Every finding on record at Beaumont Health Care Center

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (Nurse Back of Hall 200) reviewed for medication storage. The facility failed to ensure medications were not stored on top of the medication cart. This failure could place residents at risk of misappropriation of medications, adverse reactions by ingesting medication that did not belong to them, and not receiving therapeutic effects of medication.Findings included: During an observation and interview on 07/07/26 at 8:15 a.m., LVN A pulled the medication cart to the doorway of a resident's room, locked the cart, locked the electronic medical record and proceeded to walk away, going into the nurse station room located (approximately 40 feet away from the medication cart); leaving an topical pain patch medication on top of the cart and out of her visual sight. The medication cart was unattended during this time and a resident in a wheelchair was self-propelling his wheelchair next to the cart. Multiple staff members walked passed the cart and attended to a resident. At 8:18 a.m., LVN A returned to the medication cart and said she left the cart to get a pair of scissors from the nurse's station to open the topical pain patch packaging.During an interview on 07/08/26 at 8:45 a.m., LVN A stated she should not have left the topical pain patch unattended on the medication cart. LVN A said she should have taken the topical pain patch with her to the nurses' station or placed it back in the medication cart while she went to get a pair of scissors. LVN A said the topical pain patch was not in her view when she left to go to the nurse station. LVN A stated that the topical pain patch was Lidocaine Patch 4 % (topical pain patch). LVN A said she should not have left the medication on top of the medication cart unattended because someone could have taken the medication and it could have caused them to become sick. LVN A said she was trained in medication storage, use of medication carts, and to keep medications locked up when not in use. LVN A said she just got nervous and forgot.During an interview on 07/08/26 at 12:01 p.m., the ADON said the nurses needed to always maintain a view of the medication cart and never walk away from the cart with medications left on top for the safety of the residents, because it risked contamination and someone could come and take the medication off the cart. The ADON said she was not sure why this occurred. The ADON stated nurses were trained on hire and as needed, on the use of medication carts, medication storage and security.During an interview on 07/08/26 at 12:10 p.m., the DON said the nurses were responsible for keeping the medication carts locked and the medications secure. The DON said medications should not be left unattended on the medication cart. The DON said an adverse outcome could be a resident or other staff member could obtain the medication off the cart and cause missing medication or unauthorized access or use of the medication.During an interview on 07/08/26 at 1:30 p.m., the designee Administrator said she expected the staff to be compliant with the policies regarding proper medication storage. The Administrator said medications should never be left on top of a medication cart unattended because from a safety perspective, someone could come along and take it.A record review of the facility's, undated, Policy, titled Medication Storage included that; .Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 6.45%, based on two errors out of 31 opportunities, which involved 2 of 7 residents (Resident #60, and #66) and 2 of 4 staff (LVN A, and RN B) reviewed for medication error., in that: 1. The facility failed to ensure LVN A did not administer an incorrect dose of Calcium to Resident #66 on 07/07/2026 during a medication pass. 2. The facility failed to ensure RN B did not administer a dose of sliding scale Humalog insulin (used to treat diabetes) from an insulin pen labeled do not use after 06/29/2026 on 07/07/2026, to Resident #60 during a medication pass. These failures could place residents at risk for inaccurate drug administration resulting which could result in decline in health and decreased quality of life.Findings included: 1. Record review of Resident #66's admission Record, for Resident #66 dated 07/08/2026, indicated she an [AGE] year-old female who admitted to the facility on [DATE]. Resident #66 had and was [AGE] years old with diagnoses of which included right femur fracture with a joint replacement, rhabdomyolysis (breakdown of muscle tissue that releases a damaging protein into the blood), and metabolic encephalopathy (another health condition, such as diabetes, liver disease, kidney failure, or heart failure, makes it hard for the brain to work).Record review of Resident #66's admission MDS Assessment, for Resident #66 dated 06/30/2026, indicated she had moderate impairment in thinking with a BIMS score of 11. Resident #66 had and a surgical procedure of to repair fractures of the pelvis, hip, knee, or ankle (not foot). Record review of Resident #66's care plan initiated on 06/25/2026 indicated she had pain related to fractured femur and impaired cognitive function related to metabolic encephalopathy with interventions to administer medications as ordered by doctor.Record review of Resident #66's active physician orders dated 07/08/2026, indicated an order for Calcium 600mg give 1200 mg by mouth in the morning for vitamin supplement.Record review of Resident #66's MAR for July 2026 indicated Calcium 600mg tablet give 1200 mg by mouth was scheduled every morning.During an observation of medication pass on 07/07/2026 at 8:45 a.m. LVN A administered Calcium 600mg 1 tablet from facility stock Calcium bottle on the medication cart.During a record review and interview on 07/08/2026 at 7:30 a.m., LVN A acknowledged she had administered an incorrect dose of Calcium to Resident #66 during medication pass on 07/07/2026 at 8:45 a.m. Resident #66's MAR for July 2026 indicated Calcium 600mg tablet give 1200 mg by mouth every morning, LVN A said she should have given 2 tablets of Calcium 600mg totaling the 1200 mg and she only administer one 600 mg tablet during the medication pass. She said Calcium was used to build and maintain strong bones and with Resident #66's recent fracture was prescribed for bone strength. LVN A said not administering the correct dose of Calcium could cause a decrease in calcium level, decrease bone strength if calcium was not received through prescribed diet. 2. Record review of Resident #60's admission Record, dated 07/08/2026, indicated he readmitted to the facility on [DATE]. Resident #60 was [AGE] years old. Resident #60 had diagnoses which included dementia (a decline in mental ability that can interfere with daily life), and diabetes mellitus (chronic condition in which the pancreas produces little or no insulin).Record review of Resident #60's Quarterly MDS Assessment, dated 06/30/2026, indicated he did not have any impairment in thinking with a BIMS score of 15. During the seven look back period he received insulin injections.Record review of Resident #60's care plan, revised on 06/05/2026, indicated he had physician orders for insulin related to diabetes mellitus with interventions to give diabetic medications as ordered by a doctor.Record review of Resident #60's active physician orders, dated 07/08/2026, indicated an order for Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if blood sugar is 61 - 150 = 0 units; 151 - 200 = 2units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+= 12 units Re-check BS in 15 minutes. If it is still greater than 401, call MD, subcutaneously before meals and at bedtime for DM.Record review of Resident #60's blood sugars (normal blood sugar ranges before meals range from 70-130):07/07/2026 9:10 a.m. blood sugar was 155.07/07/2026 3:45 p.m. blood sugar was 229.07/07/2026 8:17 p.m. blood sugar was 178.07/08/2026 7:09 a.m. blood sugar was 163.07/08/2026 10:25 a.m. blood sugar was 223.During an observation on 07/07/2026 at 3:45 p.m., RN B checked Resident #60's blood sugar and it was 229 mg. RN B said Resident #60 would receive 4 units of Humalog per sliding scale for the 229 mg blood sugar. RN B took the Humalog pen out of the medication cart and dialed it to 4 units. RN B observed Resident #60's Humalog insulin pen and indicated the insulin open dated acknowas on 06/29/2026 and pointed to a label on the pen. RN B entered Resident #60's room and explained to Resident #60 she was administering 4 units of Humalog for his 229 mg blood sugar reading. RN B administered Humalog 4 units SQ to Resident #60's left lower abdomen using proper infection control measures.During an interview and observation on 07/07/2026 at 4:00 p.m., RN B said she used Resident #60's Humalog pen with an added orange label which indicated a use by date of 06/29/2026 while administering Resident #60's sliding scale insulin on 07/07/2026 at 3:45 p.m. RN B said the date on the orange use by date label was the opened date but was on the wrong label but no evidence provided to validate the statement. RN B denied that she had opened or labeled Resident #60's Humalog pen. She said using an expired Humalog pen could be ineffective and the blood sugar could increase.During an observation on 07/07/2026 at 4:00 p.m., the medication cart that was assigned to RN B for the day indicated one Humalog insulin pen with a white label indicating which indicated an opened date which was blank, and an orange label which indicated a use by date of 06/29/2026 prescribed to Resident #60.During an interview and observation on 07/07/2026 at 4:10 p.m., the ADON and DON said they felt the staff had placed the opened date on the wrong label but were removing Resident #60's current Humalog pen and replacing it with a new Humalog pen with the corrected opened date label to the medication cart. They said that nursing staff should follow the rights of medications that included the right resident, medication, dose and check for expiration or use by dates of each medication administered. They said the pharmacist consultant was at the facility last week to destroy drugs, checked medication carts and rooms, observed a medication pass, and provided the facility with recommendations. They said Resident #60 would be monitored for hypo/hyperglycemia, and blood sugar rechecked after supper/prior to bedtime.During an interview on 07/08/2026 at 12:05 p.m., the ADON said the nurses should be following the 5 R's checklist when administering medications: right resident, right medications, right dose, right route, right time, which also should include checking for expiration or used by date. The ADON said administering expired medication could lessen the effectiveness of the medication, with insulin could cause high or low blood sugars. The ADON said residents' not getting a complete dose of calcium could cause bone density and fragile bones which could lead to fractures if residents were prone to falls.During an interview on 07/08/2026 at 12:15 p.m., the DON said the nurses should be following the 5 R's checklist when administering medications: right resident, right medications, right dose, right route, right time, which also should include checking for expiration or used by date. The DON said the nurse administering the medications should be verifying the use by date and expiration date and pharmacy consultant checks for expiration dates during the monthly audits. The DON said administering expired medication could lessen the effectiveness of the medication, with insulin could cause high or low blood sugars. The DON said Resident #60 was monitored and blood sugar rechecked the evening of 07/07/2026 with no adverse effects indicated. The DON said she replaced Resident #60's Humalog pen immediately after identified issue and began training nursing staff on insulin pen administration, which included correctly labeling when opening (add date to white label) and use by date (add date to orange label). The DON said Resident #60's MD was notified of the incident and agreed with suggested interventions of monitoring, rechecking blood sugar and discard current Humalog pen and start using new Humalog pen. She said Resident #60's blood sugars were monitored and no ill effects identified. She said residents' not getting the complete dose of calcium could cause low calcium levels, fragile bones health which could lead to fractures if residents were prone to falls.During an interview on 07/08/26 at 1:35 p.m., the designee Administrator said she expected the staff to be compliant with the policies regarding proper medication administration. The Administrator said medications should verify the correct medicine, dosage, the right resident, medication expiration or use by date, and should check to make sure the order was correct before administering any medicine. She said the nurse called and notified everyone including the physician and replaced Resident #60's Humalog pen immediately and monitored him for any ill effects. She said Resident #60's blood sugars were monitored and no ill effects identified. She said omitting medications or administering expired medications could result in medication ineffectiveness.Record review of personnel files indicated LVN A and RN B had training and skilled check offs on medication administration both were satisfactory with medication administration.Record review of the facility's policy titled Insulin Pen indicated, .Policy Explanation and Compliance Guidelines: . 2. Insulin pens must be clearly labeled with resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date.8. Once opened, clearly label insulin pens may be stored at room temperature in a locked medication care. Insulin pens do not require refrigeration after opening. 9. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation Record review of the facility's policy titled Medication Administration indicated .Policy Explanation and Compliance Guidelines: .10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation 11. Review MAR to identify medication to be administered.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 Residents (Resident #16 and Resident #5) reviewed for catheter care. The facility failed to assess complications and their causes and maintain a record of any catheter (thin, flexible tube inserted into the body to drain fluids) related problems for Resident #16. The facility failed to assess and ensure appropriate treatment and services were provided including reporting and maintaining a record of any catheter related problems for Resident #5. These failures could place residents who require indwelling catheters at risk for catheter blockage, fistula (abnormal tunnel connecting two body parts) formation, or infection.Findings included: Record review of Resident #16's face sheet, dated 07/07/26, indicated a [AGE] year-old female with an admission date of 02/04/26. Her active diagnoses included neuromuscular dysfunction of the bladder (disruption between the nervous system and the urinary tract), aphagia following a stroke (impairs ability to speak, write, and understand both spoken and written language), and a pressure ulcer (localized soft tissue injuries) of the sacral (bone at the base of the spine) region. Record review of Resident #16's Quarterly MDS assessment, dated 05/08/26, indicated the resident was rarely/never understood and had a BIMS assessment that could not be completed. She was dependent on staff for toileting, bed mobility, and total assistance with bathing. The section bladder and bowel reflected the resident had an indwelling catheter. The active diagnosis section reflected the resident had a neurogenic bladder (disruption between the nervous system and the urinary tract). Record review of Resident #16's Undated care plan, indicated, .The resident has (indwelling foley Catheter: Neurogenic bladder.02/09/2026. The resident will be/remain free from catheter-related trauma through review date. Change Drainage Bag PRN based on clinical indications such as infection, obstruction, or when the closed system is compromised OR per physician's order.Document and notify physician for s/sx of pain/discomfort of catheter, urination, and/or frequency. Record review of Resident#16's order summary, dated 07/07/26, indicated, Urinary Catheter (Indwelling) Catheter Care Q shift and PRN every shift for Catheter Care Empty drain bag &provide peri-care.Notify MD of abnormalities (unusual urine appearance, burning, pain, feeling of full bladder).Urinary Catheter: Change indwelling catheter and Drainage Bag scheduled and PRN due to clinical indications of infection (sediment, foul odor, dark in color), obstruction (slow drainage), or when the closed system is compromised. and every 30 days as needed for Catheter Care. Record review of Resident #16's order summary (after intervention), dated 07/07/26, reflected a new order of .Urinalysis (UTI PCR Panel Reflex - checks for urinary tract infection) ** SENT to Lab 7/7/2026 10:26 AM. Record review of Resident #16's June Administration Record, dated 07/09/26, indicated the urinary catheter and drainage bag were changed on 06/26/26. Record review of Resident #16's progress notes, dated from 06/01/2026 to 07/07/26, did not indicate any notes of an assessment including sediment, any notifications to a doctor, or any other relevant changes or treatments for the indwelling catheter. During an observation on 07/07/26 at 08:45 a.m., Resident #16 was asleep in bed (not interview able). The indwelling catheter bag was hanging from the side of the bed with a privacy cover and below her bladder. The catheter was observed and urine had a large amount of sediment throughout the catheter tubing leading to the drainage bag. During an observation and interview with LVN C on 07/07/26 at 09:34 a.m., she stated the process followed when sediment was found in an indwelling catheter was to notify the doctor, check for output (to ensure no blockage), and change the catheter if needed and if there was an order. LVN C stated, I don't normally work this hall but indicated she was responsible for Resident #16's care 07/07/26. When asked about the indwelling catheter sediment and if anything had been done for Resident #16. LVN C proceeded to pull up Resident #16's chart and stated the indwelling catheter was last changed on 06/26/26 but was unable to say why it was changed. She stated there was an order to be changed as needed. LVN C stated if the doctor was contacted or if there was an assessment that noted sediment, it should have been documented in the progress notes. LVN C stated her assessment of Resident #16 did not indicate abnormal signs or symptoms. She stated the residents abdomen was soft, the urine was free flowing, and the catheter was emptied this morning. She stated the risk of not contacting the doctor or not addressing sediment in the indwelling catheter was it could cause a blockage (in the catheter tubing) or infection. During an interview on 07/07/26 at 9:53 a.m., the ADON/Infection Preventionist stated CNAs should notice changes in urine and notify the nurse. The nurse should contact the doctor for the tubing to be flushed and/or to change the indwelling catheter and bag, and/or for a urine analysis (urine sample) to be completed. She stated there were orders for some residents that included scheduled changes or as needed changes. If there were orders already in place, sometimes they changed them and then notified the doctor. She (the ADON) expected to be notified as well. She stated nurses should be looking for signs of infection when observing the indwelling catheters. The sediment and notification of the doctor should be documented under progress notes. She stated she did not know of any residents' who currently had sediment in their indwelling catheter tubing. She stated she checked catheters yesterday, but not on Resident #16's hallway. She said the potential risk for not contacting the doctor or addressing sediment in the urine was infection. During an observation on 07/07/26 at 10:03 a.m., the ADON/Infection Preventionist observed the indwelling catheter tubing and confirmed there was sediment. She said she would need to contact the doctor, for urinary analysis (urine sample). Record review of Resident #5's face sheet, dated 07/07/26, indicated an [AGE] year-old female with an admission date of 12/08/2025. Her active diagnoses included neuromuscular dysfunction of the bladder (disruption between the nervous system and the urinary tract), aphagia following a stroke (impairs ability to speak, write, and understand both spoken and written language). Record review of Resident #5's Quarterly MDS assessment, dated 06/02/2026 indicated the resident was usually understood and others usually understood her. Resident #5 had a BIMS score of 06, which indicated she had severe cognitive impairment, suggesting significant difficulties with memory, orientation, and thinking skills. She was dependent on staff for toileting, bed mobility, and total assistance with bathing. The section bladder and bowel reflected the resident had an indwelling catheter. The active diagnosis section reflected the resident had a neurogenic bladder (disruption between the nervous system and the urinary tract). Record review of Resident #5s undated care plan, indicated a focus for an indwelling foley catheter Indwelling catheter: Neuromuscular dysfunction of bladder (nerve damage disrupts communication between the brain, spinal cord, and bladder, leading to urinary control problems.) initiation date: 03/26/2026. List goal stated: The resident will be/remain free from catheter-related trauma through review date. Listed interventions indicated Position catheter bag and maintain tubing below the level of the bladder, make sure tubing is secured. Document and notify physician for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of Resident#5's order summary, dated 07/07/26, indicated Urinary Catheter (Indwelling): Urinary Catheter: Indwelling Catheter Care Q shift and PRN (as needed). Urinary Catheter: Indwelling Catheter Care Q shift and PRN every shift for Catheter Care Empty drain bag and provide peri-care (incontinent care). Position catheter bag and tubing below level of the bladder, check tubing is free of kinks and securement device in place. Notify MD of abnormalities (unusual urine appearance, burning, pain, feeling of full bladder). Catheter Care Q shift and PRN every shift for Catheter Care Empty drain bag &provide peri-care.Notify MD of abnormalities (unusual urine appearance, burning, pain, feeling of full bladder).Urinary Catheter: Change indwelling catheter and Drainage Bag scheduled and PRN due to clinical indications of infection (sediment, foul odor, dark in color), obstruction (slow drainage), or when the closed system is compromised. and every 30 days as needed for Catheter Care. Record review of Resident #5's order summary indicated a new order (after surveyor intervention) dated 07/07/26, indicated a new order of .Urinalysis (UTI PCR Panel Reflex - checks for urinary tract infection) ** SENT to Lab 7/7/2026 10:23 AM. Record review of Resident #5's June Administration Record, dated 07/09/2026, indicated the urinary catheter and drainage bag were changed on 07/03/2026. Record review of Resident #5's progress notes, dated from 06/07/2026 to 07/07/2026 indicated there were no notes related to her foley catheter, assessments, sediment, nor any notifications to the physician, or any other relevant changes or treatments for the indwelling catheter. During an observation on 07/06/2026 at 9:35 a.m., Resident #5' s indwelling catheter had thick white sediment (stationary) along with medium yellow color urine in catheter tubing. During an observation on 07/07/2026 at 9:15 a.m., Resident #5's indwelling catheter had (an increased amount of from 07/06/2026) thick white sediment (stationary) along with medium yellow color urine in catheter tubing. During an observation and interview on 07/07/2026 at 9:20 a.m., with LVN F. She said she did not look at nor assess Resident #5's indwelling foley catheter. She said usually she did, but she did not because she was busy helping other residents. She said after looking at it she was going to immediately notify the physician to ensure Resident #5 does not have a urinary tract infection. She said the potential risk to Resident #5 was her having a urinary tract infection and leading to sepsis. During an observation and interview on 07/07/2026 at 9:45 a.m., with the DON and ADON (also is the Infection Preventionist). The DON said she was not made aware of the condition of Resident #5's indwelling catheter. She said her expectation was for the nurses to follow the facility's catheter policy and assess residents' catheters to ensure they were free of thick white sediment to reduce the potential risk of infection to residents. The ADON said she saw Resident #5's catheter on 07/06/2026 but did not look at the tubing. I was just making sure it was empty. She said Resident #5's catheter should have been assessed and reported to the physician so a urinary analysis could have been ordered due to the amount of white sediment inside her catheter tubing. During an interview on 07/08/2026 at 1:50p.m., with the Administrator Designee, she said she expected staff to follow facility procedure and policy related to indwelling catheter assessment, and ensure proper/ appropriate treatment, and services were provided for residents with indwelling catheters. She said if the indwelling catheter facility policies were not followed then it could potentially place residents at risk for urinary tract infections. Record review of the facility policy titled, Catheter Care, dated February 2023, indicated, . It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.Document care and report any concerns noted to the nurse on duty. There were no other catheter policies available that covered catheter assessments. Record review of the facility policy titled, Notification of Changes, dated February 2023, indicated, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification include:. Circumstances that require a need to alter treatment. This may include: New treatment.Discontinuation of current treatment due to: Adverse consequences. Acute condition. Exacerbation of a chronic condition.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 6 residents (Resident #68) reviewed for infection control. The facility failed to ensure CNA D and CNA E wore a gown during high contact activities (bed bath) for Resident #68, who had enhanced barrier precautions in place. This failure could place residents at risk for healthcare associated cross contamination and infections.Findings include:Record review of Resident #68's admission record, dated 07/08/2026, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #68 had a diagnosis which included pressure ulcers (localized skin and soft tissue injuries).Record review of Resident #68's physician orders, dated July 2026, indicated she was on enhanced barrier precautions due to wounds, with the start date of 06/30/2026.Record review of Resident #68's care plan, dated 06/30/2026, indicated she was on enhanced barrier precautions. The interventions included enhanced barrier precautions that were necessary during high-contact care: dressing; bathing; transferring; providing hygiene; changing linens, changing briefs or assisting with toileting; device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes; Wound care: any skin opening requiring a dressing.Record review of Resident #68's admission MDS assessment, dated 07/06/2026, indicated Resident #68's BIMS was which indicated severely impaired with cognition. Resident #68 had 4 unstageable (full thickness tissue loss where wound bed is covered by dead tissue) pressure ulcers. She was dependent on 1-2 staff for bathing and grooming.During an observation on 07/07/2026 at 8:30 a.m., CNA D and CNA E were bed bathing Resident #68 and were not wearing gowns. The CNAs touched Resident #68's body with their arms and their clothes touched her linen as they turned and repositioned Resident #68 during her bed bath. During an interview on 07/07/2026 at 9:15 a.m., CNA D and CNA E said they did not think Resident #68 required enhanced barrier precautions. Observation of Resident #68's room indicated the enhanced barrier sign was posted on the wall by the door of the room. There was PPE hanging on the closet door. CNA E said she was trained in infection control about a year ago. During an interview on 07/07/2026 at 9:53 a.m., the ADON / ICP, and the DON were in their office. The ADON/ICP said the CNAs should have worn gowns and gloves to prevent infections for the residents. The DON said Resident #68 was on enhanced barrier precautions. The DON said her expectation was for the CNAs to wear gowns and gloves when they performed bed baths for residents who were on enhanced barrier precautions.During an interview on 07/08/26 at 1:50 p.m., the designee Administrator said she expected the staff to follow their policies on enhanced barrier precautions. She said with enhanced barrier precautions the staff are to wear gown and gloves when providing close contact care to prevent spreading germs.Record review of personnel files indicated RN F, CNA D, and CNA E did have training on infection control which included enhanced barrier precautions.Record review of the Enhanced Barrier Precautions, dated 2025, indicated Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 2. Initiation of Enhanced Barrier Precautions. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: I Wounds (chronic wounds such as pressure ulcers. 3 Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside the room. b. PPE for enhanced barrier precautions is only necessary when performing high contact care activities . 4. High-contact resident care activities include.b. bathing .

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 2 of 33 beds (Residents #1 and #2) reviewed for essential equipment. The facility did not ensure the 2 of 33 (Residents #1 and #2) resident beds on Hall 100 had footboards and were in safe operating condition. This failure could place residents at risk of injury and patient care equipment not in safe operating condition.Findings included: 1. Record review of Resident #1's admission record, dated 02/17/2026, indicated a [AGE] year-old female, admitted [DATE], in room [ROOM NUMBER] A, and diagnoses included high blood pressure, and Alzheimer's disease. Record review of the admission MDS assessment dated [DATE] for Resident #1 was in progress. Record reviews of the care plans dated 02/17/2026 for Resident #1 were being developed. During an observation on 02/17/2026 at 9:30 a.m., the bed in room [ROOM NUMBER] A was an unoccupied bed, missing the footboard and brackets needed to attach the footboard to the bed. Further observation indicated there were holes in the frame under the foot section of the mattress on each side. for a bracket to be mounted to attach the footboard. During an observation on 02/17/2026 at 2:20 p.m., Resident #1 was admitted today and was in her bed without a footboard, and the bed was in the lowest position. 2. Record review of Resident #2's admission record, dated 02/17/2026, indicated a [AGE] year-old female, admitted [DATE], and diagnoses included heart disease, muscle weakness, and history of falls. Record review of Resident #2's admission MDS assessment, dated 02/12/26, indicated no impaired cognition with a BIMS score of 13. This MDS assessment indicated Resident #2 fell prior to admission. Record review of the care plans, dated 02/07/2026, indicated Resident #2 was at moderate risk for falls related to muscle weakness and needed a safe environment. During an observation on 02/17/2026 at 9:50 a.m., the bed in room [ROOM NUMBER] A was empty, missing the footboard but had metal brackets for the foot board to attach to the bed. Observation indicated the brackets were extended past the mattress approximately two to three inches. During observation and interview on 02/17/2026 at 11:00 a.m., Resident #2 was sitting in her wheelchair bedside her bed. Resident #2 said she had not hurt herself on the metal. She denied reporting it. During an interview on 02/17/2026 at 11:20 a.m., the Laundry/Housekeeping Supervisor said she saw a new footboard in the storage shed but did not know it was needed. During an interview on 02/17/2026 at 1:50 p.m., the Maintenance Supervisor said the footboards were to keep mattress in place. He said no one reported the missing footboards for Resident #1 and Resident #2 in the electronic reporting system. He said he was recently hired and will be checking beds monthly. During an interview on 02/17/26 at 2:30 p.m., the Administrator said she was not sure why those beds did not have footboards. She said the facility replaced the footboard after surveyor intervention. She wanted all the beds to be in good order. Record review of the policy titled, Bed Maintenance and Inspection. dated 2024, indicated, Policy: It is the policy of this facility to conduct regular inspections of all bed frames. 3. The Maintenance Director shall review each manufacturer's recommendations and requirements for maintenance and bed inspections and shall establish a maintenance and inspection schedule accordingly.

Based on observations, interviews, and record review, the facility failed to provide proper treatment and services to prevent complications of enteral feeding for one of two residents (Residents #1) reviewed for feeding tubes. The facility failed to ensure staff followed physician's orders for 45 ml of water to be flushed every hour for Resident #1, while the tube feeding was running. These failures could place residents at risk of tube obstruction and a decrease in hydration. Findings included: Record review of Resident #1's face sheet, dated 01/12/26, reflected a [AGE] year-old female with an admission date of 04/14/23 and a re-admission date of 01/10/26. Diagnoses included dysphagia (difficulty swallowing), aphasia (impaired speaking, understanding, reading, and writing), and cerebral infarction (stroke). Record review of Resident #1's quarterly MDS assessment, dated 11/24/25, reflected Resident #1 was too cognitively impaired to complete a brief interview of mental status. She received 51% or more of her total calories through a peg tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Record review of Resident #1's care plan with a revision date of 07/18/24 reflected, .The resident has a feeding tube r/t Dysphagia, Hx of aspiration (when something other than air gets into your airway), Swallowing problem. {Resident #1} is NPO .The resident is dependent with tube feeding and water flushes. Record review of Resident #1's Physician active orders report dated 01/12/26 reflected, .TWO Cal 2.0 continuous 80ml/hr x 20hrs + 45ml/hr FWF . date active 05/12/25. Record review of Resident #1's Medication administration record for January 2026 reflected, .TWO Cal 2.0 continuous 80ml/hr x 20hrs + 45ml/hr FWF . date active 05/12/25. During an observation on 01/12/26 at 12:58 p.m. of the tube feeding pump for Resident #1, revealed the parameters on the screen showed 80 ml per hour for the formula and the water was set to 45 ml every 2 hours. The tube feeding was connected to Resident #1 and running. Resident #1 was not interviewable. During an interview with LVN A on 01/12/26 at 01:37 p.m. she stated the tube feeding was to be held from 8 a.m. until 12 p.m. She stated the order was for the formula to run 80 ml/hr and to be flushed with 45 ml of water every hour. LVN A and the surveyor proceeded to the tube feeding pump, where the parameters were read (flush 45 ml per every two hours). She stated, Oh, I will fix it right now. She stated the night nurses hung the feeding and the day nurses re-started the feeding. She stated the parameters not matching the orders could cause dehydration. During an interview with the DON on 01/12/26 at 01:55 p.m., the DON stated the expectations for tube feedings included to make sure it was labeled and dated, it was changed out every 24 hours and ensure the correct feeding rate and flushes matched the physician's orders. She stated it was the nurse's responsibility, and they should check the parameters on the pump to ensure they matched the order. She stated no recent related in-services, but they did them annually. She stated the result of parameters not matching the orders could be too many or too few calories for the resident or overhydration or dehydration of the resident. Requested recent training for the specific area from the DON on 01/12/26 at 01:55 p.m. and none were received before exit.Record review of the facility's policy, dated February 2023 and titled, Care and Treatment of Feeding Tubes, indicated. It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. 1. Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. 4. The facility will utilize the Registered Dietitian in estimating and calculating a resident's daily nutritional and hydration needs. e. Frequency of and volume used for flushing, including flushing for medication administration, and what to do when a prescriber's order does not specify.

Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 4 of 8 residents (Residents # 12, # 22, #210 and #259) reviewed for respiratory therapy. The facility failed to ensure Residents #12 and #22 had a physician order for oxygen and was care planned. The facility failed to ensure Resident #210 was set on 3 LPM per oxygen concentrator (machine that takes air from your surroundings and extracts oxygen and filters it into purified oxygen to breathe). The facility failed to keep the oxygen concentrator filter clean for Resident #259. These failures could place residents at risk of receiving incorrect or inadequate oxygen support which could result in a decline in health. Findings include: 1. Record review of the face sheet dated 05/14/25 indicated Resident #12 was admitted on [DATE] and was [AGE] years old. Her diagnoses included acute respiratory distress, chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #12 MDS had active diagnosis of debility, cardiorespiratory conditions, acute respiratory distress, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, shortness of breath with exertion and received oxygen therapy continuous. Record review of the undated care plan on 05/14/25 indicated Resident #12 did not have a care plan related to her receiving oxygen therapy. Record review of Resident #12's physician's orders dated 05/12/25 indicated no order for oxygen administration. Record review of the nursing progress notes dated 05/08/25 indicated Resident #12 Resident returned to facility via wheelchair accompanied by 1 personnel from hospital . Dx: chronic pain BLE. Current vitals: BP 122/64, HR 72, RR 21, SP02 98% 2 L[PM] (of Oxygen) and Temp 98.8 . During an observation on 05/12/25 at 09:35 a.m., Resident #12's concentrator setting indicated infusing at the rate of 3 LPM per concentrator and she was asleep in her bed with the oxygen nasal cannula on. During an observation and interview on 05/12/25 at 2:07 p.m., Resident #12's concentrator setting indicated infusing at the rate of 3 LPM per concentrator and she was sitting up in her wheelchair. Resident #12 said she was on oxygen for shortness of breath and that it helps her breath better. During an observation and interview on 05/12/25 2:30 p.m., LVN A nurse assigned to resident verified the concentrator was set on 3 LPM. LVN A said Resident #12 did not have an order for administration of oxygen. LVN A said Resident #12 used oxygen for shortness of breath and she would get an order for the oxygen. During an observation and interview on 05/13/25 at 09:00 a.m., Resident #12's said she had just finished her breakfast and her breathing was ok. Resident #12's concentrator setting indicated infusion at the rate of 3LPM and she was sitting up in her wheelchair. During an observation and interview on 05/14/25 at 09:10 a.m., Resident #12 was sitting up in her wheelchair doing a word search puzzle and said she had no breathing problems at this time. Resident #12's concentrator setting indicated infusion at the rate of 3 LPM. 2. Record review of the face sheet dated 05/14/25 indicated Resident #22 was admitted on [DATE] and was [AGE] years old. His diagnoses included essential hypertension, acute cough and chronic obstructive pulmonary disease. Record review of the annual MDS assessment dated [DATE] indicated Resident #22 MDS had active diagnosis of medically complex conditions, hypertension, chronic obstructive pulmonary disease. Record review of the undated care plan on 05/14/25 indicated Resident #22 did not have a care plan related to him receiving oxygen therapy. Record review of Resident #22's physician's orders dated 05/12/25 indicated no order for Oxygen administration. Record review of Resident #22's nursing progress notes dated 04/25/25 indicated .cough; O2 sat: 87% on room air. Resident placed on 3L NC, O2 improved to 93%. During an observation on 05/12/25 at 09:27 a.m., Resident #22's concentrator setting indicated infusion at the rate of 2LPM per concentrator and he was asleep in his bed with the oxygen nasal cannula on. During an observation and interview on 05/12/25 at 2:17 p.m., Resident #22's concentrator setting indicated infusion at the rate of 2LPM per concentrator and he was lying in bed watching TV. Resident #22 said he was on Oxygen most of the time for shortness of breath. During an observation and interview on 05/12/25 at 2:35 p.m., LVN A verified Resident #22's concentrator was set on 2 LPM. LVN A said Resident #22 did not have an order for administration of oxygen. LVN A said Resident #22 used oxygen for shortness of breath and she would get an order for the oxygen. During an observation and interview on 05/13/25 at 08:45 a.m., Resident #22's said he had just finished his breakfast and his breathing was good. Resident #22's concentrator setting indicated infusion at the rate of 2 LPM. During an observation and interview on 05/14/25 at 09:00 a.m., Resident #22 was lying in bed and said he was ok and breathing fine at this time. Resident #22's concentrator setting indicated infusion at the rate of 2 LPM. During an interview on 05/14/25 2:35 p.m., LVN A said she had forgotten to get oxygen orders for Resident #12 and #22 before she clocked out for the day on 05/12/25. LVN A said both Residents were on Oxygen for diagnosis of shortness of breath. LVN A said all nurses were responsible for making sure orders are obtained for oxygen administration and residents on oxygen without physician orders are at risk of not receiving the correct liters of oxygen. 3. Record review of the face sheet dated 05/12/25 indicated Resident #210 was admitted on [DATE] and was [AGE] years old. His diagnoses included diabetes, high blood pressure and third-degree burns. Record review of the admission MDS assessment dated [DATE] indicated Resident #210 MDS was not completed on 05/15/25, not due at that time of the record review. Record review of the care plan dated 05/08/25 indicated Resident #210 received oxygen therapy related to shortness of breath. The interventions included checking O2 saturations & provide respiratory treatments as ordered. Observe for the resident for sign/symptoms of cyanosis, hypoxia, and oxygen toxicity in relation to oxygen therapy. The signs & symptoms to observe for: blue tone to the skin and mucous membranes, rapid breathing, rapid pulse rate, restlessness, confusion, tracheal irritation, difficulty breathing, slow, & shallow rate of breathing. Notify physician upon observation. The oxygen settings were O2 at 3 liters via nasal cannula per physician order. Record review of the physician's orders dated 05/08/25 indicated an order for O2 at 3 LPM per concentrator per nasal cannula. During an observation and interview on 05/13/25 at 11:20 a.m., Resident #210's concentrator setting indicated infusing at the rate of 5 LPM per concentrator and he was in his bed with the oxygen nasal cannula on. LVN A was outside the room in the hall. The wound nurse was coming out of Resident #210's room; she verified the concentrator was set on 5 LPM but was unsure what he had ordered. LVN A said Resident #210 order indicated 3 LPM via concentrator per nasal cannula. LVN A adjusted oxygen setting to 3 LPM. During an interview on 05/13/25 at 2:00 p.m., the DON said the nurses should follow the physician orders with oxygen therapy. She said if too much oxygen was given that could depress the respiration. She said the nurses were responsible for checking the O2 settings and to follow the physician orders. During an interview on 05/14/25 at 8:00 a.m., the Administrator said her expectation was for the nurses to follow the physician's orders. 4. Record Review of Resident #259's face sheet dated 10/12/25, indicated she was a [AGE] year-old female readmitted on [DATE] with diagnoses of respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide resulting in dangerously low oxygen levels in the blood), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and heart failure (condition in which the heart does not pump blood as well as it should). Record Review of Resident #259's most recent quarterly MDS assessment dated [DATE] indicated she had a BIMS score of 5 which indicated severe cognitive impairment. The assessment indicated medical diagnoses of respiratory failure, chronic obstructive pulmonary disease and heart failure and received oxygen therapy on admission continuously and during the last 14 days while a resident in the facility. Record Review of Resident #259's care plan revised 05/13/25 indicated she received oxygen therapy related to chronic obstructive pulmonary disease with interventions including oxygen setting at 2 liters per minute per nasal canula per physician order. Record Review of Resident #259's care plan revised 05/13/25 indicated she received oxygen therapy related to chronic obstructive pulmonary disease with interventions including oxygen setting at 2 liters per minute per nasal canula per physician order. Record Review of Resident #259's Physicians Order Summary dated 05/12/25 indicated she was prescribed oxygen at 2 liters per minute by nasal canula continuously with an order date of 02/19/25. During an observation on 05/12/25 at 09:00 a.m., Resident #259 was lying in bed with oxygen per nasal canula set at 2 liters/ minute to an oxygen concentrator with a black concentrator filter. The oxygen concentrator filter was covered with a light gray powdery substance. Resident #259 said she wears her oxygen all the time. During an observation on 05/14/25 at 08:30 a.m., Resident #259 was lying in bed with oxygen per nasal canula set at 2 liters/ minute to an oxygen concentrator with a black concentrator filter. The oxygen concentrator filter was covered with a light gray powdery substance. Resident #259 said she wears her oxygen all the time. During an observation and interview on 05/14/25 at 8:30 a.m., LVN B said she was providing care for Resident #259 today. She said the filter on Resident #259's oxygen concentrator was dirty and should have been cleaned when the oxygen tubing was changed on 05/12/25. LVN B said maintenance was responsible for cleaning oxygen filters when servicing the concentrators and the night nurse that changed the oxygen tubing should be responsible for cleaning the oxygen concentrator filter. She said the nurses providing care for the residents were the back up and cleaned oxygen concentrator filters as needed. She said it was possibly overlooked but she would clean it now. LVN B said she was in-serviced to clean the oxygen concentrator filters as needed when visibly soiled. She said the resident risk was infection or the oxygen not properly traveling through the oxygen tubing. During an interview on 05/14/25 at 9:31 a.m., the DON said the night nurse was responsible for changing the oxygen tubing and checking the humidifier bottles (oxygen can be drying to your nose so some patients use a humidifier bottle to moisten the oxygen you breath) weekly and ensuring oxygen concentrator filters were cleaned as needed. She said the ADON was the back up and checked the oxygen concentrator filters every Monday. The DON said Resident #259's oxygen concentrator filter may have been overlooked when LVN C changed the oxygen tubing and humidifier bottle. She said the staff were in-serviced on 11/13/24 on respiratory training and to ensure oxygen concentrator filters were cleaned when visible soiled. The DON said there was no resident risk of an oxygen concentrator filter being dirty, if the air flow was obstructed the concentrator would alarm and it was not alarming. She said her expectation was oxygen concentrator filters checked weekly when the oxygen tubing was changed and if visibly soiled cleaned or changed. During an interview on 05/14/25 at 10:11 a.m., the Administrator said the night nurse that changed the oxygen tubing was responsible for ensuring the oxygen concentrator filters were clean and the ADON was the back up. She said all the nurses were educated on ensuring oxygen concentrator filters were clean. She said Resident #259's oxygen concentrator filter was possibly overlooked. The Administrator said there was no resident risk for oxygen concentrators with dirty filters. She said if the oxygen concentrator machine was not receiving proper airflow an alarm would sound if it needed to be addressed and Resident #259's oxygen concentrator was not alarming. She said her expectation was all oxygen concentrator filters were cleaned as needed. During a phone interview on 05/14/25 at 12:09 p.m., the ADON said she made rounds on Resident #259 on Monday, 05/12/25 and Resident #259's oxygen concentrator filter was not dirty, and she was unsure why the oxygen concentrator filter was on 05/14/25. The ADON said the oxygen concentrator filter was a grey/ charcoal color. The ADON said Resident #259 was a recent readmission from the hospital and was given a concentrator that was serviced with a clean filter. She said the night nurse that checked the oxygen humidifier bottle and changed the tubing was responsible for ensuring the oxygen concentrator filter was cleaned. The ADON said she was the back up and checked every Monday to ensure the oxygen concentrator filters were clean. She said all the nurses were in-serviced recently on cleaning oxygen concentrator filters. The ADON said the resident risk of a dirty oxygen concentrator filter was respiratory infection. Unable to interview LVN C, the night nurse that checked Resident #259's oxygen concentrator and changed the tubing on 5/12/25, due to no returned phone message. Record review of a facility in-service dated 11/13/24, titled, Respiratory Training indicated addressed, O2 devises . O2 concentrators Record Review of a facility policy revised 2023, titled, Oxygen Concentrator indicated, .The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. a. Follow manufacturer recommendations for the frequency of cleaning filters and servicing the device. Record review of the undated Oxygen Administration policy indicated Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such cases, oxygen is administered, and orders are obtained as soon as practicable when the situation is under control.4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessments and orders.5. a. Follow manufacturer recommendations for the frequency of cleaning equipment filters. 33460 41057

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure all staff wore hair restraints and restrained all of their hair while plating the food. (05/12/25) This failure could place residents who ate meals prepared in the kitchen at risk of foodborne illnesses. Findings included: During observation on 05/12/25 at 7:50 a.m., the DM was in the kitchen. The DM walked by the stove and by the food prepping tables. The DM operated the dish machine. There was a 2 inches wide area on each side of her neck of unrestrained hair approximately 3 to 4 inches long. During an interview and observation on 05/12/25 at 12:27 p.m., the kitchen staff was serving food for lunch in the dining room from steam table and soup cooker. The DM had a 2-inch-wide area on each side of her neck of unrestrained hair approximately 3 to 4 inches long and she was placing the soup in the bowls. [NAME] C was plating from the steam table the 1 inch to 1 1/2-inches of unrestrained hair on top of her hair which extended from her right ear to the left ear. A long braid along the left side of her face was out of the hair net approximately 4 inches long. DM said all hair should be restrained while serving. [NAME] C and the DM went and secured their hair and washed their hands, after surveyor intervention. The DM said she was responsible for ensuring the staff secured their hair. She said a hair could fall in the food if not secured. During an interview on 05/14/25 at 8:00 a.m., the Administrator said her expectation was for anyone serving food or in the kitchen to wear hair nets. Record review of the undated Dietary Employee Personal Hygiene policy indicated It is the policy of this facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food by foodservice employees. 4. a. Food employees shall wear hair restraints such as hats, hair covering or nets, beard restraints and clothing that covers body hair, that are designed and worn effectively keep their hair from contacting exposed FOOD, . Record review of the FDA food code dated 2022 indicated . Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for residents that included their specific needs as identified in each resident's comprehensive assessment for 2 of 10 residents (Residents #12 and #22) reviewed for person-centered care plans. Residents #12 and #22 did not have care plans developed for oxygen therapy. This failure could place residents at risk of not receiving proper care or inadequate oxygen support which could result in diminished physical, mental and psychosocial well-being. The findings included: 1. Record review of the face sheet dated 05/14/25 indicated Resident #12 was admitted on [DATE] and was [AGE] years old. Her diagnoses included acute respiratory distress, chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #12 MDS had active diagnosis of debility, cardiorespiratory conditions, acute respiratory distress, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, shortness of breath with exertion and received oxygen therapy continuous. Record review of the undated care plan on 05/14/25 indicated Resident #12 did not have a care plan related to her receiving oxygen therapy. Record review of the physician's orders for Resident #12 dated 05/12/25 indicated no order for oxygen administration. Record review of the nursing progress notes dated 05/08/25 indicated Resident #12 Resident returned to facility via wheelchair accompanied by 1 personnel from hospital . Dx: chronic pain BLE. Current vitals: BP 122/64, HR 72, RR 21, SP02 98% 2L[PM](of Oxygen) and Temp 98.8 . During an observation on 05/12/25 at 09:35 a.m., Resident #12's concentrator setting indicated infusing at the rate of 3 LPM per concentrator and she was asleep in her bed with the oxygen nasal cannula on. During an observation on 05/12/25 at 2:07 p.m., Resident #12's concentrator setting indicated infusing at the rate of 3 LPM per concentrator and she was sitting up in her wheelchair. Resident #12 said she was on oxygen for shortness of breath and that it helped her breath better. During an observation and interview on 05/12/25 at 2:30 p.m., LVN A verified Resident #12's concentrator was set on 3 LPM. LVN A said Resident #12 did not have an order for administration of oxygen. LVN A said Resident #12 used oxygen for shortness of breath. 2. Record review of the face sheet dated 05/14/25 indicated Resident #22 was admitted on [DATE] and was [AGE] years old. His diagnoses included essential hypertension, acute cough and chronic obstructive pulmonary disease. Record review of the annual MDS assessment dated [DATE] indicated Resident #22 MDS had active diagnosis of medically complex conditions, hypertension, chronic obstructive pulmonary disease. Record review of the undated care plan on 05/14/25 indicated Resident #22 did not have a care plan related to him receiving oxygen therapy. Record review of Resident #22's physician's orders dated 05/12/25 indicated no order for oxygen administration. Record review of Resident #22's nursing progress notes dated 04/25/25 indicated .cough; O2 sat: 87% on room air. Resident placed on 3 L[PM] NC, O2 improved to 93%. During an observation on 05/12/25 at 2:17 p.m., Resident #22's concentrator setting indicated infusion at the rate of 2 LPM per concentrator and he was lying in bed watching TV. Resident #22 said he was on oxygen most of the time for shortness of breath. During an observation and interview on 05/12/25 2:35 p.m., LVN A verified Resident #22's concentrator was set to 2 LPM. LVN A said Resident #22 did not have an order for administration of oxygen. LVN A said Resident #22 used oxygen for shortness of breath. During an observation and interview on 05/14/25 3:35 p.m., the DON verified Resident #12's concentrator was set on 3 LPM and Resident #22's concentrator was set on 2 LPM. The DON said oxygen therapy should have been included on Residents #12 and #22's care plans. After the DON reviewed Resident #12 and 22's care plans, she agreed there were missing care plans specific to the resident current needs of oxygen and did not know why or how it was missed. The DON said no one person was responsible for completing care plans and that it was the responsibility of all administrative nurses of the interdisciplinary team. The DON said she expected the team to complete care plans and to make sure they reflected the current care needs of the resident. Record review of facility undated policy titled Comprehensive Care Plan read in part . be developed for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs and ALL services that are been identified in the resident's comprehensive assessment . 3. The comprehensive care plan will describe, at minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . 4. The comprehensive care plan will be prepared by an interdisciplinary team .

Based on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 3 of 7 residents (Residents #9, #47, and #104) reviewed for unnecessary medications. The facility did not have appropriate indications for medications based on Resident #9's, #47's, and #104's diagnoses. This failure could place residents at risk of complications related to receiving unnecessary medications. Findings included: 1.Record review of the physician orders dated April 2024 for Resident #9 indicated she was a [AGE] year-old female readmitted on [DATE] with diagnoses including type 2 diabetes and morbid (severe) obesity due to excess calories. The orders indicated the resident had an order dated 08/16/23 indicated she was to receive Ozempic subcutaneous solution (used to treat weight loss) every Friday related to type 2 diabetes mellitus. Record review of a Nurse Note dated 03/22/24 indicated Resident #9 was trying to lose weight and was taking Ozempic to help with weight loss. During an observation and interview on 04/01/24 at 09:36 a.m. Resident #9 was a very large built person in a bariatric bed. She said she had started taking Ozempic for weight loss and was hoping it would help some because she wanted to lose weight. During an interview on 04/02/24 at 02:00 p.m. the DON said medications should have a diagnosis for the medication. She said the indications for Resident #9 were symptoms and drug classifications, not diagnoses. During an interview on 04/02/24 at 03:08 p.m. the former DON/Corporate Nurse said medications should have appropriate diagnoses for their medication indication. She said Resident #9 was taking the Ozempic for weight loss and not for her diabetes. 2. Record review of the physician orders dated April 2024 for Resident #47 indicated she was a [AGE] year-old female admitted on [DATE] with diagnoses included senile degeneration of the brain and dementia. The orders indicated the resident had an order dated 03/22/24 for valproic acid (anticonvulsant) for dementia. During an interview on 04/02/24 at 02:00 p.m. the DON said dementia was not an appropriate indication Resident #47's medications. 3. Record review of the physician orders dated April 2024 for Resident #104 indicated she was an [AGE] year-old female admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation (a type of irregular heartbeat) and restless leg syndrome. The orders indicated the resident had: * an order dated for Eliquis (blood thinner) for blood thinner; * an order dated for pramipexole dihydrochloride (used to treat restless leg syndrome) for antiparkinson's. During an interview on 04/02/24 at 09:20 a.m. Resident #104 said she did not have Parkinson's, but she took medication for her restless legs. During an interview on 04/02/24 at 02:00 p.m. the DON said medications should have an appropriate diagnosis for their use. During an interview on 04/02/24 at 03:08 p.m. the former DON/Corporate Nurse said medications should have appropriate diagnoses for their indication. Surveyor requested a medication policy related to medications and diagnoses on 04/03/24 from the DON and no policy was provided.

Based on interview and record review, the facility failed to ensure residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 3 residents reviewed for unnecessary psychotropic drugs. (Resident #47) The facility failed to ensure Resident #47 had an appropriate diagnosis or adequate indication for the use of Trazadone (an antidepressant used to treat depression) and Zoloft (an antidepressant used to treat depression). This failure could place residents at risk for receiving unnecessary medication, having unnecessary medication side effects, and a decreased quality of life. Findings included: Record review of the physician orders dated April 2024 for Resident #47 indicated she was an [AGE] year-old female admitted on [DATE] with diagnoses included senile degeneration of the brain (mental deterioration associated with aging) and dementia (loss of cognitive functioning). The orders indicated she had the following medications: * an order dated 02/23/24 for Trazadone (antidepressant) for dementia; and * an order dated 02/23/24 for Zoloft (antidepressant) for dementia. During an interview on 04/02/24 at 02:00 p.m. the DON said dementia was not an appropriate indication Resident #47's medications. Surveyor requested a medication policy related to medications and diagnoses on 04/03/24 from the DON and no policy was provided.

Based on interviews and record reviews, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 4 residents reviewed for resident rights. (Resident #5) The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Resident #5. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, and possibly being brought back to life in an unaware and unresponsive state. Findings included: Record review of physician orders for [DATE] indicated Resident #5 was an [AGE] year-old female readmitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), hypertension (condition in which the force of the blood against the artery walls is too high), and abdominal aortic aneurysm (enlargement of the main blood vessel that delivers blood to the body, at the level of the abdomen). She had an order dated [DATE] for DNR. Record review of the current MDS assessment dated [DATE] indicated Resident #5 was alert to person, place, and time with a BIMS of 11 indicating she had moderately impaired cognition. Record review of the EMR on [DATE] at 09:33 a.m. indicated Resident #5 had a scanned OOH-DNR dated [DATE] with no printed name of physician and no license number of physician. During an observation and interview on [DATE] at 11:05 a.m., Resident #5 was up in her recliner in her room. She said she did not want CPR done. During an interview on [DATE] at 02:00 p.m., the DON said she had just started at the facility yesterday, but she knew DNRs should be completed or they can be deemed as invalid. She said missing physician information would make a DNR invalid. She said they would start CPR and possibly bring the person back to life while possibly breaking rib bones. During an interview on [DATE] at 03:07 p.m., the former DON/Corporate Nurse said the SW usually did the DNRs. During an interview on [DATE] at 03:23 p.m., the SW said DNRs without complete information would be invalid. She said Resident #5's DNR would be invalid due to not having the physician information completed. Record review of a Do Not Resuscitate Order policy revised [DATE] indicated Policy Interpretation and Implementation: 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident .

Based on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 1 resident (Resident #42) reviewed for enteral feeding. LVN A failed to verify placement of Resident #42's G-tube by checking for residual (fluid and contents that remain in the stomach) before enteral administration of water and medications. This failure could place residents receiving enteral nutrition and medications at increased risk of not receiving proper nutrition, infection, and aspiration. Findings include: Record review of Resident #42's physician orders dated April 2024 indicated she was [AGE] years old and admitted to the facility 11/27/23. Her diagnosis included dysphagia (difficulty or discomfort swallowing) and aphasia (affects the ability to communicate). Orders indicated she was NPO (nothing by mouth) and was to receive all feedings and medications via G-tube (a tube inserted through the stomach that brings nutrition directly to the stomach). Record review of a care plan last revised 12/08/23 indicated Resident #42 had a feeding tube related to dysphagia, history of aspiration (breathing in a foreign object such as food), and swallowing problem. Interventions included to verify tube placement prior to use. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #42 had severely impaired cognition, was dependent for all ADLs, and received her nutrition and hydration via G-tube. During an observation during medication administration on 04/02/24 at 9:18 a.m., LVN A checked placement of Resident #42's G-tube by inserting 10ml of air into the tube and listening at the abdomen for the swish of air. She then administered water flushes and medications through the G-tube. During an interview on 04/02/24 at 9:28 a.m., LVN A said she normally checked placement of a G-tube by auscultation (listening for a swish of air inserted into the abdomen with a stethoscope) and checking for residual in the stomach. She said she forgot to check for residual today. She said possible negative outcome of not performing a residual check for placement of the G-tube could be administering medications to a stomach that was too full. She said she had received training on G-tubes at nursing school and during orientation at the facility. During an interview on 04/03/24 at 10:15 a.m., the DON said she was not aware of the recommendation in the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities that auscultation was no longer recommended for checking placement of a feeding tube. She said the facility policy indicated placement could be checked by auscultation or aspiration of residual. She said possible negative outcome of not checking placement of a G-tube by residual check could be administration of medications and/or feeding outside of the stomach. During an interview on 04/03/24 at 10:20 a.m., the Corporate Nurse said that the corporation was in process of reviewing and updating facility/corporate policies and she would bring the Confirming Placement of Feeding Tube policy to the attention of those updating policies. She said she was the former DON at the facility and all LVNs had received training on G-tubes and other skills during orientation to the facility. The training was given by staff LVNs, the ADON, and the DON. Record review of the facility policy titled Confirming Placement of Feeding Tubes revised March 2015 indicated .Observe for placement by: a. verify placement by auscultating stomach or b. verify placement by residual: little to no residual may suggest that the tube has migrated from the stomach to the esophagus.

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to professional standards of practice for 1 of 14 residents reviewed for respiratory care and services. (Residents #15) The facility did not provide Resident #15's oxygen concentrator with a clean filter. The filter was covered with a thick layer of white powdery substance. This failure could place residents who required respiratory care at risk of not receiving proper care and treatment and decreased quality of life. Findings included: Record review of the admission record indicated Resident #15 was admitted on [DATE]. Resident #15 was [AGE] years old male with diagnoses with chronic lung disease Record review of quarterly MDS assessment dated [DATE] indicated Resident #15 had moderately impaired cognition, and had not received oxygen during last 7 days. Resident#15 had diagnosis of chronic lung disease. Record review of the care plan dated 02/23/23 revealed Resident #15 was resistive to care with a history of non-compliance with O2 use as ordered. Interventions include an order for oxygen as ordered by physician. Record review of physician orders dated March 2023 indicated Resident #15 was [AGE] years old and had diagnoses of chronic lung disease. The orders included Administer O2 @ 2 LPM via N/C PRN (as needed) related to Chronic Obstructive Pulmonary disease (lung disease) with acute exacerbation (sudden worsening of symptoms) with a start date of 02/23/2023. During an observation and interview on 03/12/23 at 9:00 a.m., Resident #15 was receiving O2 at 2 LPM and filter on the concentrator was covered with a thick layer of white powdery substance. Resident #15 said the nurses change tubing and take care of that machine. During an observation on 03/13/23 at 9:38 a.m., Resident #15 concentrator's filter was still covered with a thick layer of white powdery substance. During an observation and interview on 03/13/23 at 10:00 a.m., LVN A checked Resident #15 concentrator's filter and said it was dirty and should have been cleaned last night. She said she normally worked the night shift and was trained to clean all filters on Sunday nights. However, she did not work last night. She said the filter being covered with dust could affect the output of the concentrator . During an observation and interview on 03/13/23 at 10:20 a.m., the ADON removed Resident #15's filter said she was taking the dirty filter to the DON. During an observation on 03/13/23 at 10:35 a.m., the DON said she expected the night nurse to clean filters every Sunday night and they had been trained. During the exit meeting on 03/14/23 at 2:02 p.m., the Administrator was given the opportunity to provide additional information related to oxygen concentrators. No additional information was provided.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for one of one kitchen reviewed food service safety, in that: There were unlabeled, undated, and unsealed containers of food items stored in the dry goods storage, freezers, and refrigerator. These failures could place residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: During an observation and interview with DM (who identified foods) on 1/24/22 at 9:10 a.m. of the dry goods storage, freezers and refrigerator in the kitchen revealed the following: Refrigerator/Cooler #1 * 2-quart bag of cooked okra, unlabeled (identifying what it was) and undated (when prepared or when to discard), DM stated, why they didn't put a label on it, it was cooked Friday and that it was cooked okra. DM also said kitchen staff who open and use food/liquids were responsible for labeling the item with the identity of the food/liquid and dating when it was opened or when to be discard. Freezer #1 * 1, Ziploc gallon bag of uncooked diced potatoes, unlabeled (identifying what it was) and dated 12/29/21. DM stated, she did know it was potatoes, but the bag should be labeled to identify the food inside. Freezer #2 * 1 original label bag of breakfast sausage patties, ripped open and used, the opened end was folded down on itself and tied in a knot and undated. Dry Goods Storage * 10-pound bag of [NAME] Noodles ripped open used and undated. On the end of the bag was ripped hole folded down on itself and not secure exposing the noodles to the elements. DM (Dietary Manager) stated the saved food must be labeled and dated properly to prevent cross contamination and from using spoiled foods. Dm further said if foods were not labeled and dated, it would be thrown out. DM stated eating outdated foods could make residents sick. Dietary Manager stated she monitors for that every day by looking in those areas where food was stored and would re-educate the staff on the spot who worked with that item of food. She said she was there but expects staff to do it on the weekends and she didn't have time to do it because surveyors came in on Monday. DM said the staff had been trained to properly store food by labeling it when it was opened and sealing it to reduce its exposure to the elements. DM stated she expects staff to date when it was opened or used by date and label food as to what it is as they are being put back in the refrigerator, freezer, or pantry. During an interview on 1/26/22 at 2:30 p.m., Administrator stated the food in the kitchen must be labeled and dated properly to prevent cross contamination and using spoiled foods. The Administrator said the dietary manager was responsible for ensuring/monitoring the freezer and refrigerator were in order. She said she expected for foods in the freezer and refrigerator to be labeled, dated and DM to follow the facility policy when it comes to food safety and maintaining the kitchen. Record Review of the facility's policy titled Food Receiving and Storage revised dated 12/08, documented the following: Policy Interpretation and Implementation .6. Dry foods that are stored in bins will be removed from original packing, labeled, and dated (used by date). Such foods will be rotated using a first in first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (used by date). The US FDA Food Code accessed on 2/7/22 at https://www.fda.gov/media/ 2/download, effective 2017 indicated the following: .302.12 Food Storage Containers, Identified with Common Name of Food Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD . During the exit on 1/26/22 at 4:00 p.m., the Administrator was asked for any additional information related to food service safety. No additional information was provided.

Based on interview and record review, the facility failed to ensure the drug regimen was free from unnecessary drugs for 1 of 15 residents reviewed for medication monitoring. (Resident #27) The facility did not monitor side effects for Resident #27's anticoagulant medication. This failure could place residents at risk for receiving unnecessary medications. Findings included: Record review of physician orders for Resident #27 dated January 2022 indicated Resident #27 admitted on [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated Resident #27 received [MEDICATION(S)] (blood thinner prevents blood clots) 5 mg by mouth two times daily for irregular heartbeat with start date of 9/20/21. The physician orders did not include monitoring for the [MEDICATION(S)]. Record review of the MAR for Resident #27 dated January 2022 indicated Resident #27 received [MEDICATION(S)] 5 mg twice daily and no documentation of monitoring for adverse reactions. Record review of the annual MDS for Resident #27 dated 10/10/21 indicated Resident #27 had impaired cognition and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the care plan for Resident #27 dated 10/19/21 indicated Resident #27 was on anticoagulant therapy with [MEDICATION(S)] related to irregular heartbeat. The goal indicated the resident would be free of adverse reactions related to anticoagulant therapy. Approaches indicated monitor/document/report as needed adverse reactions of anticoagulant therapy blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools. During an interview on 1/26/22 at 8:30 a.m., LVN A said Resident #27 was receiving [MEDICATION(S)] 5 mg twice daily and was not being monitored for adverse reactions. LVN reviewed Resident #27 orders, the MAR, and said the medication was not being monitored and should have been monitored. She said all the nurses were trained on monitoring blood thinners and it was important to monitor so the resident doesn't have excessive bleeding or bruising. She said on admit it should have been included in the orders and if not, the nurses could add monitoring. During an interview on 1/26/22 at 11:00 a.m., the DON said her expectation was for nurses to monitor anticoagulants and said it was important to monitor and then inform physician if excessive bleeding is observed. During an interview on 1/26/22 at 11:03 a.m. the Administrator said she expected the nurses to monitor medications which required monitoring. Record Review of Medication therapy dated April 2007 Policy indicated . 3 All medication orders will be supported by appropriate care processes and practices.5. B. when the results of ongoing assessments, or the presences of clinically significant adverse monitoring suggest that medication should be reduced or discontinued. During the exit on 1/26/22 at 4:00 p.m., the Administrator was asked for any additional information related to unnecessary medications. No additional information was provided.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in 1 of 3 medication carts reviewed. (medication cart assigned to Hall 200) Medication cart assigned to Hall 200 was left unlocked and unattended. This failure could place the residents who received medications at risk for drug diversion. Findings include: During an interview and observation on 1/25/22 at 7:47 a.m., LVN B was giving a resident medication in room [ROOM NUMBER] during the medication pass observation. She left the cart unlocked and walked into a resident's room and pulled the privacy curtain and gave the resident's medications. After the medications were given, she walked back to the medication cart and said she had left the medication cart unlocked. She said she was nervous. LVN B said she was trained to keep cart secure and should have locked it. She said we have residents that could take medications not for them. During an interview on 1/26/22 at 10:45 a.m., the DON said the medication carts should be locked when the nurse leaves the cart. She said the nurses were responsible for their medication carts. The DON said she makes rounds and checks the carts, all the time and the cart should be locked to prevent drug diversion. During an interview on 1/26/22 at 10:50 a.m., the Administrator said the medication carts should be locked when not within the sight of the nurse assigned to the cart. Record review of the Security of Medication Cart policy dated April 2007 indicated The medication cart shall be secured during medication passes. 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 4. Medication carts must always be securely locked . when out of the nurse's view. During the exit on 1/26/22 at 4:00 p.m., the Administrator was asked for any additional information related to drug security. No additional information was provided.

Surveyor: Benoit,(NAME)T. Based on observation, interview, and record review, the facility failed to ensure the environment remained as free of accident hazards as possible and adequate supervision was provided to prevent an elopement for 1 of 9 residents reviewed for accidents. (Resident #22) The facility did not prevent Resident #22, a resident who was cognitively impaired with exit seeking behaviors, from eloping from the facility. Resident #22 was found on a high traffic street, on a bridge, which crossed over multiple rail road tracks. This failure could place the residents with exit seeking behaviors at risk for injury or death. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 10/13/2020. While the IJ was removed on 10/15/2020, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: A hospital history and physical/psychiatric evaluation dated 8/8/20 (prior to Resident #22s admission to the nursing facility) indicated Resident #22 walked out of the family home with her 10-month-old grandson. Her family is worried about her safety as well as their safety and thinks she needs help for her care. Today patient is seen in bed. Patient is blind and hard of hearing. A hospital progress noted dated 8/8/20 indicated Resident #22 was diagnosed with [REDACTED]. Physician orders [REDACTED].#22, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. There were no orders for a wanderguard (monitoring bracelet used to prevent a resident from eloping). During an interview on 10/15/20 at 10:03 a.m., the MDS nurse said the admission MDS assessment dated [DATE] for Resident #22 was incorrect and should indicate the resident wandered and had a wander guard. An admission assessment dated [DATE] indicated Resident #22 had an admitting [DIAGNOSES REDACTED]. The safety section of the assessment indicated the resident was alert and oriented x 3 and was legally blind. The Elopement Risk section indicated Resident #22's cognitive status was alert and oriented x 3, she did not wander, and was at low risk for elopement. The intervention did not indicate the resident had a wanderguard. A nursing note dated 8/19/20 indicated a wanderguard was placed on Resident #22. A baseline care plan dated 8/20/2020 indicated Resident #22 wandered. The interventions included use of a wanderguard, placement on the secure memory unit, and redirect the resident. The baseline summary indicated the resident had a prosthetic right eye. An elopement risk assessment dated [DATE] indicated Resident #22 had [DIAGNOSES REDACTED]. Nursing notes for Resident #22 between 8/22/20 and 9/2/20 indicated the following: *8/22/20 - The resident continued to wander the halls stating I'm looking for my house.; *8/23/20 - The resident wanders in and out of other resident's rooms. Has attempted to exit building. Needs constant redirection; *8/31/20 - The resident was going in and out of other resident's rooms. Staff tried to redirect but it was not effective.; and *9/2/20 - The resident continued to wander in and out of resident's rooms. The most recent MDS assessment dated [DATE] indicated Resident #22 had severely impaired cognitive skills for daily decision making, ambulated with a cane, did not have an alarm in place, and did not wander. During an interview on 10/15/20 at 11:16 a.m., LVN D said Resident #22 wandered the hall all day and would wander off to the sitting area at the front of the facility and/or to the doors. LVN D said the resident had to be constantly redirected. She said the resident often went to the doors and would set the alarm off. When asked about the nursing note dated 8/23/2020, she said the resident kept going to the door, pushing on the bar and setting off the alarm. LVN D said the wanderguard alarm could be heard from the nurses' station. A physician assistant note dated 9/3/2020 indicated Resident #22 was a New patient; resident noted to be confused and wandering in and out of other patient's rooms. Hospital notes indicated patient is at risk to herself as she wonders away from home and is only oriented to self. She did receive a [DIAGNOSES REDACTED]. A nursing note dated 9/5/20 indicated Resident #22 wandered the halls all day and redirection was not effective. The note indicated .at this time resident is exit seeking . Resident #22's clinical record did not include nursing notes regarding the resident's wandering behaviors from 9/6/20 - 9/16/20. An elopement risk assessment initiated by LVN C, dated 9/16/2020, indicated Resident #22 had a [DIAGNOSES REDACTED]. The summary section indicated the resident needs a lock down unit. During an interview on 10/14/2020 at 11:12 a.m., the administrator said she did not know why the MDS coordinator put the intervention to place for Resident #22 to be on the secured memory unit. The administrator said the facility did not have a secured memory unit. During an interview on 10/15/20 at 10:59 a.m., LVN C said the elopement assessment dated [DATE] was initiated because administration gave the nurses a list of all residents who needed to have their information updated. She said Resident #22 would often get close to the door and the alarm would go off. She said the resident often had to be redirected. A nursing note dated 9/17/20 indicated Resident #22 wandered in and out of other resident's rooms disrupting their sleep. Resident #22 was redirected various times. A care plan updated 9/17/2020 indicated Resident #22 was at risk for elopement related to dementia and [MEDICAL CONDITION]. The interventions included Resident requires secure unit placement. Assist and provide resources for safe placement for resident. Resident #22's clinical record did not include any nursing notes regarding the resident's wandering behaviors from 9/18/20 and 9/30/20. A nursing note dated 9/30/20 indicated Resident #22 eloped and was found one block away from the facility. An incident report dated 10/1/2020 indicated the facility received a phone call from a good Samaritan on 9/30/20 reporting Resident #22 was walking down the street. The incident report indicated the resident was a wanderer. There were no witnesses found. The report did not include interventions to prevent future elopements. A nursing note dated 10/2/2020 (written by the DON regarding the incident on 9/30/20) indicated per shift nurse: received a phone call from a good Samaritan stating he saw an older lady with a cane walking on the side of the street and he was concerned it was one of our residents. After checking all rooms, (LVN A) found (Resident #22) was missing and left with (CNA B) in his car to go find and pick up the resident. Found her on the bridge. Was not hurt. Put her in the car and drove back to the facility. During an interview on 10/13/2020 at 1:28 p.m., LVN A (who was on duty 9/30/20 when Resident #22 eloped) said Resident #22 was very confused and constantly wandered around the facility and never stayed still. She said on 9/30/2020, someone from the community called while she was looking for the resident and said there was an elderly person on the bridge. She said the last time she saw the resident was around 7:30 p.m. and found the resident around 9:00 p.m. She said she and CNA B got in his car and went and got the resident as she was walking up the bridge. The resident was assessed and did not have any injuries. She said she was not sure how the resident got out and she did not hear the alarm. She said the wanderguard was in place on Resident #22. She said she did not put monitoring sheets in place for Resident #22. During an interview on 10/14/2020 at 2:15 p.m., the DON said Resident #22 eloped on 9/30/2020 and was found at the bridge. She said LVN A thought the wanderguard alarm would not reset if a resident was still outside, so she reset the alarm and went to account for all of the residents. The DON said LVN A did not check outside. The DON said that was when the good Samaritan called and told LVN A the resident was walking down the road. She said her expectations were for the nurses to have knowledge of how the alarm functions, to check the doors immediately when the alarm sounds, to check outside when the alarm sounds, and to monitor residents who were known wanderers. During an observation and interview on 10/14/20 at 11:02 a.m., the administrator said the MDS nurse texted her on 9/30/20 at 6:44 p.m. to tell her Resident #22 eloped and was found down the street. She said the text indicated the alarm sounded and LVN A did not know the alarm would reset with a resident outside. The administrator showed the surveyor the text message which was dated 9/30/20 with a time of 6:44 p.m. and indicated the MDS nurse notified the administrator the resident had eloped. During an interview on 10/13/20 at 11:59 a.m., the administrator said Resident #22 walked all day long to the point of wearing herself out. She said the nurses did not sit at the front door after the receptionist left and she did not have anyone she could put one on one with the resident. She said she was aware of Resident #22's elopement risk upon admission but felt the facility could manage it with the wanderguard. She said Resident #22 did not have monitoring sheets in place and the incident was not investigated or reported to the state survey agency. The administrator said she did not know why the MDS coordinator listed the secure memory unit as an intervention in the baseline care plan when the facility did not have a secure unit. When asked when she realized they could not meet the resident's needs, the administrator said when they made the referral to APS on 10/12/2020. During an interview on 10/16/20 at 10:25 a.m., CNA B (who was on duty 9/30/20 when Resident #22 eloped) said the resident got out of the front door just after they had finished serving supper. CNA B said he was in the breakroom, when a staff person came and told him Resident #22 had eloped, was on the bridge, and he needed to go get her. He said Resident #22 had a wanderguard in place, but he did not hear the alarm sound from the breakroom. CNA B said the resident was 1/4 of the way up the bridge when they found her walking with her cane. She did not appear to be injured. During an interview on 10/13/2020 at 11:03 a.m., the receptionist said she worked at the facility Monday through Friday and when she left at 5:00 p.m., the nurses on the hall monitored the front door. She said there was not a specific nurse assigned to the front desk after 5:00 p.m. During an interview on 10/15/2020 at 12:00 p.m., the administrator said the road in front of the facility, where Resident #22 had eloped to, was a busy road with speeding cars. She said the road was dangerous. An in-service regarding the door alarms and elopement dated 10/1/2020 did not contain the signatures of LVN A and CNA B, who were present on the hall the evening Resident #22 eloped. During an interview on 10/14/2020 at 2:24 p.m., the ADON said she had not completed instruction to all staff on the in-service dated 10/1/2020 regarding the door alarms and elopement. During an observation and interview on 10/13/20 at 11:02 a.m., Resident #22 was sitting in the front lobby in a chair. The resident said she was waiting to get in line and she repeatedly asked where she was, where she needed to be, and what she needed to be doing and then said she was scared. During an observation and interview on 10/13/20 at 11:05 a.m., Resident #22 was brought to front door by the MDS nurse with alarm sounding when the resident stepped on the door jamb plate. The MDS nurse said the resident wandered around the facility constantly and said she had a history of [REDACTED]. During an interview on 10/13/2020 at 1:45 p.m., the DON said there was no documentation to indicate Resident #22 was monitored for elopement behaviors. An elopement risk assessment dated [DATE] (after surveyor intervention) indicated Resident #22 was continuously confused, wandered with a history of elopement and was ambulatory/independent with an elopement risk score of 17, which indicated the resident was at high risk for elopement. The care plan updated 10/14/2020, after surveyor intervention, indicated Resident #22 was at risk for elopement related to dementia, [MEDICAL CONDITION], and an elopement risk score of 17. During an interview on 10/16/20 at 8:45 a.m., the medical director said his expectations were for the facility to increase monitoring on a resident who was at risk for elopement. He said assessment and evaluation of the resident were the most important interventions and the facility should call the resident's physician for advise. He said if they could not contact them, they could always call the medical director for recommendations. An Elopements policy dated 2001 indicated: . 4. If an employee discovers that a resident is missing from the facility, he/she shall: . e. initiate an extensive search of the surrounding area. The administrator and DON were notified on 10/13/2020 at 3:30 p.m., an Immediate Jeopardy situation was identified due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 10/14/2020 at 5:45 p.m. and included: * Identified resident was reassessed for risk of elopement using 9/30 elopement information. Resident will be placed with 1:1 until transfer to secure unit can be accommodated. * All other residents currently wearing a wanderguard or marked as having an elopement risk score higher than 15 will be reassessed by charge nurse for changes and accuracy. * All residents currently wearing a wanderguard will have Q shift checks of device placement and skin integrity around bracelet by charge nurse. This will be documented on the Medication Administration Record by the Charge nurse. * MDS nurse will Update residents care plans with current elopement risk scores and interventions to prevent elopement. * DON will In-service all staff on response to elopement to include prevention and intervention response by end of week or prior to return to work. * The Charge nurse will check all wanderguards in facility weekly for correct operation and function and document on Medication Administration Record. * Maintenance Director will check all exits in facility weekly to ensure correct operation and function and log the results. * All new admissions will be audited to ensure proper risk scores are in place with adequate intervention. On 10/15/20 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Resident #22 was observed with 1 on 1 supervision from 10/14/2020 at 8:00 a.m. until the time of exit on 10/16/2020 at 3:20 p.m. An in-service dated 10/14/2020 indicated staff were in-serviced regarding response time to alarms, to check surrounding areas for residents when the alarm sounds, start accountability rounds (checks to make sure all residents are in the facility), notify administrator/physician/RP immediately if a resident is missing, complete the head to toe assessment if the resident is found, complete an incident report and chart in the resident's medical record, monitor residents with wanderguards for changes in their current status or behavior and if noted notify the administrator immediately, complete a new elopement assessment, check wanderguard placement every shift and check wanderguard function every week. 4 CNAs, 1 staffing coordinator, 2 housekeeping staff, 1 receptionist, 1 human resource staff, the social worker, and the activity director were interviewed and were able to verbalize the appropriate interventions of timely response to the wanderguard alarm, checking outside for residents if the alarm sounds, securing the resident if found, and reporting a missing resident immediately to the charge nurse. 4 nurses were interviewed and were able to verbalize the appropriate interventions of timely response to the wanderguard alarm, checking outside for residents if the alarm sounds, securing the resident if found, performing a head count immediately, routine reassessment of residents at risk for elopement and checking the wanderguard device for skin integrity/placement and function, Care plans for the 9 residents at risk for elopement were updated to reflect their current elopement risk score. MARs of the 9 residents at risk for elopement indicated the resident's wanderguard assessments were updated to reflect their current elopement status and included Q shift checks. A Door Alarm form dated January 2020 to present indicated maintenance was performing weekly operation tests of door alarms and lock systems. On 10/15/2020 at 12:00 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During the exit on 10/16/20 at 3:45 p.m., the facility was asked for any additional information related to these findings. No additional information was provided.

Based on interview and record review, the facility failed to ensure a discharge summary was completed for 2 of 2 residents reviewed for discharge summary (Residents #47 and 48). Residents #47 and 48 did not have discharge summary's indicating a recapitulation of stay and reasons for discharge. This failure could place discharged residents at risk of incomplete medical records or not receiving needed services and equipment after discharge. Findings included: 1. Physicians orders dated 8/1/20 indicated Resident #47 was admitted to the facility 7/27/20, was [AGE] years old, and a had [DIAGNOSES REDACTED]. A discharge summary for Resident #47 dated 8/19/20 only indicated Resident #47 was on speech therapy, occupational therapy, and physical therapy services. The discharge summary did not include a summary of the resident's course of treatment, disposition, in case of death: where the remains were sent to, or the date and time of death. A care plan dated 8/19/20 indicated Resident #47 had an advance directive DNR (Do Not Rescucitate), had a terminal prognosis related to a [DIAGNOSES REDACTED]. A discharge MDS assessment dated [DATE] indicated Resident #47 had a death in facility. A report titled Release of Body: indicated Resident #47's hospice nurse pronounced the resident's death, notified his physician, and released the body to the funeral home. During an interview on 10/16/20 at 11:10 a.m., the medical records personnel said the discharge summary for Resident #47 was not complete, and it should have been. 2. Physicians orders dated 10/1/20 indicated Resident #48 was admitted to the facility 9/4/20, was [AGE] years old, and had [DIAGNOSES REDACTED]. A baseline care plan dated 9/5/20 indicated Resident #48 planned to discharge home and no anticipated discharge needs were noted. An MDS assessment dated [DATE] indicated Resident #48 was discharged and return was not anticipated. During an interview on 10/16/20 at 11:10 a.m., the medical records personnel said she could not locate a discharge summary for Resident #48. During an interview on 10/16/20 at 11:35 a.m., the DON and ADM both said it was expected that every resident discharged from the facility would have a complete discharge summary. A policy dated December 2016 titled Discharge Summary and Plan indicated the following: .When the facility anticipates a resident's discharge to a private residence, another nursing care facility, a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: . i. Special treatments or procedures (treatments and procedures that are not part of basic services provided); . k. Discharge potential (the expectation of discharging the resident from the facility within the next three months); . During the exit on 10/16/20 at 3:20 p.m., the facility was asked for any additional information related to these findings. No additional information was provided.

Based on observation, interview, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 24 residents reviewed for assessments. (Resident #22, 23 and 26) Resident #'s 22, 23, and 26 MDS assessments were not accurate and did not indicate the residents wandered and had a wanderguard in place. This failure could place the residents at risk for not receiving services to maintain their highest practicable well-being. Findings included: 1. Physician orders [REDACTED].#22, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A baseline care plan dated 8/20/2020 indicated Resident #22 wandered with interventions of wanderguard, secure memory unit and redirect resident. Nursing notes from 8/19/20 through 8/23/20 indicated the following wandering behaviors for Resident #22: *8/19/2020 - a wanderguard was placed on the resident; *8/22/2020 - the resident continued wandering halls . Stated I'm looking for my house; and *8/23/2020 - resident wanders in and out of other resident's rooms. Has attempted to exit building. Needs constant redirection The most recent MDS assessment dated [DATE] indicated Resident #22 had severely impaired cognitive skills for daily decision making, did not have an alarm in place, and did not wander. During an interview on 10/15/20 at 10:03 a.m., the MDS nurse said the admission MDS assessment dated [DATE] for Resident #22 was incorrect and should indicate the resident wandered and had a wanderguard. During an observation and interview on 10/13/20 at 11:02 a.m., Resident #22 was sitting in the front lobby in a chair. The resident said she was waiting to get in line and repeatedly asked where she was, where she needed to be, and what she needed to be doing and then said she was scared. During an interview on 10/13/20 at 11:05 a.m., the MDS nurse said the resident did wander around the facility constantly. During an interview on 10/13/20 at 11:59 a.m., the administrator said Resident #22 walked all day long to the point of wearing herself out. During an interview on 10/13/2020 at 1:28 p.m., LVN A said Resident #22 was very confused, constantly wandered around the facility, and never stayed still. 2. Physician orders [REDACTED].#23, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An order dated 2/13/19 indicated the resident may have a wanderguard due to their elopement risk. During an observation on 10/13/20 at 10:00 a.m., Resident #23 was self-propelling their wheelchair on the 200 hall wandering aimlessly in and out of rooms and was redirected by staff as they passed. Resident #23 had a wanderguard on the left ankle. A care plan dated 10/5/20 indicated Resident #23 was an elopement risk/ wandered aimlessly with interventions of wanderguard, and distract and redirect the resident. An elopement risk assessment dated [DATE] indicated Resident #23 was at risk for elopement. During an interview on 10/13/20 at 10:30 a.m., LVN E said Resident #23 used the wheelchair to move around the facility, needed constant redirection from entering other residents' rooms, and had a wanderguard placement. The most recent MDS assessment dated [DATE] indicated Resident #23 had severely impaired cognitive skills for daily decision making, did not have an alarm in place, and did not wander. During an interview on 10/15/20 at 11:00 a.m., the MDS Nurse said the annual MDS assessment dated [DATE] for Resident #23 was incorrect and should indicate the resident wandered and had a wanderguard alarm in place. The MDS Nurse said Resident #23 was confused and wandered aimlessly around the facility using a wheelchair. 3. Physician orders [REDACTED].#26, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An order dated 2/26/19 indicated the resident may have a wanderguard due to their elopement risk. During an observation on 10/13/20 at 10:15 a.m., Resident #26 was self-propelling their wheelchair on the 200 hall wandering aimlessly in and out of rooms and was redirected by staff as they passed. Resident #26 had a wanderguard on the right ankle. A care plan dated 7/22/20 indicated Resident #26 was an elopement risk/ wandered aimlessly with interventions of wanderguard, and distract and divert the resident. An elopement risk assessment dated [DATE] indicated Resident #26 was 12, at risk for elopement. During an interview on 10/13/20 at 10:45 a.m., LVN E said Resident #26 used the wheelchair to move around the facility, needed constant redirection from entering other residents rooms, and had a wanderguard placement. The most recent MDS assessment dated [DATE] indicated Resident #26 had severely impaired cognitive skills for daily decision making, did not have an alarm in place, and did not wander. During an interview on 10/15/20 at 11:00 a.m., the MDS Nurse said the annual MDS assessment dated [DATE] for Resident #26 was incorrect and should indicate the resident wandered and had a wanderguard alarm in place. The MDS Nurse said Resident #26 was confused and wandered aimlessly around the facility using a wheelchair. During the exit on 10/16/20 at 3:20 p.m., the facility was asked for any additional information related to these findings. No additional information was provided.