dietary manager who stated the resident is given 3 hard boiled eggs and 4 ounces of milk which he eats before he goes to [MEDICAL TREATMENT]. Review of the meal ticket for resident #32 provided by the dietary manager documents the resident is to receive large portion protein food, avoid food high in potassium with a fluid restriction of 1500 milliliters a day. There is no evidence of documentation the resident is also to be on a no concentrated sugar and no added salt diet in addition to no documentation the resident is to receive a boiled egg on the a.m. of [MEDICAL TREATMENT] days. Further review of the meal ticket for resident #32 documents under " Dislikes " - Hard Boiled Egg.