Every finding on record at Bedford Care Center of Mendenhall

Based on observation, interview, and record review, the facility failed to implement an effective infection prevention and control program for two (2) of three (3) residents observed for infection prevention practices related to medication administration and wound care. (Residents #4 and #42).Findings Include:Record review of the facility policy Handwashing/Hand Hygiene revised 8/2/22 revealed, This facility considers hand hygiene the primary means to prevent the spread of infection and recommends to perform hand hygiene after removing gloves .Record review of the facility policy Enhanced Barrier Precautions revised 3/27/26 revealed, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .Resident #4 During an observation of wound care at 2:30 PM on 6/24/26 provided by Registered Nurse (RN) #1 revealed the nurse cleansed the dirty sacral wound with normal saline soaked gauze, changed gloves, then cleansed with [NAME] violet compound, applied clean gloves and applied silver collagen and dressing. She then discarded her gloves and applied a clean pair before performing wound care on the resident's left gluteal wound site. During care, she did not perform hand hygiene between glove changes or before starting care on the second wound.In an interview at 2:43 PM on 6/24/26, RN #1, noted that hand hygiene should be performed any time gloves are removed to cleanse any contaminants that reached the hands through the gloves. She noted that cross contamination was possible when not performing hand hygiene particularly between care provided on multiple wounds and noted that consequences include increased risk for infection of the resident's wound.An interview at 3:08 PM on 6/24/26, with the Infection Preventionist revealed nurses should perform hand hygiene any time gloves are removed during care to prevent spreading infection to a wound and again prior to moving from care of one wound to another to avoid spreading bacteria in one wound bed to another. She further explained that failure to do so could increase the risk of wound infection for the resident.An interview with the Director of Nursing (DON) at 3:14 PM on 6/24/26, revealed the nurse should have cleansed her hands between each glove change and before performing a second wound change because glove changes do not negate the need to clean hands to remove possible contaminants from them. She confirmed that by not doing so can increase risk for wound infection. She also stated that her expectation of staff is that they will wash hands in appropriately as instructed by facility policy.A record review of Resident # 4's admission Record revealed that she was admitted on [DATE] with diagnoses that included Alzheimer's.A record review of Resident # 4's Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 5/5/26 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment.A record review of the resident's Order Summary Report with active orders as of 6/24/26 revealed an order dated 6/24/26, Cleanse stage III Pressure Ulcer to left gluteal fold daily and as needed with normal saline or wound cleanser pat dry apply gentian violet to peri wound apply silver collagen to wound bed, secure with dry dressing .Resident # 42:On 06/24/2026 at 7:52AM, Licensed Practical Nurse (LPN) #1 was observed performing medication administration of gastrostomy tube medications. Prior to administration, the resident was noted to have a sign on the door indicating Enhanced Barrier Precautions (EBP) during care which involves close contact. LPN#1 did not apply a gown prior to administering drugs and was observed with her scrubs touching the resident's bed linens while adjusting the bed height and when looking for the resident's gastrostomy tube in the resident's linens. At 8:01 AM. on 6/24/26, LPN #1 was interviewed and when asked about EBP. She stated that she thought they had to be worn for the resident's wound care or for nephrostomy tube site care, but not for medication administration. She noted that EBP would help prevent spread of germs from staff to the resident when performing care such as in this instance when her scrubs came in contact with the resident's linens.An Interview at 3:08 PM, on 6/24/26, with the facility's Infection Preventionist stated nurses should utilize EBP to prevent contamination of a resident's indwelling medical devices by staff or from resident to resident to and failure to wear them correctly puts residents at risk.An interview with the DON at 3:14 on 6/24/26, revealed gowns should be worn when performing medication administration via gastrostomy tube to avoid spreading infection to the tube site as it is an opening to the skin for contamination and failure to follow EBP can lead to the resident getting an infection. She further noted that she expects staff to follow EBP in accordance with the facility policy.A record review of Resident #42's admission Record revealed she was admitted on [DATE] with diagnoses that included cerebral infarction.A record Review of Resident #42's Order Summary Report revealed an order dated 4/15/26 for Enhanced Barrier Precautions.A record review of the MDS with an ARD of 4/20/26 revealed the resident had a BIMS score of 07 which indicated severe cognitive impairment.

Based on observation, interviews, record review, and facility policy review, the facility failed to respond to Resident Council concerns and recommendations for three (3) of (3 ) residents interviewed. (Residents #11, #22, and #26).Findings Include:A record review of the facility policy titled, Resident Council Meeting, with a revision date of 10/1/22, revealed, .7. The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate decisions to the Council .At 9:25 AM on 6/23/26, during an interview, Resident #22 reported that upon admission less than a year ago, she was told that Certified Nursing Assistants (CNAs) would make her bed daily, as she is unable to do so due to chronic lower back problems. Resident #22 mentioned that despite repeated requests, staff continued to fail to make her bed. She stated, This is my home, and she expected the facility to provide the service as promised. On 6/23/26 at 3:00 PM, during the Resident Council meeting, several residents expressed a desire for their beds to be made daily, believing CNAs were responsible for this task. They felt that having their beds made contributed to a clean, organized, and homelike environment and noted that this concern had been previously raised with staff in earlier meetings. Resident #11 reported that her bed remained unmade despite being out of it most of the day. She indicated that she had repeatedly asked staff to make her bed, but they only changed the sheets on shower days but still neglected to make the entire bed. Resident #11 shared that she made her bed daily when living at home and expected the same in the facility. Resident #26 mentioned his desire for his bed to be made every day. He stated that since staff did not routinely make his bed, he attempted to straighten it himself from his wheelchair to keep his room neat.On 6/23/26 between 3:30 PM and 5:30 PM, the State Agency made observations of randomly selected resident rooms. This revealed several residents were not present in their rooms and their beds remained unmade.On 6/24/26 between 1:00 PM and 2:30 PM, additional random observations revealed residents were not present in their rooms and several beds remained unmade.On 6/24/26 at 9:48 AM, during an interview, the Activities Director acknowledged residents raised concerns during the Resident Council meeting regarding daily bed making. The Activities Director acknowledged the concern was not documented in the Resident Council meeting minutes.On 6/24/26 at 9:52 AM, during an interview, the Administrator stated he regularly attended Resident Council meetings when invited by residents. The Administrator acknowledged residents discussed concerns regarding daily bed making during the Resident Council meeting but stated he did not consider the concern significant enough to document as a grievance. The Administrator further stated it was the responsibility of the CNAs to make residents' beds daily.On 6/25/26 at 9:09 AM, during a follow-up interview, Resident #22 stated she routinely attended Resident Council meetings where the Administrator was often present. Resident #22 stated residents had repeatedly voiced concerns regarding beds not being made but the concerns continued without resolution.A record review of the most recent Resident Council Meeting dated 6/5/26 shows no reference of concerns mentioned by any Residents who attended.A record review of Resident #22's admission Record revealed an admission date of 1/9/26 with diagnoses including Unspecified Cirrhosis of the Liver.A review of Resident #22's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/21/26 revealed a Brief Interview for Mental Status (BIMS) score of 9.A review of Resident #26's admission Record revealed an admission date of 7/8/25 with diagnoses including Chronic Respiratory Failure.A review of Resident #26's MDS with an ARD of 4/14/26 revealed a BIMS score of 14, indicating the resident was cognitively intact.A review of Resident #11's admission Record revealed an admission date of 11/13/25 with diagnoses including anxiety disorder.A review of Resident #11's MDS with an ARD of 5/19/26 revealed a BIMS score of 11, indicating the resident had moderate cognitive impairment.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure residents were transferred using the care planned mechanical lift, resulting in Resident #14 being transferred with an inappropriate sit to stand lift rather than the required total lift for one (1) of three (3) residents who required a lift for transfers.Findings include:A record review of the facility policy titled Safe Transfer and Lifting of Residents, revised 8/2/22, revealed, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility used appropriate techniques and devices to lift and move residents.V. c. Identifies resident/ensures proper transfer is followed per care plan.Record review of the Incident Investigation Summary dated 4/20/26 revealed, .The investigation identified that the CNA did not follow the resident care plan and facility policy related to transfer technique during the shifts on 4/15/26.On 6/23/26 at 2:02 PM, during a phone interview, Certified Nursing Assistant (CNA) #1 stated she was assigned to Resident #14 on 4/15/26 and transferred the resident from the bed to the wheelchair using a sit to stand lift. She acknowledged the resident was supposed to be transferred with a total lift and confirmed the total lift requirement was identified on the Kardex. CNA #1 stated she knew the correct transfer method but failed to follow the Kardex and comprehensive care plan because she was exhausted. She stated the resident could halfway stand and hold onto the sit to stand lift.On 6/23/26 at 2:10 PM, during a phone interview, CNA #2 stated CNA #1 asked her to assist with transferring Resident #14. She stated when she entered the room, the sit to stand lift was already in use. She stated they used the lift to complete the transfer and pull the resident's pants into place before placing the resident in the wheelchair. CNA #2 stated Resident #14 was not her assigned resident, and she did not review the Kardex prior to assisting with the transfer. She stated she had observed staff use both a total lift and a sit to stand lift with the resident.On 6/25/26 at 10:20 AM, during an interview, CNA #2 stated she routinely reviews the Kardex before using a mechanical lift. She stated if a resident is new or the transfer method is unclear, she checks with the nurse or therapy staff. She further stated a sit to stand lift is appropriate only for residents who can partially bear weight.On 6/25/26 at 11:14 AM, during an interview, the Nurse Practitioner stated Resident #14 could not consistently follow commands. She stated residents must be able to follow commands before a sit to stand lift is used and confirmed she would not recommend its use for Resident #14.On 6/25/26 at 11:54 AM, during an interview, Licensed Practical Nurse (LPN) #2 stated Resident #14 had foot drop and osteoporosis. She stated the resident should not have been transferred using a sit to stand lift because of those conditions.On 6/25/26 at 1:13 PM, during an interview, the Director of Nursing stated a sit to stand lift should not be used for residents who cannot bear weight or consistently follow instructions. She confirmed Resident #14 could not consistently follow commands and acknowledged there is a possibility of injury when the wrong lift is used. She further confirmed staff failed to follow the resident's care plan.A record review of Resident #14's admission Record revealed an admission date of 11/5/20 with diagnoses including Alzheimer's (Alz) disease, dementia, and disorders of bone density and structure.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/19/26 revealed the resident was severely cognitively impaired. Section GG indicated the resident was dependent on transfers. The assessment further revealed bilateral lower extremity range of motion impairments involving the hips, knees, ankles, and feet.A record review of Resident #14's Care Plan Report revealed .Focus: The resident has.Alz Dementia.01. Dependent using [NAME] 11 Total Lift . with a date initiated of 9/26/25.A record review of Resident #14's Kardex Report as of 4/16/26 revealed the resident was to be transferred using a total lift.A record review of the facility's Documentation Survey Report dated April 2026 revealed the resident was transferred using a total lift during the 7:00 AM to 3:00 PM shift on 4/15/26. However, staff interviews confirmed a sit to stand lift was actually used during the transfer.

Based on observations, interviews, record reviews and facility policy review the facility failed to implement comprehensive care plans for two (2) of (15) sampled Residents. Residents #14 and Resident #42.Findings include: A record review of the facility policy Comprehensive Care Plan, revised 8/24/22, revealed, Policy: It is the facility's policy to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs identified through the comprehensive assessment . A record review of the facility policy titled Safe Transfer and Lifting of Residents, revised 8/2/22, revealed, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility used appropriate techniques and devices to lift and move residents.V. c. Identifies resident/ensures proper transfer is followed per care plan. Resident #14 Record review of the Incident Investigation Summary dated 4/20/26 revealed, .The investigation identified that the CNA did not follow the resident care plan and facility policy related to transfer technique during the shifts on 4/15/26. During a phone interview on 6/23/26 at 2:02 PM, Certified Nursing Assistant (CNA) #1 stated she was assigned to Resident #14 on 4/15/26 and transferred the resident from the bed to the wheelchair using a sit to stand lift. She acknowledged the resident was supposed to be transferred with a total lift and confirmed the total lift requirement was identified on the Kardex. CNA #1 stated she knew the correct transfer method but failed to follow the Kardex and comprehensive care plan because she was exhausted. She stated the resident could halfway stand and hold onto the sit to stand lift. During a phone interview on 6/23/26 at 2:10 PM, CNA #2 stated CNA #1 asked her to assist with transferring Resident #14. She stated when she entered the room, the sit to stand lift was already in use. She stated they used the lift to complete the transfer and pull the resident's pants into place before placing the resident in the wheelchair. CNA #2 stated Resident #14 was not her assigned resident, and she did not review the Kardex prior to assisting with the transfer. She stated she had observed staff use both a total lift and a sit to stand lift with the resident. During an interview on 6/25/26 at 10:20 AM, CNA #2 stated she routinely reviews the Kardex before using a mechanical lift. She stated if a resident is new or the transfer method is unclear, she checks with the nurse or therapy staff. She further stated a sit to stand lift is appropriate only for residents who can partially bear weight. During an interview on 6/25/26 at 11:14 AM, the Nurse Practitioner stated Resident #14 could not consistently follow commands. She stated residents must be able to follow commands before a sit to stand lift is used and confirmed she would not recommend its use for Resident #14. During an interview on 6/25/26 at 11:54 AM, Licensed Practical Nurse (LPN) #2 stated Resident #14 had foot drop and osteoporosis. She stated the resident should not have been transferred using a sit to stand lift because of those conditions. During an interview on 6/25/26 at 1:13 PM, the Director of Nursing (DON) stated a sit to stand lift should not be used for residents who cannot bear weight or consistently follow instructions. She confirmed Resident #14 could not consistently follow commands and acknowledged there is a possibility of injury when the wrong lift is used. She further confirmed staff failed to follow the resident's care plan. A record review of Resident #14's admission Record revealed an admission date of 11/5/20 with diagnoses including Alzheimer's (Alz) disease, dementia, and disorders of bone density and structure. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/19/26 revealed the resident was severely cognitively impaired. Section GG indicated the resident was dependent on transfers. The assessment further revealed bilateral lower extremity range of motion impairments involving the hips, knees, ankles, and feet. A record review of Resident #14's Care Plan Report revealed .Focus: The resident has.Alz Dementia.01. Dependent using [NAME] 11 Total Lift . with a date initiated of 9/26/25. A record review of Resident #14's Kardex Report as of 4/16/26 revealed the resident was to be transferred using a total lift. A record review of the facility's Documentation Survey Report dated April 2026 revealed the resident was transferred using a total lift during the 7:00 AM to 3:00 PM shift on 4/15/26. However, staff interviews confirmed a sit to stand lift was actually used during the transfer. Resident # 42: On 06/24/26 at 7:52 AM, Licensed Practical Nurse (LPN) #1 was observed providing medication administration of gastrostomy tube medications. Prior to administration, the resident was noted to have a sign on the door indicating Enhanced Barrier Precautions (EBP). During care which involves close contact, LPN#1 did not don (put on) a gown prior to administering the medications and was observed with her uniform touching the resident's bed linens while adjusting the bed height and when looking for the resident's gastrostomy tube in the resident's linens. On 6/24/26 at 8:01 AM, during an interview LPN #1 stated that she thought gowns had to be worn for the resident's wound care or for nephrostomy tube site care, but not for medication administration. She noted that EBP would help prevent spread of germs from staff to the resident when performing care such as in this instance when her uniform came in contact with the resident's linens. On 6/24/26 at 3:08 PM, the Infection Preventionist stated nurses should utilize EBP to prevent contamination of a resident's indwelling medical devices by staff or from resident to resident to and failure to wear them correctly puts residents at risk. On 6/24/26 at 3:14 PM, during an interview the DON revealed gowns should be worn when performing medication administration via gastrostomy tube to avoid spreading infection to the tube site as it is an opening to the skin for contamination and failure to follow EBP can lead to the resident getting an infection. She further noted that she expects staff to follow EBP in accordance with the facility policy. A record review of Resident #42's admission Record revealed she was admitted on [DATE] with diagnoses that included cerebral infarction. A record Review of Resident #42's Order Summary Report revealed an order for Enhanced Barrier Precautions. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/12/26 revealed the resident was unable to complete a Brief Interview for Mental Status (BIMS) due to cognitive impairment.

Based on record review, interview, and facility policy review, the facility failed to ensure residents were free from significant medication errors by failing to accurately reconcile hospital discharge medications and ensure timely and accurate medication administration, which resulted in missed doses of prescribed antibiotic therapy and subsequent rehospitalization for wound infection and dehiscence (surgical incision that opens or pulls apart) for Resident #1 and duplicate administration of antihypertensive medications for Resident #2, affecting two (2) of four (4) sampled residents.Findings Include:Review of the facility's policy, Administering Medications revised 8/02/22, revealed, .Medications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation.3. Medications must be administered in accordance with the orders, including any required time frame.17. The individual administering the medication must initial the resident's EMAR (Electronic Medication Administration Record) on the appropriate line after giving each medication and before administering the next resident's medication. Review of the facility's policy, Reconciliation of Medications on Admission revised 8/02/22, revealed .The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation 1. Gather the information needed to reconcile the medication list: a. Medication list from referring facility; b. Discharge summary from referring facility.e. Most recent medication administration record (MAR), if this is a readmission.General Guidelines 1. Medication reconciliation is the process of generating a master list of the resident's current medications . Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process.4. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Resident #1Record review of the admission Record revealed the facility admitted Resident #1 on 7/01/22 and he had a Principal Diagnosis of Encounter for Surgical Aftercare Following Surgery on the Digestive System with an Onset Date of 11/10/2025. Record review of the 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 12/09/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated his cognition was intact. Record review of the After Visit Summary dated 12/05/25 from an acute care hospital revealed Instructions including .Your medications have changed START taking doxycycline.Prescribed Medication Information.All medication must be taken as prescribed. Contact your physician before stopping any medication .Your Medication List.Doxycycline 100 mg (milligram) capsule Take 1 capsule by mouth in the morning and 1 capsule before bedtime. Do all this for 5 days.Record review of the Medication Administration Record (MAR) for 12/01/25 through 12/31/25 for Resident #1 revealed Doxycycline was not administered until 12/08/25, which was three (3) days after his discharge from the hospital.Record review of the Medication Error Report for Resident #1, dated 12/08/25, revealed the Date of Error was 12/5/25. Further review revealed the Medication and Dosage Given was Pyridoxine (Vitamin B6) 100 mg and What is Physician's order was listed as Doxycycline 100 mg BID (two times daily) x (times) 5 days. The Reason for Medication error revealed Nurse states oversight. The Outcome to resident revealed there was a delay in treatment. The Physician response was The good thing is there is not harm from receiving Vitamin B6. Just start doxycycline. Surgical Site looks good. Record review of the Progress Notes, dated 12/9/25 revealed Resident #1 was transferred to an acute care hospital due to the surgical site noted to have dehiscence.Record review of the History and Physical, dated 12/09/25, revealed Resident #1 had wound dehiscence, with purulent drainage.On 12/17/25 at 1:45 PM, an interview with the Director of Nursing (DON) revealed that during a medication review of the medications for Resident #1 following return from hospitalization on 12/05/25 with discharge instructions that included a physician's order for Doxycycline 100 milligrams by mouth twice daily for surgical wound infection had been mistakenly entered into the resident's medical record as pyridoxine 100 milligrams by mouth twice daily by Registered Nurse #1. She confirmed he missed six (6) doses of the antibiotic therapy prescribed for infection of his abdominal surgical wound. She confirmed that on 12/09/25 the resident was hospitalized due to dehiscence of his abdominal surgical wound and was treated during his hospitalization with intravenous antibiotic therapy for infection in his surgical wound. On 12/16/25 at 1:30 PM an interview with Nurse Practitioner (NP) #1 revealed that on 12/08/25 record review of the medications for Resident #1 following return from hospitalization on 12/05/25 with discharge instructions that included a physician's order for Doxycycline for surgical wound infection had been mistakenly entered into the resident's medical record as pyridoxine. She confirmed that the resident missed six doses of Doxycycline. She confirmed that on 12/09/25 the resident was hospitalized due to dehiscence of his abdominal surgical wound. She confirmed that wound infection could result in dehiscence, the partial separation of edges resulting in reopening of a wound exposing underlying tissues.Resident #2Record review of the admission Record revealed the facility admitted Resident #2 on 9/15/22 and he had diagnoses including Hypertension. Record review of the Quarterly MDS with an ARD of 11/06/25 revealed Resident #2 had a BIMS score of 9, which indicated his cognition was moderately impaired. Record review of the Order Summary Report revealed Resident #2 had a Physician's Order, dated 6/30/24, for Lisinopril Tablet 10 mg Give 1 tablet by mouth one time a day. and an order dated 6/30/24 for Metoprolol Tartrate Tablet 50 MG 1 tablet by mouth two times a day. Record review of the Progress Notes for Resident #2 revealed a note, dated 12/10/25, for .A MIS-DOSING OF AM MEDICATIONS THIS AM WHERE RESIDENT RECEIVED HIS MEDICATIONS BY TWO DIFFERENT NURSES TWICE.Record review of the High Risk Event-Investigation Statement, dated 12/10/25, revealed Licensed Practical Nurse (LPN) #3 administered medications to Resident #2 at approximately 11:45 AM on 12/10/25 and later discovered that LPN #1 had already administered the medications to Resident #2 at approximately 9:45 AM, which indicated that the resident received twice the physician ordered dosage of Lisinopril and Metoprolol, which are antihypertensives. Record review of the Medication Error Report dated 12/10/25 for Resident #2 revealed the Date of Error was 12/10/25 and the Reason for Medication error revealed Assigned nurse not allowed to care for resident so nurse on a different hall took over and failed to sign eMAR that meds were given at 9:45 (AM). On 12/16/25 at 1:30 PM, during an interview, NP #1 stated that she had been concerned about the wrong (double) dose of Resident #2's blood pressure medications, Lisinopril and Metoprolol, being administered on the morning of 12/10/25 because the error could have caused a dangerous decrease of the resident's blood pressure. She stated that she ordered close monitoring of the resident and his vital signs for the four hours following notification by nursing staff that the resident had been given his antihypertensive medications twice. She stated that Resident #2's physician was notified of the medication error and ordered intravenous fluids, which were administered at the facility.On 12/16/25 at 3:10 PM during an interview with LPN #1 she stated that LPN #2 came to the dining room and told her that LPN #3 had administered the medications scheduled for Resident #2 for 8:00 AM a second time. She explained that due to family request, LPN #2 was not allowed to administer Resident #2's medications. LPN #1 reported that at approximately 9:45 AM LPN #2 asked if she was going to give Resident #2 his medications, and she used LPN #2's laptop which was already signed in to the Electronic Medication Administration Record (EMAR) in the healthcare software, on the laptop on the top of the medication cart and prepared Resident #2's 0800 medications and administered them to him. LPN #1 stated that after all residents had their medications administered, she went to sign in on her own laptop to sign medications as administered to Resident #2 but was called away due to an emergent situation involving a different resident and forgot to sign the medications administered to Resident #2. She acknowledged that correct procedure included signing the EMAR for each resident following medication administration. She correctly identified the five rights of medication administration, including Right Dose and that the resident had not received the right dose of multiple medications including antihypertensive medications. She stated that LPN #2 was standing by the medication cart as she prepared the medications for Resident #2. She stated she was in the dining room at about 11:45 AM and LPN #2 came to the dining room and told her that LPN #3 had administered the medications scheduled for Resident #2 for 8:00 AM a second time. She reported that she assisted with monitoring Resident #2 on 12/10/25 and he had not had adverse effects related to having received the wrong dose.On 12/17/25 at 11:06 a telephone with LPN #2 revealed that she reported that she was on duty on 12/10/25 assigned to a group of residents on the 300 Hall. She stated that due to family request she was not allowed to administer medications to Resident #2, therefore, another nurse was required to administer the resident's medications. She stated that she was at her medication cart and LPN #1 used her laptop which she had logged into with her credentials to access Resident #2's EMAR to prepare and administer the medications scheduled for 8:00 AM for Resident #2 at approximately 9:45 AM. She stated that later, on the morning of 12/10/25 she had walked into a resident's room due to an emergency need and forgot to lock her cart. She stated that LPN #3, having noted on Resident #2's MAR that his medications scheduled for 8:00 AM had not been documented as administered, prepared the medications and administered medications to Resident #2 a second time at approximately 11:45 AM. She stated that this failed to ensure one of the five (5) Medication Rights, the right dose, because the resident received double the prescribed dosage, which included his medications for high blood pressure. On 12/17/25 at 3:00 PM during an interview the DON reported that she was notified by LPN #3 at approximately 11:45 AM on 12/10/25 Resident #2 received his hypertensive medications, Lisinopril and Metoprolol, twice, resulting in the resident receiving twice the physician prescribed dosage. She stated that an incident report was completed, and she conducted an investigation, Root Cause Analysis and Plan of Correction and notified the NP, primary physician and Responsible Party (RP) for Resident #2. She stated that the resident's physician ordered monitoring and IV fluids for Resident #2 because of the incident. She stated that there was no noted adverse effect noted.

Based on observation, interviews, and facility policy review, the facility failed to follow infection prevention guidelines by improperly implementing enhanced barrier precautions, failing to adhere to handwashing/hand hygiene practices during care and failed to ensure clean and soiled items were not stored together in a biohazard room for two (2) of four (4) days of survey that affected Resident #13 and Resident #31. Findings Include: A record review of the facility's Enhanced Barrier Precautions policy dated 3/7/24 revealed .Policy Explanation and Compliance Guidelines .2. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes), even if the resident is not known to be infected or colonized with a multidrug-resistant organism (MDRO). ii. Infection or colonization with a Centers for Disease Control and Prevention (CDC)-targeted MDRO when Contact Precautions do not otherwise apply A record review of the facility's Handwashing/Hand Hygiene policy, revised on 08/02/2022, revealed Policy Statement: The facility considers hand hygiene the primary means of preventing the spread of infections Policy Interpretation and Implementation .7. Use an alcohol-based rub containing at least 70% alcohol; or, alternatively, soap and water in the following situations . h. Before moving from a contaminated body site to a clean body site during resident care .l. After contact with objects .in the immediate vicinity of the resident .m. After removing gloves . A record review of the facility's Infection Prevention and Control Program policy, revised 06/15/2023, revealed Policy: This facility has established and maintains 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 in accordance with accepted national standards and guidelines . On 02/03/2025 at 11:17 AM, an observation of the biohazard room, conducted with the Housekeeping Supervisor, revealed several boxes of new sharps containers with lids stored inside. The Housekeeping Supervisor stated that the containers were being stored there for later use by nurses. During an interview, she explained that due to a lack of storage space, they used the empty shelving in the biohazard room. However, she acknowledged that storing clean items in the biohazard room posed a risk of contamination and the potential spread of infection. Resident #31 On 02/04/25 at 2:08 PM, an observation of foley catheter care and interview revealed upon entrance to Resident 31's room there was Enhanced Barrier Precautions (EBP) signage posted. Certified Nursing Assistant (CNA) #1 placed supplies on the bedside table but did not sanitize the table or use a protective barrier. She did not put on a gown prior to providing care. She applied clean gloves, adjusted the bed using the remote while wearing gloves, and proceeded with catheter care. After touching the remote with her gloves, she continued providing care without changing them. She removed the resident's brief and used peri-wipes, pulling them from the package with contaminated gloves throughout the procedure. Upon completion of care, she removed her gloves and placed two clear bags containing soiled towels, briefs, and wipes on the floor while washing her hands.CNA #1 stated during the interview that she had received training on Enhanced Barrier Precautions and acknowledged that she should have donned (put on) a gown before beginning care. She stated that the gown is used to protect both staff and residents. She also stated that she typically relies on personal protective equipment (PPE) hanging on the door as a reminder to wear PPE. She further acknowledged that she should have removed her gloves after touching the bed remote and washed her hands before resuming care. CNA #1 stated she was unaware that she needed to sanitize the table and use a barrier before placing items on it. She also confirmed that placing soiled bags on the floor constituted cross-contamination and that the resident could develop an infection from the care provided. A record review of Resident #31's Admission Record revealed an admitted [DATE] with a diagnoses that included Neuromuscular Dysfunction of the Bladder. A record review of Resident #31's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/24 revealed a Brief Interview of Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #13 On 02/04/2025 at 2:08 PM, an observation was conducted of Licensed Practical Nurse (LPN) #2 performing percutaneous endoscopic gastrostomy (PEG) tube site care for Resident #13. LPN #2 did not don a sterile gown prior to or during the procedure. On 02/04/2025 at 2:12 PM, during an interview, LPN #2 was asked about the EBP signage on Resident #13's door, she stated that EBP are required for residents with catheters, PEG tubes, and similar devices to prevent infection. LPN #2 acknowledged that she had not worn a gown during the procedure and admitted that she should have done so to protect the resident's PEG tube site from infection. On 02/05/2025 at 1:55 PM, during an interview, the Director of Nursing (DON) stated that CNA #1 should have washed her hands upon entry, sanitized the bedside table before placing items on it, and used a barrier. She also stated that CNA #1 should have donned (put on) a gown before starting care. The DON confirmed that all peri wipes should have been removed from the package before beginning care to prevent cross-contamination. Additionally, she stated that CNA #1 should have removed gloves and performed hand hygiene when transitioning between front and back perineal care. The DON emphasized that staff should never place soiled bags on the floor, as this practice constitutes cross-contamination, transferring germs from the floor to the CNA's uniform. The DON stated that all staff have been trained in EBP, which are implemented to protect residents from staff-related contamination. On 02/06/2025 at 8:38 AM, during an interview, the DON stated that only contaminated items should be stored in the biohazard room. She confirmed that storing clean items in the biohazard room could contaminate staff while retrieving the containers, potentially bringing infections back to the residents on the floor. During an interview on 2/6/25 at 11:35 AM, the DON stated that EBP should be followed when providing care to residents with invasive lines, such as catheters. She confirmed that LPN #2 should have worn a gown before performing PEG tube site care for Resident #13 on 2/5/25. The DON stated that staff are expected to adhere to infection control guidelines, as reinforced through facility signage and training, and failure to comply could result in infection transmission among residents and staff. She further noted that Resident #13 required EBP not only due to the PEG tube but also because of a history of multidrug-resistant organism (MDRO) colonization, including methicillin-resistant Staphylococcus aureus (MRSA) at the site. She stated Resident #13 had recently completed a course of antibiotics. When asked whether the resident's infection could have been caused by staff failing to wear gowns, she stated, Yes. A record review of Resident #13 Admission Record revealed he was admitted on [DATE] with a diagnoses that included Encounter for Attention to Gastrostomy. A record review of the Order Summary Report with active orders as of 2/5/25 revealed an order dated 12/02/24 . Apply abdominal binder for g-tube for pt (patient) comfort. An order dated 12/03/24 revealed Clean the PEG site with normal saline (NS), pat dry, apply triple antibiotic ointment (TAO), apply split gauze until healed two times a day for PEG site infection. An order dated 12/3/24 for a PRN (as needed) PEG site care using the same order as the routine PEG site care. An order dated 6/29/24 to Administer Enteral Feeding once daily using Total Formula . A record review of the Minimum Data Set (MDS) dated [DATE], Section K, revealed that Resident #13 had a PEG tube. A record review of the facility's EBP signage indicated that EBP should be followed when providing care for devices such as central lines, urinary catheters, feeding tubes, tracheostomies, and wound care, including any skin opening requiring a dressing. 48669 50751

Based on observations, interviews, record reviews and facility policy review the facility failed to ensure resident rights were honored as evidenced by Resident #44 was not allowed to get out of bed as requested and residents not receiving preferred snacks at bedtime for five (5) of 31 sampled residents reviewed for choices. Resident #26, Resident #33, Resident #40, and Resident #41 and Resident #44 Findings Include: Resident #44 A record review of the facility's Resident Rights with a revision date of 6/1/23 revealed .4. Respect and dignity .c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences . On 02/03/25 at 11:37 AM, in an interview and observation Resident #44 in bed. She stated she wants to get up, but they (facility staff) won't get me up. Resident #44 stated she wants to go activities, but they won't get her up out of bed. She stated she is in bed all the time. On 02/03/25 at 02:25 PM, during an observation and interview revealed Resident #44 was in bed watching TV. She stated the facility staff does not ask her if she wants to get up. She stated she asked them several times a week to get up and they do not do it. Resident #44 stated she knew they were playing Bingo. She stated it was listed on the calendar but did not offer to get her up for Bingo. She stated when she asks them to get her, they say okay and never come back to get her up. She stated it has happened a lot of times. On 02/04/25 at 10:25 AM, during an observation and interview revealed Resident # 44 was in bed. She stated they did not ask her if she wanted to get up. She stated they do not ask her daily if she wants to get up. Resident #44 looked away when talking about wanting to get up out of bed. On 02/05/25 at 01:30 PM, in an interview with Resident #44 she stated they got her up this morning and put her back to bed after lunch. She stated she wants to get up daily but does not like to stay up all day. She stated she did not ask them to get her up today they did it on their own. She stated they got her up to weigh her this morning. On 02/5/25 at 2:15 PM, in an interview with the Director of Nurses (DON), Certified Nursing Assistants are supposed to be daily asking residents after breakfast if they want to get up. She stated they got Residents #44 up today for weights. All residents are gotten up on weight day. She stated she expects staff to give care with residents' rights in mind. A record review of Resident #44 Admission Record revealed an admitted [DATE] with diagnoses that included Cerebral Infarction and Restless Leg Syndrome. A record review of Resident #44's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 12/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the Resident #44 is cognitively intact. Section GG revealed Resident #44 is dependent for chair/bed-to-chair transfer. Resident Council On 02/04/25 at 2:45 PM, a Resident Council meeting was held, attended by 14 residents. The residents expressed several concerns, including not receiving sandwiches at night. Residents who specifically voiced concerns about not receiving sandwiches included Resident #26, Resident #33, Resident #40, and Resident #41. On 02/05/25 at 9:00 AM, during an interview, the Activities Director (AD) stated that residents do not receive sandwiches at night as snacks. She stated that, as far as she knew, they were given other snacks. On 02/05/25 at 9:23 AM, during an interview, the Director of Nursing (DON) stated that she was aware that residents were not receiving sandwiches at night. On 02/05/25 at 9:50 AM, during an interview, the Dietary Manager (DM) stated that dietary staff leave around 7:15-7:30 PM daily. She explained that she stopped preparing sandwiches because she was receiving 15-20 sandwiches back daily from the nurses' station. She stated that she instead sends a bulk of snacks to the nurses' station. She further explained that once the kitchen is closed, residents cannot receive sandwiches. She stated that she made the decision to stop sending sandwiches on her own and did not consult the Nursing Home Administrator (NHA) or the Director of Nursing (DON) about it. She confirmed that she stopped providing sandwiches several weeks ago. On 02/06/25 at 11:20 AM, during an interview, the NHA stated that the DM informed him the previous day that she had decided to discontinue providing sandwiches to residents at night. He stated that this decision should have been brought to his attention beforehand, as it was his responsibility to make that call. He further stated that the discontinuation of sandwiches should not have happened. A record review of Resident #26's Admission Record revealed an admitted [DATE] with diagnoses including Major Depressive Disorder and Essential Hypertension. A record review of Resident #26's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/09/24 revealed a Brief Interview of Mental Status (BIMS) score of 9, indicating mild cognitive impairment. A record review of Resident #33's Admission Record revealed an admitted [DATE] with diagnoses including Bipolar Disorder and Depression. A record review of Resident #33's MDS with an ARD of 09/09/21 revealed a BIMS score of 15, indicating cognitive intactness. A record review of Resident #40's Admission Record revealed an admitted [DATE] with diagnoses including Type 2 Diabetes Mellitus and Essential Hypertension. A record review of Resident #40's MDS with an ARD of 11/23/24 revealed a BIMS score of 15, indicating cognitive intactness. A record review of Resident #41's Admission Record revealed an admitted [DATE] with diagnoses including Type 2 Diabetes Mellitus and Essential Hypertension. A record review of Resident #41's MDS with an ARD of 01/10/25 revealed BIMS score of 15, indicating cognitive intactness.

Based on observations, interviews, facility policy review, and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan for two (2) of five (5) residents observed for care (Resident #13 and Resident #31). Findings include: Resident #13 Record review of the facility policy Comprehensive Care Plans, revised on 08/24/22, revealed It is the policy of this facility to develop a comprehensive, person-centered care plan for each resident Record review of the facility policy Gastrostomy/Jejunostomy Site Care, revised 08/02/22, revealed .Preparation . 2. Review the resident's care plan and provide for any special needs of the resident . Record review of the Order Summary Report with active orders as of 2/5/2025 revealed an order dated 4/12/24 for Enhanced Barrier Precautions related to presence of PEG tube, use of gloves and gown as appropriate when providing care. A record review of Resident #13's care plan revealed Enhanced Barrier Precautions (EBP) related to the presence of a percutaneous endoscopic gastrostomy (PEG) tube, requiring the use of gloves and a gown as appropriate when providing care was not listed on the care plan. On 02/06/25 at 11:30 AM, during an interview, the Director of Nursing (DON) confirmed that Enhanced Barrier Precautions was not listed in the resident's care plan. She stated that Licensed Practical Nurse (LPN) #3 is responsible for updating and writing out residents' care plans, but the interdisciplinary team meets nearly daily during stand-up meetings to discuss changes in residents' plans of care. She further stated that it is her expectation that staff follow care plans accordingly. On 02/06/25 at 12:03 PM, during an interview, LPN #3/Care Plan Nurse stated that care plans are written to guide nurses, Certified Nursing Assistants (CNAs), and other staff on how to care for the resident, including orders, preferences, and concerns. She stated that all staff should use the care plan when providing care, as failure to follow a comprehensive and updated care plan could result in inadequate care. A record review of Resident #13 Admission Record revealed he was admitted on [DATE] with a diagnoses that included Encounter for Attention to Gastrostomy. A record review of the Minimum Data Set (MDS) dated [DATE], Section K, revealed that Resident #13 had a Percutaneous Endoscopic Gastrostomy (PEG) tube. Resident #31 A record review of Resident #31's care plan revealed Focus: Enhanced Barrier Precautions related to presence of foley catheter .Interventions/Task . Personal Protective Equipment (PPE): Gowns and gloves, to be worn when providing direct care as appropriate . with a date initiated of 9/11/2024. On 02/04/25 at 2:08 PM, an observation and interview of Foley catheter care for Resident #31 by CNA #1 revealed upon entrance to Resident 31's room there was EBP signage posted. She did not put on a gown prior to providing care. CNA #1 stated that she had received training on EBP and acknowledged that she should have donned (put on) a gown before beginning care. She stated that the gown is used to protect both staff and residents and admitted that she did not follow the care plan. On 02/06/25 at 11:30 AM, during an interview, the DON confirmed that Enhanced Barrier Precautions were listed in the resident's care plan. She reiterated her expectation that staff follow care plans. On 02/06/25 at 12:03 PM, during an interview, LPN#3/Care Plan Nurse stated that care plans are written to guide nurses and CNAs on resident care, including orders, preferences, and concerns. She emphasized that all staff should use the care plan when providing care, as failing to follow a comprehensive and updated care plan could compromise the resident's well-being. A record review of Resident #31's Admission Record revealed an admitted [DATE] with a diagnoses that included Neuromuscular Dysfunction of the Bladder. A record review of the MDS with an ARD of 12/28/24 revealed a BIMS score of 7, indicating severe cognitive impairment. Section H was coded for indwelling catheter use. 50751

Based on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure residents who use enabling devices have physician orders as part of the professional standard of practice for one (1) of (19) residents who use enabling devices in the facility. Resident #52. Findings include: A review of the facility policy, Provision of Quality of Care, revised on September 20, 2022, revealed: . Policy Explanation and Compliance Guidelines .4. Qualified persons will provide the care and treatment in accordance with professional standards of practice On 2/4/25 at 10:38 AM, Licensed Practical Nurse (LPN) #1, stated in an interview that there is no documentation regarding the monitoring of the resident while using the seatbelt. She mentioned that they usually check on her every 15 minutes, but this is not documented. During an interview and record review with the Director of Nursing (DON) on 2/4/25 at 10:49 AM, revealed Resident #52 had been using the seatbelt since December 2024. However, there was not a physician's order for the seatbelt. The DON explained that this must have been an oversight, as the resident should have an order in her medical file. At 11:02 AM on 2/4/25, during an observation with the Director of Nursing (DON), the State Agency (SA) attempted to interview Resident #52, who was sitting near the nurses' desk with a seatbelt fastened around her waist. Upon the DON's request, the resident was able to self-release from the seatbelt without any direction given. During the attempted interview, Resident #52 was unable to speak fluently and mumbled in response to the SA's questions about the seatbelt. No clear communication was obtained. In a follow-up interview on 2/4/25 at 1:17 PM, the DON explained that the purpose of the seatbelt is to help reduce falls. She noted that there is no documentation in place to provide evidence of ongoing assessment of the resident regarding the seatbelt, despite the possibility of decline due to the resident's Parkinson's diagnosis. She indicated that she, along with the rest of the Interdisciplinary Team (IDT), discussed this issue in December 2024 when the seatbelt was issued. However, beyond that, they rely on visual monitoring for any signs of decline and on the quarterly Brief Interview for Mental Status (BIMS) assessment to determine the resident's ability to release the seat belt. A record review of the Admission Record revealed that the facility admitted Resident #52 on 6/5/2024 with diagnoses that Parkinson's disease without dyskinesia and Unspecified dementia. A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/7/2024 revealed a BIMS score of 10 indicating the resident had moderate cognitive impairment.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure adequate supervision to prevent a burn from hot coffee for one (1) of seven (7) sampled residents, with the potential to affect all residents who drink coffee in the Dining Room. Resident #1 The facility's failure to ensure adequate supervision resulted in Resident #1, who had diagnoses including Diabetes Mellitus (DM, Hemiplegia (left side), Vascular Dementia, and moderately impaired cognition sustaining a third-degree burn to his left thigh and placed other residents who drink hot coffee at risk for sustaining serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 4/11/24 when Resident #1 sustained a third-degree burn to his left thigh. The facility Administrator was notified of the IJ on 8/2/24 at 11:15 AM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 8/2/243, in which they alleged all corrective actions to remove the IJ were completed on 8/2/24, and the IJ removed on 8/3/24. The SA validated the Removal Plan on 8/5/24 and determined that the IJ was removed on 8/3/24, prior to exit. Therefore, the scope and severity for CFR 483.25(d)(2) Accidents was lowered to an E while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Safety of Hot Liquids, dated 7/25/22, revealed Policy Statement Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions .Policy Interpretation and Implementation: 1. The potential for burns from hot liquids is an ongoing concern for elderly and compromised residents . 3. Appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include a. maintaining a hot liquids serving temperature of no more than 140 degrees Fahrenheit b. serving hot beverages in a cup with a lid; c. wide-based cups; d. limit Styrofoam cups to residents with no difficulties; e. encouraging residents to sit at a table while drinking or eating hot liquids; f. providing staff supervision or assistance with hot beverages. 4. General safety precautions when serving hot liquids include .d. Regulate temperature of hot liquids to which residents have direct access; e. Place filled containers directly on the table. Do not hand them directly to resident .5. Food service staff will monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. A record review of the facility's policy, Safety and Supervision of Residents, revised 8/2/22, revealed Our facility strives to make the environment as free from accident hazards as possible, with resident safety, supervision, and assistance to prevent accidents being facility-wide priorities . On 08/01/2024 at 09:55 AM, during an interview, Resident #1's family member explained that her father was burned on his left side when staff on the night shift took Resident #1 into the dining room, gave him a cup of coffee, left him unsupervised, and he spilled the coffee on himself. At 10:55 AM on 08/01/24, during an observation of the dining room, residents were observed with coffee cups at their tables. Resident #1 was sitting in the dining room at a table with an empty coffee cup, and there was no lid on the coffee cup or on the table. At 11:30 AM on 08/01/24, during a dining room observation, some residents had coffee cups with lids, and some did not. An industrial-style coffee machine was on a countertop with cups and lids noted nearby. Resident #1 was sitting in his wheelchair eating lunch, and there was an empty coffee cup without a lid noted nearby. At 11:40 AM on 08/01/24, during an observation and interview with Resident #4, he explained he had always been able to get coffee anytime from the machine in the dining room whenever he wanted it. He said that he normally got up around 2:00 AM, came to the dining room, and served himself coffee. He mentioned he liked to use a lid on his coffee cup and reported that he had not spilled coffee on himself or received a burn from hot coffee. On 08/01/24 at 12:00 PM, during an interview with Housekeeper #1, she explained that residents came to the dining room early in the mornings, and some of them got coffee themselves while others needed staff assistance. She was working in the dining room on 04/11/24 when Resident #1 spilled his coffee on himself but was unable to recall what time it occurred. She thought someone from the night shift brought Resident #1 to the dining room, and someone gave him a cup of coffee. Housekeeper #1 said Resident #1 did not like having a lid on his coffee cup. He reported to her that he had spilled the coffee on his pants and needed to be changed. She took the resident to his room and told a Certified Nurse Aide (CNA) that he needed to have his pants changed. She was unable to recall which CNA assisted him, but the CNA changed his clothes and brought him back to the dining room. At 12:50 PM on 08/01/24, during an observation and an interview with Resident #1, he was sitting in his wheelchair with a bedside table in front of him. He explained he did not like to have a lid on his coffee cup because not having a lid helped to cool the coffee. He stated that when he spilled coffee on himself on 4/11/24, it was an accident. He was unable to recall who had served him the coffee that day and commented that he liked to drink about three (3) cups of coffee a day. At 3:00 PM on 08/01/24, during an interview with the Director of Nursing (DON), she reported she was working on 04/11/24 when Resident #1 spilled coffee on himself and had a burn to his left thigh. She said the incident was discussed that morning in the daily Stand-Up meeting. She expressed that she was unaware of the incident until the morning meeting. She confirmed Resident #1 had hemiplegia affecting his left side, causing decreased or no sensation to his left leg. She confirmed that residents in the facility got coffee for other residents, as well as themselves, from the coffee machine in the dining room. She explained that she assessed Resident #1 and the area where he had spilled the coffee, around 11:00 AM when the day shift CNA reported he had a raised blister to his left inner thigh. The DON measured the blister, notified the facility's Nurse Practitioner and received orders for a treatment. She completed the incident report for the incident/burn, and during the investigation, it was determined Resident #1 had told the Housekeeper Supervisor he had spilled his coffee and wanted his pants changed. The DON stated it was a horrible accident and confirmed there were no interventions put in place to prevent the incident from occurring again. At 03:30 PM on 08/01/24, during an interview with the Administrator, he confirmed there were no interventions put in place to prevent further incidents with spilling coffee after Resident #1 received a third-degree burn. The temperature of the coffee had never been checked and the coffee machine had been in the dining room at the facility for a long time. At 06:45 AM on 08/02/2024, during an observation of residents in the dining room waiting for breakfast, there were no staff present in the dining room and there were no kitchen staff at the serving line. Resident#1 had an empty coffee cup at the table, without a lid. Residents were drinking coffee, and some had lids and some did not. Resident #6 went to the coffee machine while sitting in a wheelchair and got a coffee cup and served herself coffee. Resident #6 did not get a lid for her coffee cup. At 06:55 AM on 08/02/2024, during an interview and observation with Dietary #1, she explained the residents can come into the dining room and get coffee at any time and they serve themselves, even though there were some residents who should not serve themselves. Dietary #1 and the SA poured a cup of coffee from the coffee machine, walked it over to Resident #1's table, and checked the temperature using a digital thermometer. The coffee was 167 degrees Fahrenheit (F) and Dietary #1 reported she was unaware the coffee was that hot. She explained the kitchen staff did not check and record the coffee temperatures. At 07:20 AM on 08/02/2024, during an observation and interview, Resident #7 was standing up in front of the coffee machine and got herself a cup of coffee. She explained the coffee was always hot and she tried to be careful not to spill it. At 07:25 AM on 08/02/2024, during an observation and interview, the DON was checking the temperature of the coffee in the dining room. She explained she got a reading of 157 degrees F. The SA obtained another cup of coffee, walked over to Resident #1's table, and the DON obtained the temperature of the coffee which indicated it was 167 degrees F. Dietary #1 confirmed the temperature of the coffee was also 167 degrees F when it was checked earlier with the SA. At 09:45 AM on 08/02/2024, during an interview with the Administrator, he confirmed the coffee temperature had never been checked before or after Resident #1 received a burn from spilling hot coffee on himself. At 11:30 AM on 08/02/24, during a phone interview with the Wound Care Nurse Practitioner, she explained she made aware that Resident #1 received a burn, and she assessed it and classified the burn as a third-degree burn. She stated the area had slough and necrotic tissue (unviable and dead tissue) in the beginning and the treatments were changed a few times, but the area healed. At 12:55 PM on 08/02/2024, during an interview with Dietary #1, she explained the coffee machine was never turned off or put up, it ran continuously, and residents had access to it at any time they wanted it day or night. A record review of Resident #1's Admission Record revealed the facility admitted Resident #1 on 09/15/22 with current diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Vascular Dementia A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/25/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) Score of 11, which indicated his cognition was moderately impaired. A review of Section M revealed resident had a burn (second or third degree). A record review of the Order Summary Report with an Order Date Range: 04/01/24 - 04/30/24 revealed Resident #1 had a Physician's Order, dated 4/11/24 to Clean blister to left inner thigh with NS (normal saline) gently, pat dry, apply Silvadene cover with dry dressing and paper tape QD (every day) and PRN (as needed) dislodgement until resolved. On 04/24/24, the Physician's Order was changed to Clean blister to left inner thigh with NS, apply xeroform, dry dressing. Change daily and PRN dislodgement until resolved. A record review of the facility's investigation report Self Inflicted Injury dated 04/11/24 revealed . Incident location: Dining room . Incident Description: It was reported in standup this morning that resd(resident) had spilled his coffee in his lap this morning before breakfast. The housekeeper took him to his room to be changed but he was upset because he wanted the housekeeper to change him that she could not change him. Resident Description: Resd stated that he just spilled his coffee . Immediate Action Taken .RESD was taken to his room to have his clothes changed .Other info Unable to determine predisposing environmental, physiological factors or situation at the time of the incident . No witnesses found . A record review of Resident #1's Progress Note with effective date 04/11/24 at 12:49 PM, revealed self-inflicted injury 04/11/24 10:40 AM, . It was reported in standup this morning that resd had spilled his coffee in his lap this morning before breakfast. The housekeeper took him to his room to be changed but he was upset because he wanted the housekeeper to change him, and she was informing him that she could not change him. Around lunch, the CNA notified writer that resd had a blister noted. Upon Assessment, a blister measuring 4.1 cm (centimeters) x 6.0 cm was noted to left inner thigh. Silvadene and dry dressing was applied . nurse practitioner was notified, and she stated to continue with same treatment daily. Attempted to notify RP (responsible party) but no answer. Resd without any pain noted and tolerated well. A record review of Resident #1's Progress Note dated 05/08/24 12:15 PM revealed . Resd was seen by NP (nurse practitioner) with wound management specialists today . Burn blister to left thigh has ruptured and is classified as a 3rd degree burn. New order to clean with NS, apply Medi-honey and Aquacel ag and dry dressing daily. RP notified . A record review of Resident #1's Progress Note dated 06/06/24 10:48 AM revealed . Resd was seen by NP with wound management specialists on 06/05/24. New order for burn to left inner thigh received. Updated orders and notified RP . A record review of Resident #1's Progress Note dated 07/03/24 11:52 AM revealed . Resd was seen by NP with wound management specialists today. No change to orders were made but writer did update treatment orders. Wound assessment completed as well. RP notified . A record review of Resident #1's Progress Note Details from Wound Care NP with notes from 01/03/24 through 05/08/24 revealed . 04/24/24 . report of spilling coffee on himself last week. Now has a large third degree burn to left upper thigh, denies pain. Full thickness tissue loss, slough covering wound bed. Plan to start covering with xeroform daily . 05/01/24 . Burn to left thigh remains covered with some adherent slough. Provided gentle debridement . 05/08/24 . Burn also slowly improving with some pink granulation tissue along edges, continues to have a large area of adherent slough. Plan to start applying Medi-honey daily . A record review of Resident #1's Progress Note Details from Wound Care NP with notes from 05/08/24 through 06/26/24 revealed . 05/15/24 . Burn to left thigh with similar dimensions, however increased about of pink tissue noted along edges, adherent slough remains in middle. Continue Medi-honey daily . 05/22/24 . Burn to left thigh continues to have a large amount of slough to middle of wound bed, pink granulation tissue surrounding. Peri wound moist and macerated. No s/s (signs and symptoms) of infection. Tolerated gentle debridement, was able to remove most of the slough. Plan to start applying collagen plus super absorber dressing daily . 05/31/24. Burn with slightly smaller dimensions. Continue collagen plus aquacel ag . 06/05/24 . No change to burn left thigh-pink wound bed, scant slough, less drainage, no s/s of infection. Resume covering with Xeroform . 06/12/24 . Burn to left thigh with similar dimensions. Pink wound bed, moderate amount of yellow drainage. Peri-wound intact, no erythema. Plan to start covering with Dakins moist dressings daily . 06/19/24 . Burn to left thigh improved this week with smaller dimensions, less drainage. Plan to continue covering with Dakins moist dressing daily . 06/26/24 . Burn to left thigh unchanged, peri-wound macerated. Plan to start covering with Gentamicin plus Aquacel Ag . A record review of Resident #1's Procedure/Progress Note-Outreach Component for wounds completed by the wound nurse practitioner revealed measurements of the burn third degree burn to the left thigh for Resident #1 measured 4.5 centimeters (cm) x (by) 5.8 cm x 0.2 cm on 04/24/24 and the area was healed on 07/10/24. The facility submitted the following acceptable Removal Plan on 08/02/24: On 8-2-2024 at 11:15 P.M. the State Survey Agency notified the administrator that the facility failed to ensure adequate supervision when Resident 1, who had diagnoses including Diabetes Mellitus (DM), Hemiplegia (left side), Vascular Dementia, and moderately impaired cognition, spilled hot coffee onto his left thigh, which resulted in a third degree burn. On 4/11/2024 at lunch, after 11:15 a.m., it was reported to the resident care coordinator (RCC) nurse that Resident 1 had spilled coffee on himself and upon assessment it was noted that there was an intact blister to the left medial thigh. The site was cleaned with normal saline and Silvadene and dry dressing applied. The resident care coordinator notified the provider and order to continue the same treatment were received and to be completed daily. The resident did not complain of any pain at the time. The nurse attempted to notify the resident representative unsuccessfully initially. However, the resident representative did call back and was notified about the burn and the treatments and was updated weekly. After the blister ruptured, the wound care nurse practitioner classified the wound as a third degree burn with new treatment orders. The resident representative was notified and updated. Treatment and care to the burn was ongoing and have since been discontinued as the site has healed. 1. In an effort to immediately protect the residents, the coffee machine was taken out of service on 8-2-2024 so that individuals cannot serve themselves coffee. Individual pots of coffee will be made beginning today, 8-2-2024 and temperatures of the pots will be monitored to ensure that the coffee served is at or below 140 degrees Fahrenheit. Resident #1 will be served coffee at or below 140 degrees Fahrenheit. 2. The root cause of the accident was the hot liquid policy was not followed. This along with the lack of proper supervision resulted in the injury. 3. On 8-2-2024, Coffee Temperature logs were created to indicate the temperature of the beverage prior to serving. This will serve as record of temperatures of coffee being served. 4. Training for all staff prior to working shifts was initiated on 8/2/2024 by the staff development nurse and the Director of Nursing on the following topics: Safety and supervision of residents -Care Plans Temperature logs for coffee hot liquids policy No staff will be allowed to work until they have received appropriate training. 5. Updated the care plans for resident # 1 and identified thirty-three residents that were at risk to include interventions to prevent burns. 6. Weekly body audits were completed for all residents on 8-2-2024 and there were no burns noted. 7. Quality Assurance and Performance Improvement committee meeting was conducted on August 2, 2024, at 12:21 p.m. and the issue was discussed including root cause and appropriate remedies. Attending the meeting: Medical Director, Administrator, Director of Nursing, Resident Care Coordinator/ Infection Preventionist, Dietary Manager, Social Worker, Business Office Manager, Staff Development Nurse, Minimum Data Set Nurse, Medical Records Clerk, Environmental Services Manager, Maintenance Director and the staff scheduler. The facility alleges all corrective actions were completed on 8-2-2024 at 2:00 p.m. and the IJ was removed on 8-3-2024. Validation: The State Agency (SA) validation of the Removal Plan was made on-site during the Complaint Investigation (CI) MS #25877 through record review and interviews on 8/5/24. The SA determined all corrective actions were completed on 8/2/24 and the IJ was removed on 8/3/24.

Based on observation, interviews, record review, and facility policy review, the facility failed to develop comprehensive care plan interventions to prevent burns and for the use of tobacco for one (1) of seven (7) sampled residents. (Resident #1) The facility's failure to develop comprehensive care plan interventions resulted in Resident #1, who had diagnoses including Diabetes Mellitus (DM, Hemiplegia - left side, Vascular Dementia, and moderately impaired cognition sustaining a third-degree burn to his left thigh and placed other residents who drink hot coffee at risk for sustaining serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 4/11/24 when Resident #1 sustained a third-degree burn to his left thigh. The facility Administrator was notified of the IJ on 8/2/24 at 11:15 AM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 8/2/243, in which they alleged all corrective actions to remove the IJ were completed on 8/2/24, and the IJ removed on 8/3/24. The SA validated the Removal Plan on 8/5/24 and determined that the IJ was removed on 8/3/24, prior to exit. Therefore, the scope and severity for CFR 483.21(b) Comprehensive Care Plans was lowered to an E while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A record review of the facility's policy Comprehensive Care Plans with revised date of 08/24/22 revealed . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . A review of the medical record for Resident #1 revealed there were no care plan interventions developed for preventing burns from hot coffee or for the use of chewing tobacco. A record review of the Order Summary Report with an Order Date Range: 04/01/24 - 04/30/24 revealed Resident #1 had a Physician's Order, dated 4/11/24 to Clean blister to left inner thigh with NS (normal saline) gently, pat dry, apply Silvadene cover with dry dressing and paper tape QD (every day) and PRN (as needed) dislodgement until resolved. On 04/24/24, the Physician's Order was changed to Clean blister to left inner thigh with NS, apply xeroform, dry dressing. Change daily and PRN dislodgement until resolved. At 9:25 AM on 08/01/2024, during an interview with the Administrator, he explained Resident #1 was admitted to the facility two (2) years ago. Because the facility's census was very low at the time, he agreed to give special permission for the resident to chew tobacco at the facility even though the facility's policy did not allow it. He stated the resident has now been allowed to continue to use chewing tobacco while at the facility. During an interview on 08/01/2024 at 9:55 AM, Resident #1's family member explained that her father was burned on his left side when staff on the night shift took Resident #1 into the dining room, gave him a cup of coffee, left him unsupervised, and he spilled the coffee on himself. The family member also stated that Resident #1 had been at the facility for two (2) years and was cleared on admission by the Administrator and the doctor to use chewing tobacco while at the facility. However, it was taken away for him on 7/4/24 but was returned to him on 7/11/24. During an observation at 12:50 PM on 08/01/24, Resident #1 was sitting up in his wheelchair with his bedside table in front of him in which there were three (3) cups with tobacco in them. At 2:30 PM on 08/01/24, during an interview with Licensed Practical Nurse (LPN)#2/Care Plan/Minimum Data Set (MDS) Nurse, she stated she was responsible for updating resident care plans daily. She confirmed Resident #1 received a third degree burn after spilling coffee on himself and the facility never developed care plan interventions to prevent the re-occurrence of a burn from hot coffee. She stated the facility had developed interventions related to treating the burn. LPN #1 also confirmed she was aware Resident #1 used tobacco and the facility had never developed a care plan with interventions for the staff to follow on his tobacco use. She reported the purpose of a care plan was to provide instructions on how to care for the residents and if there was no care plan, then the staff would not be able to care for the residents as needed. During an interview at 3:00 PM on 08/01/24, the Director of Nursing (DON), reported she was working on 04/11/24 when Resident #1 spilled coffee on himself and had a burn to his left thigh. The DON stated it was a horrible accident and confirmed there were no interventions put in place to prevent the incident from occurring again. She was not aware Resident #1 did not have a care plan for chewing tobacco but expected the care plan nurse to develop care plans as required. At 3:30 PM on 08/01/24, during an interview with the Administrator, he explained he had been made aware Resident #1 had no care plan related to the use of chewing tobacco and confirmed there were no interventions put in place to prevent further incidents with spilling coffee after Resident #1 received a third-degree burn. He stated he expected the staff to develop care plans and for care plans interventions to be implemented to meet each individual resident's needs. A record review of Resident #1's Admission Record revealed the facility admitted Resident #1 on 09/15/22 with current diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Vascular Dementia A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/25/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) Score of 11, which indicated his cognition was moderately impaired. A review of Section M revealed resident had a burn (second or third degree). The facility submitted the following acceptable Removal Plan on 08/02/24: On 8-2-2024 at 11:15 P.M. the State Survey Agency notified the administrator that the facility failed to ensure adequate supervision when Resident 1, who had diagnoses including Diabetes Mellitus (DM), Hemiplegia (left side), Vascular Dementia, and moderately impaired cognition, spilled hot coffee onto his left thigh, which resulted in a third-degree burn. On 4/11/2024 at lunch, after 11:15 a.m., it was reported to the resident care coordinator (RCC) nurse that Resident 1 had spilled coffee on himself and upon assessment it was noted that there was an intact blister to the left medial thigh. The site was cleaned with normal saline and Silvadene and dry dressing applied. The resident care coordinator notified the provider and order to continue the same treatment were received and to be completed daily. The resident did not complain of any pain at the time. The nurse attempted to notify the resident representative unsuccessfully initially. However, the resident representative did call back and was notified about the burn and the treatments and was updated weekly. After the blister ruptured, the wound care nurse practitioner classified the wound as a third degree burn with new treatment orders. The resident representative was notified and updated. Treatment and care to the burn was ongoing and have since been discontinued as the site has healed. 1. In an effort to immediately protect the residents, the coffee machine was taken out of service on 8-2-2024 so that individuals cannot serve themselves coffee. Individual pots of coffee will be made beginning today, 8-2-2024 and temperatures of the pots will be monitored to ensure that the coffee served is at or below 140 degrees Fahrenheit. Resident #1 will be served coffee at or below 140 degrees Fahrenheit. 2. The root cause of the accident was the hot liquid policy was not followed. This along with the lack of proper supervision resulted in the injury. 3. On 8-2-2024, Coffee Temperature logs were created to indicate the temperature of the beverage prior to serving. This will serve as record of temperatures of coffee being served. 4. Training for all staff prior to working shifts was initiated on 8/2/2024 by the staff development nurse and the Director of Nursing on the following topics: Safety and supervision of residents Care Plans Temperature logs for coffee hot liquids policy No staff will be allowed to work until they have received appropriate training. 5. Updated the care plans for resident # 1 and identified thirty-three residents that were at risk to include interventions to prevent burns. 6. Weekly body audits were completed for all residents on 8-2-2024 and there were no burns noted. 7. Quality Assurance and Performance Improvement committee meeting was conducted on August 2, 2024, at 12:21 p.m. and the issue was discussed including root cause and appropriate remedies. Attending the meeting: Medical Director, Administrator, Director of Nursing, Resident Care Coordinator/ Infection Preventionist, Dietary Manager, Social Worker, Business Office Manager, Staff Development Nurse, Minimum Data Set Nurse, Medical Records Clerk, Environmental Services Manager, Maintenance Director and the staff scheduler. The facility alleges all corrective actions were completed on 8-2-2024 at 2:00 p.m. and the IJ was removed on 8-3-2024. Validation: The State Agency (SA) validation of the Removal Plan was made on-site during the Complaint Investigation (CI) MS #25877 through record review and interviews on 8/5/24. The SA determined all corrective actions were completed on 8/2/24 and the IJ was removed on 8/3/24.

Based on observation, interviews, and record review, the facility failed to ensure a resident's right for self-determination as evidenced by facility staff taking a resident's chewing tobacco without notice, which he was previously granted permission to have, and resulted in the resident crying and begging in distress and continued fear of staff taking away his tobacco for one (1) of three (3) residents sampled for tobacco usage. (Resident #1) Findings include: A record review of the facility's policy Smoking/Tobacco -Free Policy-Residents dated 2019 revealed .All residents, employees, and visitors are prohibited from using any type of tobacco, snuff, e-cigarettes, and similar products, in company buildings, parking areas, on company property, or in any company owned or leased vehicle. No resident who uses any of these products will be admitted unless the Resident and Resident Representative agree for the Resident to accept and continue a smoking cessation program or cessation patch . A record review of the facility's policy Resident Rights with revision date of 06/01/23 revealed . The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all the rules and regulations governing resident conduct and responsibilities during the stay in the facility .5. Self-determination. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice .b.The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident . At 09:25 AM on 08/01/2024, during an interview with the Administrator, he explained Resident #1 was admitted to the facility two (2) years ago. Because the facility's census was very low at the time, he agreed to give special permission for the resident to chew tobacco at the facility even though the facility's policy did not allow it. He explained Resident #1 was passionate about his tobacco as he had used it almost his entire his life. When the agreement was made upon admission, Resident #1 should have used the chewing tobacco outside of the building only, but it had gotten to the point that he was allowed to use chewing tobacco in his room and inside the facility. The Administrator reported that on 7/4/24, there was a communication issue as it had been discussed with staff that the facility's tobacco-free policy was going to be strictly enforced. He had notified the family prior to 7/4/24 and had explained the tobacco-free policy was being strictly enforced and he had no choice but to take the tobacco away. The family asked the Administrator to allow them some time to discuss what to do and he agreed. He explained the resident has now been allowed to continue to use chewing tobacco while at the facility. On 08/01/2024 at 09:55 AM, an interview with Resident #1's family member revealed Resident #1 had been at the facility for two (2) years and was cleared on admission by the Administrator and the doctor to use chewing tobacco while at the facility. On 07/03/24 while the family member was at the facility, the Administrator talked to her husband and advised the resident would have to stop using tobacco and said the tobacco-free policy was now going to be enforced. The family explained to the Administrator they would need about two (2) weeks to discuss what to do, and the Administrator agreed to allow time to plan a method to wean him from chewing tobacco. The family member stated that she felt it was unfair for the Administrator to enforce the tobacco-free policy now, when he had been given permission upon admission two years ago when the policy was in place then as well. She explained on 07/04/24, she received a call from the current Director of Nursing (DON) explaining she had taken Resident #1's tobacco away because the facility stopped allowing him to use chewing tobacco. She was told the DON had taken his tobacco, locked it up in her office, and told all the staff that Resident #1 was not to get any tobacco, and she would not support the nurses if they gave it to him. She explained that staff members called her and told her Resident #1 was heartbroken and was yelling and screaming for his tobacco. A family member went to the facility to give the resident some tobacco and the DON would not allow them to give it to him. The next day, 07/05/24, she received a call from staff at the facility who stated they were going to allow him to use chewing tobacco, and they were going to try to wean him off the tobacco products. However, there was still confusion among staff because some staff were still not allowing him to use tobacco, and some were allowing him to use it. The following Wednesday, 07/10/24, she had a meeting with the Administrator who informed her that Resident #1 could either stop chewing tobacco or she could remove him from the facility. She had contacted the facility's Ombudsman about the tobacco situation and other concerns and was told to file a grievance and the facility would have to follow through with the problems and resolve them, therefore, she filed a grievance on 7/11/24. She stated Resident #1 was now allowed to have chewing tobacco, but he continued to fear daily the facility was going to take it away. At 12:20 PM on 08/01/24, during an interview with Licensed Practical Nurse (LPN) #1, she explained she was working on 07/04/24 when Resident #1's tobacco was taken away and she was told he could no longer have tobacco due to the facility's tobacco free policy. LPN #1 explained Resident #1 yelled and screamed and was very upset and the other residents could hear him. She did not give the resident any tobacco on that day or any other days until it was later cleared for him to have tobacco. At 12:50 PM on 08/01/24, during an interview with Resident #1, he reported that approximately one (1) month ago, he went almost two (2) weeks without chewing tobacco because the nurses had taken it from him. He explained he had been chewing tobacco for what seemed like his entire life and the doctor had told him he could chew tobacco while in the facility, which is why he agreed to come to the facility in the first place. He said that he did not want the facility to take his tobacco again and admitted he was afraid every day that someone was going to take it away. On 08/01/24 at 01:00 PM, during an interview with Resident #5, she stated Resident #1 cried, screamed, and begged for his tobacco to be returned to him when the facility took it away. On 08/01/24 at 01:30 PM, during an interview with Social Services #1, she explained she was responsible for the facility's grievances. She reported she was aware of the incident with Resident #1 that happened on 07/04/24, and afterward on 7/11/24, the family filed a grievance. On 07/12/24, the Administrator advised the family Resident #1 would be allowed to continue using chewing tobacco and he would be Grandfathered in. At 01:50 PM on 08/01/24, during an interview with Certified Nurse Aide (CNA) #1, she reported Resident #1 was heart-broken, screaming, crying, and even begging for her or anyone to give him some tobacco during the time the facility took it away from him. She reported that some of the other residents complained about Resident #1 yelling and screaming for his tobacco because he got very loud. At 03:00 PM on 08/01/24, during an interview with the DON, she explained it was brought to her attention the first of July that Resident #1 was chewing tobacco in the facility and the facility was a tobacco-free facility. It was decided that the staff would strictly enforce the tobacco free policy, and she thought the Administrator was going to discuss this with Resident #1's family at that time. The DON had advised all the nurses the policy would be enforced and on 7/4/24, the nurse refused to allow Resident #1 to use tobacco. The DON explained that on 07/04/24, she took Resident #1's tobacco and told him he could no longer chew tobacco in the facility. The resident was calm and wanted to tell his daughter he was ready to go home, however, she was unsuccessful when she attempted to call his daughter. The DON said that she took the resident's tobacco from him and locked it in her office. She was unaware the Administrator had talked with the family previously and they had agreed to allow him a couple of weeks to be weaned from tobacco. Therefore, the tobacco was given back to the nurses and it was determined the nurses could use their discretion on whether they wanted to give him the tobacco. To her understanding, some of the nurses gave him tobacco and some did not. The night shift nurse complained one morning that he was told not to give the resident tobacco and felt like the facility needed a plan on whether to give Resident #1 the tobacco. The nurse said that some staff were giving Resident #1 tobacco on day shift, but he was told not to give it to the resident, which caused the resident to yell, scream and beg for tobacco all night. The Administrator was informed, and a meeting was set up with Resident #1's family on Wednesday 07/10/24. At 03:30 PM on 08/01/24, during a follow up interview with the Administrator, he admitted the confusion regarding Resident #1's use of chewing tobacco was his fault. He confirmed he had a meeting on 07/03/24 with Resident #1's family and discussed the options regarding the facility having to strictly enforce the tobacco free policy. The family asked for some time to think of a plan, and he told them the only option was to take away the resident's tobacco or transfer him to another facility that allowed tobacco products. He did not talk to the staff about the outcome of the meeting or what was discussed. Then on 07/04/24 he was phoned by Resident #1's daughter, who was very upset and angry because the facility's staff had taken her father's tobacco even after he agreed to give them a couple weeks to decide on a plan. The Administrator explained he then called the facility and told staff that Resident #1 was allowed to have his tobacco, and the facility was going to wean him from the tobacco. On 07/10/24, he had another meeting with Resident #1's family and the daughter was visibly upset and told him she had filed a complaint with the State Agency (SA) and she would go further if needed. The Administrator said he had explored changing the policy but that was not an option and that only left two (2) choices, to create a plan to wean him off tobacco or relocate the resident to another facility. The daughter explained Resident #1's tobacco use was more psychosocial than nicotine addiction. Then on 07/11/24 the family filed a grievance. The Administrator talked to Resident #1's physician about the tobacco-free policy being enforced and the Physician stated he would talk to the family about transferring him to other nearby facilities, but the doctor did not think that would help. After all the considerations, it was decided that Resident #1 would be grandfathered in and would be allowed to use chewing tobacco, and he was given back his tobacco full time on the 07/12/24. The family was notified and pleased with the resolution. On 08/02/2024 at 08:30 AM, in an observation, Resident #1 was in the hallway talking with Registered Nurse (RN) #1 who explained she had him a cup of chewing tobacco and an empty cup to spit in, and she would place it by his bed. Resident #1 stated, You better not throw my tobacco away. At 10:30 AM on 08/02/24, during an interview with RN #1/Supervisor, she explained she was at the facility on the day the DON took away Resident #1's tobacco. Resident #1 was visibly terribly upset, crying out for staff to bring him his tobacco and was begging any staff member to bring him some tobacco. She stated when she left the building for the day, she could hear the resident still yelling and asking for tobacco from outside the building. To her understanding, he was to be weaned from the chewing tobacco and that it would not be taken away cold turkey. She reported he would yell out and scream, they have taken my tobacco away and that he did not want to be here anymore. She said he was still afraid someone would take his tobacco away. She confirmed that once the tobacco was taken on 07/04/24, some nurses would allow him to have it and some would not and it depended on which way they defended their decision, to follow policy or to just give him his tobacco. She said she gave him tobacco anytime he asked for it because the facility was going to have to wean him from it gradually. She confirmed that as of 07/12/24, Resident #1 could have his tobacco at any time. At 12:30 PM on 08/02/24, during a phone interview with CNA #5, she explained she was working on 7/4/24 when the DON took Resident #1's tobacco. The resident was very upset and was crying, screaming, and yelling for staff to get away from him. He refused care and refused to let anyone do anything for him even after staff tried and tried to calm him down. She said Resident #1 was upset all day and some of the other residents complained about all the yelling and screaming he was doing. Several days later, Resident #1 had calmed down, but was still upset and kept asking for his tobacco to the point where he was begging staff for it. Some of the nurses did allow him to have tobacco, but others would not because it was against the facility's policy. She explained that since he has gotten his tobacco back, he continues to tell staff no one better not take or throw my tobacco away. A record review of Admission Record revealed the facility admitted Resident #1 on 09/15/22 with current diagnoses including Type 2 Diabetes Mellitus, Vascular Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/25/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) Score of 11, which indicated his cognition was moderately impaired. A record review of Resident 's Progress Note dated 07/10/24 07:40 AM revealed . Resident was chewing tobacco that was given on previous shift. Resident was screaming and asking for more tobacco, while he had tobacco in his mouth. Explained to the resident that he had tobacco already, and that it was against our policy for me to give it to him. Resident refused to take, his meds because he wasn't given more tobacco. Resident kept screaming for the nurse (Proper Name) who does not work on this rotation. Informed Nurse Supervisor . A record review of Resident #1's Progress Note dated 07/11/24 02:04 PM created by the Physician revealed . This patient is doing well and receiving excellent care at this institution. The problem we have now is that for two years he was using his chewing tobacco and now the regulation of no tobacco is being enforced strictly in this too very unhappy that he can't use his chewing tobacco. The administrator has no choice to follow the rules of his institution. The family is very unhappy about this . A record review of the Resident Grievance/Complaint Investigation Report Form, dated 7/11/24, with the Date Incident/Issue Occurred was 7/4/24, revealed Resident #5's family complained the resident's tobacco was taken from him.

CI MS 23522 Based on record reviews, interviews, and facility policy and procedure review the facility failed to ensure a resident was free of accidents and/or hazards during transfer when staff physically lifted and transferred Resident #1 from her bed to her wheelchair without using the required full body lift with two (2) person (s) to assist, resulting in a fracture of the left tibia and fibula and a left non-displaced intertrochanteric femur fracture for one (1) of three (3) residents reviewed for accident/hazards. Resident #1. Based on implementation of the facility's corrective actions on 11/09/23 through 11/12/23, this was determined to be Past Non-Compliance. Findings include: Record review of the facility policy and procedure titled Resident Lift/Transfer Policy and Procedure Acknowledgement for Nurses and Certified Nursing Assistants dated 01/01/2019 revealed It is the Policy of (Proper Name of Facility)this facility) to provide a safe environment for .Residents by providing mechanical lift equipment for Resident lifts/transfers. Mechanical lifts are available on each Nursing Unit for Resident lifts/transfers. Procedures for Mechanical Lifts/Transfers 1. Only trained and authorized employees are allowed to lift/transfer Residents .according to each Resident's Care Plan . Record review of the facility policy and procedure titled Safe Transfer and Lifting of Residents dated revised 8/2/22 revealed: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents . VI. Procedure for transferring resident with full body lift: . c.identifies resident/ensures proper transfer is followed per care plan .Ensures 2nd person is assisting . Record review of the facility's investigation report revealed an unsigned typed note dated 11-9-2023 (no time documented) revealed It appears that three CNA's broke policy and assisted resident (Proper Name of Res #1) to stand. (Res #1) has a condition where her bones are extremely brittle. On the morning of 11-9-2023, (Res #1) was noted to have a hematoma on her lower leg. There were no breaks in the skin, and she denied being dropped. Interviews with the CNA's indicated that they had stood her in lieu of following her care plan. This is preliminary and the investigation continues . Record review of the review of the facility's investigation dated 11/14/23 and signed by the Nursing Home Administrator revealed On 11-9-2023 at approximately 9:15 A.M. it was discovered that (Proper Name of Res #1) had a hematoma on her lower left extremity on the anterior of her leg. After the discovery, she was sent to Proper name of the local hospital) for examination and subsequent treatment. At that point, an investigation was begun to determine the cause of the injury. In questioning Certified Nursing Assistants (CNA's) that had been assigned to her on 11-8-2023, it was discovered that she was transferred improperly, she was care planned for a total lift. She had a history of Osteopenia They discovered fractures of the left fibula and tibia. Due to this diagnosis (Proper Name of Res #1) was scheduled with an orthopedic doctor the following day .He determined that she (Res #1) had a fracture of the left tibia and fibula fracture and left non-displaced intertrochanteric femur fracture . Additional pain medication was ordered . Certified Nursing Assistant ( Proper Name of CNA #1) was interviewed and gave a written statement that indicated that she inappropriately pivoted (Proper Name of Res #1) instead of using the lift she performed a one person pivot .Based on the interviews and the timeline it appeared that (Proper Name of Res #1's) CNA inappropriately transferred her using a one person assist pivot causing injury. CNA #1 was terminated . Interview on 12/13/23 at 11:30 AM, with the facility Administrator (ADM) he stated that they completed the facility investigation on 11/10/23 and determined that Res #1 was injured by CNA #1 due to her not using the proper technique for a total full body lift with a two (2) person transfer assistance. CNA #1 was terminated as a result of not following the policies and procedures for transfers of Res #1. The ADM stated that Res #1 received fractures to her tibia and fibula and a left non-displaced intertrochanteric femur fracture . Record review of the facility's investigations dated 11/9/23 and signed by the DON revealed, Interview with resident (Proper name of Res #1) Spoke with resident to inquire about injury to LLE (left lower extremity). Resident confirmed being transferred without lift but denied being dropped, bumped or falling. Resident stated she did not recall having anything bump into her. Resident stated she did not remember being injured in any way. Resident denied being mistreated or hurt in any way. Interview on 12/13/23 at 12:00 PM with the Director of Nursing (DON) revealed she had determined that Res #1 was injured as a result of being improperly transferred by three (3) CNA's. Interview on 12/13/23 at 1:15 PM, with the Social Services Director (SSD) revealed that Res #1 had been interviewed by staff on 11/09/23 and on 11/10/23 concerning the injuries that she received on 11/08/23 and Res #1 denied any abuse and denied being dropped. Res #1 did confirm to staff that she had been transferred without the use of the total body lift. Res #1 stated that she did not want to be transferred by the total body lift. SSD stated that on 11/10/23 that she assessed Res #1 and found her to issue no complaints. Record review of the handwritten statement signed by CNA #1 (undated) revealed .I raised her (Res #1's) bed just a little bit to make transfer easier. (Proper Name Res #1) wrapped her arms around my shoulders and I wrapped around her, under her shoulders but around ribs/under breast, one hand flat on her back and one hand holding her waist band. I easily and slowly lifted her and pivoted her. I turned her around towards sink put legs of chair on and put my hands on bottom of her feet and sat them down, one by one at a time on her foot rests . I checked on her on and off throughout the day and when I left at the end of my shift she was asleep at the front. Interview via telephone on 12/13/23 at 2:00 PM, with CNA #1 she stated that Res #1 did not complain of pain did not call out in pain and did not make any complaints of pain or injury when CNA #1 transferred Res #1 from her bed to her wheelchair without a full body lift or the assistance of another staff. CNA #1 confirmed that she did not use a lift to transfer Res #1 and did not utilize another staff to assist with the transfer. CNA #1 stated that Res #1 was not injured during the improper transfer. CNA #1 stated that she placed Res #1 in her wheelchair and then assisted to dress her and provide personal grooming. CNA #1 pushed Res #1 from her room to the nursing station at approximately 10:00 AM on 11/08/23. CNA #1 stated that Res #1 was cognitive and was able to communicate her needs and wants and she wanted CNA #1 to manually transfer her from her bed to the wheelchair without the use of the full body lift. CNA #1 confirmed that she was terminated on 11/10/23 as a result of the improper transfer of Res #1. CNA #1 denied that Res #1 received any injuries as a result of not using the lift for transferring Res #1 on 11/08/23 at approximately 10:00 AM. Record review of the handwritten statement dated 11/10/23 and signed by CNA #2 revealed I was working as shower aide on 11/8/23 when resident came into shower room saying the back of her left leg under where the knee bend was hurting her. At the time whoever her aide was did not have total sling under her, so me and other shower aide did 2 person assist with her. I asked was she ok was her leg ok before removing clothes, resident said yes. Removed clothes and put clothes back on, resident did not complain about anything hurting her. Proceeded to take her back to nurse station where she was sitting before shower. (Res #1) was never stood on her feet when doing 2 person assist. One staff was under arms another staff under legs and transfer her from wheelchair to shower chair. Interview on 12/13/23 at 2:45 PM, with CNA #2 revealed that she and CNA #3 were giving baths as a team on 11/08/23. She confirmed that they transferred Res #1 from her wheelchair to the shower area without using a full body lift. CNA #2 stated that they did not drop or injure Res #1 and that Res #1 did not complain of pain or injury. CNA #2 assisted with Res #1's bath on 11/08/23 at approximately 2:30 PM or 3:00 PM. CNA #2 stated that Res #1 was placed in her wheelchair without a sling underneath her when she was brought to the shower area. CNA #2 stated that because Res #1 had no sling underneath her they were unable to use the lift and there were no lifts in the shower area to use. CNA #2 stated that she and CNA #3 used 2 person assistance to transfer Res #1 from her wheelchair to the shower chair and back in to her wheelchair. After the shower was completed the CNA's returned Res #1 to her room per her request. Record review of the handwritten statement signed by CNA #3 (undated) read: On November 8th 2023 It was (Res #1's) bath day. We asked (Res #1) was she going to take a bath and she replied yes. We took Res #1's in the shower room and asked her again was she sure she wanted a shower. She replied yes again. Res #1 was complaining of her left leg hurting before the shower and during the shower. We didn't notice any spots or bruises during her shower. Res #1 didn't have a sling under her when brought into the shower room. We did a 2 assist with her since their was no sling under her to transfer. Her feet did not hit the floor when we transferred her. When we got finished with her shower we put her back into her chair from the shower chair and still noticed anything wrong with Res #1. When doing the 2 person assist we put our arms under her arm pits to secure her. We then lifted her up out of her wheelchair holding on to her and put her in the shower chair, making sure her feet didn't hit the floor. Record review of a written investigation report signed by the RN #1/ Quality Assurance (QA)/Infection Control Nurse dated 11-10-23 (no documented time) revealed On 11-9-23 .resident's anterior lower leg was bruised with a knot and was painful to the touch .NP was notified and gave orders for resident to be sent out for Doppler and XRAY .sent out via ambulance .to be transported via ambulance. Orders placed to monitor left lower extremity for discoloration and to monitor pedal pulses. After resident returned resident was interviewed again by DON. While DON interviewed resident I went to get resident her pain medication. Pain medication was administered by the cart nurse. Nurse Practitioner (NP) notified the oncoming NP for 11-10-23 to evaluate resident. Resident was evaluated by NP on 11-10-23 and is placing order for resident to receive something else for pain. Interview on 12/13/23 at 3:35 PM with Registered Nurse (RN #1) revealed that she was the Quality Assurance (QA) nurse and immediately on 11/09/23 at approximately 12:00 noon an emergency QA meeting was held. The QA committee assisted with the completion of the facility's investigation and they determined that CNA #1 did not transfer Res #1 in accordance to the care plan and because of not using the lift for transferring with a two (2) person (s) assist, Res #1 was injured. Interview on 12/13/23 at 4:00 PM, with the DON she confirmed that Res #1 was found to have injuries of bruises and a hematoma to her lower left leg on 11/09/23 at approximately 9:15 AM and was transferred via ambulance to the local hospital emergency roiagnom on [DATE] at approximately 10:00 AM and was found to have fractures of her lower left leg. The DON confirmed that on 11/10/23 Res #1 was transported via ambulance to a doctor's orthopedic clinic in another nearby town approximately 50 miles away. The DON stated that on 11/10/23 at approximately 8:30 PM, Resident #1 was pronounced dead at the facility. Record review of the local hospital Emergency Department report dated 11/09/23 at 10:27 revealed a discharge note that read: The patient was discharged to Home or Self Care. Instructions given to the patient: Fracture, tibia and Fibula (Both Bones) and the patient was advised to return if worsening or increasing symptoms or return as needed. Record review of the (Proper Name) Ortho dated 11/10/23 revealed .she was at the emergency room yesterday .she was found to have a fracture and referred here .Pain is severe with a rating 10/10 .The problem started after an injury .Left Lower Leg Examination: There is swelling and ecchymosis (bruising) in the lower leg. She is very tender to palpation (touch) over the distal fibula .Hip/Pelvis Xrays: .looks like there is a nondisplaced fracture in the intertrochanteric region .Tibia Xrays: There is an oblique midshaft tibia fracture with mild displacement and a nondisplaced distal fibula fracture . Record review of the Progress Notes dated 11/10/2023 at 17:35 (5:35 PM) and signed by RN #1 revealed Resident was evaluated by (Proper Name of Nurse Practitioner). Ordered Tramadol 2 x a day for pain. Record review of the progress notes dated 11/10/2023 at 20:38 (8:38 PM) revealed: Resident was heard by roommate making gurgling sounds and immediate attention was provided by increasing o2% rate of delivery and suctioning excess secretions. After about half an hour, her nurse found the said resident not moving. Assessment by this writer found resident pulseless without signs of breathing, and pupils not reactive to light. Notifications made to Administrator, RP, Coroner, and Funeral Home. Resident was cleaned and dressed. Death protocol implemented. Record review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia and Other specified disorders of done density and structure. Record review of the Minimum Data Set (MDS) dated [DATE] contained a Brief Interview of Mental Status (BIMS) score of 13 which indicated that Res #1 was cognitively intact. Record review of the Death Certificate of Res #1 dated 11/10/23 at 8:38 P.M. listed the cause of death for Res #1 as Failure to Thrive and Dementia. The State Agency (SA) validated the facility's Past Non-Compliance (PNC) Corrective Action on 12/13/23: The SA validated through interviews and record review that on 11/10/2023 the facility held an Emergency QA meeting with the Medical Director and the Inter-Disciplinary Team. The SA validated through interviews and record review that on 11/10/2023 through 11/12/2023 the facility completed a 100% body audit completed by the DON with involvement by the Administrator. The SA validated through interviews and record review that on 11/09/2023 the facility began in-services for all direct care staff on proper lift techniques by the staff development nurse. The SA validated through interviews and record review that a 100% audit of all residents was completed to ensure that they had a *BCARE Lifts/Transfer Assistance Evaluation completed appropriately, and that the facility compared the Lift Evaluation, Care Plan and Kardex of all residents to ensure that they match and were correct. The SA validated through interviews and record review that in-services for all nursing staff, including agency staff on using the Transfer and Kardex Training was performed by the Staff Development nurse. The SA validated through interviews and record review that an ongoing processes to ensure that the correct lift and procedures are and will be used included: Skill observations for the Stand Lift and Total Lift for all nursing staff and CNA's and agency staff was completed. This was performed by the Staff Development nurse and audited by the Director of Nursing. The SA validated through interviews and record review that the facility will use the QA Transfer Audit when completing transfer audits and the Nurse Supervisor will visualize a transfer and verify that CNA's are using the appropriate lift and technique. This will be used through 12/31/23. The SA validated through interviews and record review that transfer audits will be completed by a cart nurse 2 x per shift per day. The DON will visualize one (1) transfer on each shift every week. The other audits for the week may be delegated. This will be completed through 12/31/23. The SA validated through interviews and record review that the facility's investigation determined that CNA #1 was responsible for the injuries to Res #1.CNA #1 was terminated for not following the care plan for the proper transfer of Res #1 and not using the full body lift with a (2) person assist.

CI MS #23522 Based on staff interviews, record reviews, and facility policy and procedure reviews, the facility failed to implement the care plan for a two (2) person transfer using a full body lift, resulting in an injury to Resident #1 for one (1) of three (3) care plans reviewed for transfers. Based on implementation of the facility's corrective actions initiated on 11/09/23-11/12/23, this was determined to be Past Non-Compliance (PNC). Findings Include: The facility policy and procedure titled Using the Care Plan dated revised 8/2/22 revealed: The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident The facility policy and procedure titled Comprehensive Care Plans dated revised 8/24/22 revealed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . to meet a resident's medical, nursing needs. Policy Explanation and Compliance Guidelines .f. Resident specific interventions .reflect the resident's needs and preferences . Record review of the Care Plan Detail for Res #1 revealed Focus: The resident has an ADL (Activities of Daily Living) self-care deficit . Interventions/Task .ADL Transferring-Total assist x 2 staff using total lift with medium sling . Record review of the Task List Report revealed . ADL - Total Assist x 2 staff using total lift with medium sling Date Initiated 02/06/2023. Record review of the review of the facility's investigation dated 11/14/23 and signed by the Nursing Home Administrator revealed On 11-9-2023 at approximately 9:15 A.M. it was discovered that (Proper Name of Res #1) had a hematoma on her lower left extremity on the anterior of her leg. After the discovery, she was sent to Proper name of the local hospital) for examination and subsequent treatment. At that point, an investigation was begun to determine the cause of the injury. In questioning Certified Nursing Assistants (CNA's) that had been assigned to her on 11-8-2023, it was discovered that she was transferred improperly, she was care planned for a total lift. She had a history of Osteopenia They discovered fractures of the left fibula and tibia. Due to this diagnosis (Proper Name of Res #1) was scheduled with an orthopedic doctor the following day .He determined that she (Res #1) had a fracture of the left tibia and fibula fracture and left non-displaced intertrochanteric femur fracture . Additional pain medication was ordered . Certified Nursing Assistant ( Proper Name of CNA #1) was interviewed and gave a written statement that indicated that she inappropriately pivoted (Proper Name of Res #1) instead of using the lift she performed a one person pivot .Based on the interviews and the timeline it appeared that (Proper Name of Res #1's) CNA inappropriately transferred her using a one person assist pivot causing injury. The CNA #1 was terminated . Interview via telephone on 12/13/23 at 2:00 PM, with CNA #1 she stated transferred Res #1 from her bed to her wheelchair without a full body lift or the assistance of another staff. CNA #1 confirmed that she did not use a lift to transfer Res #1 and did not utilize another staff to assist with the transfer. Interview on 12/13/23 at 2:30 PM, with Licensed Practical Nurse (LPN) #1 she confirmed that she was the Care Plan and Minimum Data Set (MDS) nurse. LPN#1 confirmed that Res #1 was care planned since 02/06/23 for a full body lift with two (2) person (s) to assist for all transfers. LPN #1 stated that all staff had been educated on the care plan of Res #1 and that CNA #1 knew that Res #1 was to be transferred via a full body lift with two (2) person (s) to assist. LPN #1 stated that the CNA 's had access to the CNA care plan that was available in the Kiosk under Point of Care. Interview on 12/13/23 at 3:35 PM with Registered Nurse (RN #1) revealed that she was the Quality Assurance (QA) nurse and immediately on 11/09/23 at approximately 12:00 noon an emergency QA meeting was held. The QA committee assisted with the completion of the facility's investigation and they determined that CNA #1 did not transfer Res #1 in accordance to the care plan and because of not using the lift for transferring with a two (2) person (s) assist, Res #1 was injured. Record review of the facility's investigations dated 11/9/23 and signed by the DON revealed, Interview with resident (Proper name of Res #1) Spoke with resident to inquire about injury to LLE (left lower extremity). Resident confirmed being transferred without lift but denied being dropped, bumped or falling . Record review of the facility's investigation report revealed an unsigned typed note dated 11-9-2023 (no time documented) revealed It appears that three CNA's broke policy and assisted resident (Proper Name of Res #1) to stand. Interviews with the CNA's indicated that they had stood her in lieu of following her care plan . Record review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia and Other specified disorders of done density and structure. The State Agency (SA) validated the facility's Past Non-Compliance (PNC) Corrective Action on 12/13/23: The SA validated through interviews and record review that on 11/10/2023 the facility held an Emergency Quality Assurance (QA) meeting with the Medical Director and the Interdisciplinary Team. The SA validated through interviews and record review that on 11/10/2023 through 11/12/2023 the facility completed a 100% body audit completed by the DON with involvement by the Administrator. The SA validated through interviews and record review that on 11/09/2023 the facility began in-services for all direct care staff on proper lift techniques by the staff development nurse. The SA validated through interviews and record review that a 100% audit of all residents was completed to ensure that they had a *BCARE Lifts/Transfer Assistance Evaluation completed appropriately, and that the facility compared the Lift Evaluation, Care Plan and Kardex of all residents to ensure that they match and were correct. The SA validated through interviews and record review that in-services for all nursing staff, including agency staff on using the Transfer and Kardex Training was performed by the Staff Development nurse. The SA validated through interviews and record review that an ongoing processes to ensure that the correct lift and procedures are and will be used included: Skill observations for the Stand Lift and Total Lift for all nursing staff and CNA's and agency staff was completed. This was performed by the Staff Development nurse and audited by the Director of Nursing. The SA validated through interviews and record review that the facility will use the QA Transfer Audit when completing transfer audits and the Nurse Supervisor will visualize a transfer and verify that CNA's are using the appropriate lift and technique. This will be used through 12/31/23. The SA validated through interviews and record review that transfer audits will be completed by a cart nurse 2 x per shift per day. The DON will visualize one (1) transfer on each shift every week. The other audits for the week may be delegated. This will be completed through 12/31/23. The SA validated through interviews and record review that the facility's investigation determined that CNA #1 was responsible for the injuries to Res #1. CNA #1 was terminated for not following the care plan for the proper transfer of Res #1 and not using the full body lift with a (2) person assist.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the possible spread of infection when a nurse dispensed medication into her bare hands during the administration of medications for two (2) of nine (9) residents observed for medication administration. Residents #10 and #41. Findings include: Review of the facility's policy, Infection Prevention and Control Program, with a revision date of 6/15/23, revealed This facility has established and maintains 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 as per accepted national standards and guidelines . Resident #41 On 09/06/23 at 11:50 AM, an observation of Licensed Practical Nurse (LPN) #1 preparing medications to be administered to Resident #41, revealed the LPN dispensed four (4) pills out of the medication card into her bare hands and then placed them into the medication cup. The oral medications dispensed into her hand were Furosemide 40 mg (milligrams), Amiodarone HCL 200 mg, Gabapentin 100 mg, and Extended-Release Potassium Chloride 20 meq (milliequivalent). Prior to preparing the medications for administration to Resident #41, LPN #1 touched cart keys, the cart drawers, and the computer numerous times before dispensing the medication into her bare hands and placing them into the medication cup. After placing the medications into the medication cup, LPN #1 administered medications to Resident #41. Resident #10 On 09/06/23 at 1:05 PM, an observation of LPN #1 preparing medications to be administered to Resident #10, revealed LPN #1 dispensed eight (8) pills out of the medication card into her bare hands and placed them into the medication cup. The oral medications dispensed into her hand were Carvedilol 6.25 mg, Clopidogrel Bisulfate 75 mg, Hydrochlorothiazide 25 mg, Loratadine 10 mg, Extended-Release Potassium Chloride 20 meq, Risperidone 1 mg, Rosuvastatin Calcium 20 mg, and Sertraline 100 mg. Prior to preparing the medications for administration to Resident #10, LPN #1 touched the medication cart keys, the medication cart drawers, and the computer numerous times prior to dispensing the medications into her bare hands and placing them into the medication cup. After placing medication into the medication cup, LPN #1 administered the medications to Resident #10. On 09/06/23 at 2:58 PM, in an interview with LPN #1, she revealed she should not have touched the medications with her bare hands, as that contaminated the resident's medications. LPN #1 explained that she knew better, but just forgot. LPN #1 confirmed that by putting the mediation in her hand, she could cause the spread of infection. On 09/06/23 at 5:30 PM, in an interview with the Director of Nurses (DON), she stated nurses should never put pills into their bare hands. She explained that nurses should dispense pills directly into the medication cup. The DON confirmed that the actions of LPN #1 is an infection control issue and could cause the spread of infection to the residents receiving the medications. A record review of the Admission Record of Resident #10, revealed the facility admitted the resident on 7/21/23, with diagnoses that included Type 2 Diabetes Mellitus, Essential Hypertension, and Anxiety Disorder. A record review of the Admission Record of Resident #41, revealed the facility admitted the resident to the facility on [DATE], with diagnoses that included Chronic Destructive Pulmonary Disease, Paroxysmal Atrial Fibrillation, and Congestive Heart Failure.

Based on observation, interviews, and facility policy review, the facility failed to discard expired medications and ensure that opened multi-dose vials were dated when opened for two (2) of two (2) medication carts reviewed for medication storage. Findings include: Review of the policy, Administering Medications, with a revision date of 8/2/22, revealed, Medications shall be administered in a safe and timely manner, and as prescribed . 12. The expiration date on the medication label must be checked prior to administering. When opening a multi-dose container, the date shall be recorded on the container . On 09/05/23 at 3:50 PM, a check of medication cart #1 with Licensed Practical Nurse (LPN) #1 revealed a 60-tablet bottle of sugar and starch free Magnesium Chloride with an expiration date of 9/30/22, a 100-tablet bottle of B complex vitamins with an expiration date of 12/22, an opened vial of Humulin R insulin without an open date on the vail and a vial of Lispro Insulin opened without an open date on the vail. LPN#1 stated she doesn't have time to check everything on the cart, every day. She revealed that she checks the expiration date prior to administering the medication, and if it were expired or if the insulin was not dated, she would not administer the medication. She stated that she would discard the medication and get a new bottle out of the medication room. LPN #1 explained that insulin can be given for 28 days after the vial is opened and after that, it is considered expired and should be discarded. LPN #1 confirmed that expired medications may not be as effective, causing residents to not receive the therapeutic effect desired from the medication. On 09/05/23 at 4:55 PM, a check of medication cart #2 with LPN #3 revealed Novolog Solution 100 unit/ml open without an open date on the vial. She stated insulin from opened, undated vials should have not be given, as insulin is only considered effective for 28 days once the vial is opened. LPN #1 explained that nurses should checks the expiration dates of medications prior to administration and replace any medications that are outdated. LPN #1 confirmed that it is the responsibility of the nursing staff to check their carts for expired medication and replace as needed but admitted that she had not checked her cart today. On 09/06/23 at 5:08 PM, in an interview with Registered Nurse (RN) #1/Charge Nurse, she stated nurses should discard all expired medications when they expire, as some expired medications can become toxic after the expiration date and others will not prove the therapeutic effect desired. The RN confirmed that insulins should be dated when opened and discarded after 28 days. The RN added that with so many over-the-counter medications being used, the best practice is for the nurse to check the expiration date prior to administering the medication to a resident. On 09/06/23 at 5:35 PM, in an interview with the Director of Nursing (DON), she confirmed expired medications should not be in medication cart. She stated the nurse should check the over-the-counter medications kept in the medication carts weekly for expired dates and replace them with new bottles available in the medication room. She further explained that when insulin vials are opened, the nurses are supposed to date the bottles and discard the unused insulin after 28 days, as the residents may not receive the desired therapeutic effect after 28 days. The DON also confirmed that nurses should not administer insulin from an undated vial, as without knowing the date the vial was opened, there is no way to know whether it has been opened more than 28 days.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure cautionary signage was posted related to oxygen usage for one (1) of one (1) resident reviewed for respiratory conditions. Resident #8 Findings Include: Review of the facility's policy, Oxygen Administration, with revised date of 08/02/22, revealed, Purpose .The purpose of this procedure is to provide guidelines for safe oxygen use . Equipment and Supplies .The following equipment .will be necessary when performing this procedure .4. No Smoking/Oxygen in Use signs . Steps in the Procedure . 2. Place an Oxygen in Use sign on the outside of the room entrance door. Close the door . On 09/05/23 at 11:21 AM, an initial observation of Resident # 8, revealed the resident was receiving oxygen by way of nasal cannula using an oxygen concentrator. There was no cautionary signage on the door of the room, indicating that oxygen was being administered. Observation on 09/05/23 at 01:43 PM, revealed Resident #8, was lying in bed with the head of bed elevated and receiving oxygen by way of oxygen concentrator per nasal canula. There continued to be no cautionary signage on the door of the room, indicating that oxygen was being administered. A record review of the Admission Record of Resident # 8 revealed the resident was admitted by the facility on 8/14/2020, with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Chronic Obstructive Pulmonary Disease and Unspecified and Obstructive Sleep Apnea. Record review of the Physician's Order Sheet, revealed a Physician's Order dated 06/07/23, for Oxygen at 2L (liters) prn (as needed) N/C (nasal cannula) r/t (related to) shortness of breath. On 09/06/23 at 12:20 PM, in an interview with the Director of Nursing (DON), she stated it was her expectation that all residents receiving oxygen therapy have cautionary signage on the doors for safety. On 09/07/23 at 12:15 PM, in an interview and observation with Licensed Practical Nurse (LPN) #2, she confirmed there was an O2 Concentrator in the room for Resident #8. She also confirmed that there were no cautionary signs on the door indicating the use of oxygen.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure that tube placement was checked prior to flushing the enteral feeding tube with water for one (1) of (1) observations of enteral feedings. Resident #9 Findings include: Review of the policy, Administering Medications through an Enteral Tube, with a revision date of 8/2/22, revealed, .19. For nasogastric (NG) and gastrostomy (G) tubes, check placement: .a. Observer for a change in the external tube length. b. Observe for signs of respiratory distress. C. Auscultate the abdomen, but do not rely on this as the singular method to differentiate between respiratory, gastric, esophageal and bowel placement: (1) Attach 60 mL (milliliter) syringe containing approximately 10 cc (cubic centimeter) air. (2) Auscultate the abdomen (approximately 3 inches below the sternum) while injecting the air from the syringe into the tubing. (3) Listen for whooshing sounds to check placement of the tube in the stomach . On 09/06/23 at 2:35 PM, observed Licensed Practical Nurse (LPN) #2 flushing the peg (percutaneous endoscopic gastrostomy) tube of Resident #9 with 200 ml of water. LPN #2 drew up 60 ml of water in the syringe and began to flush the peg tube. She continued until she had flushed the tube with 200 ml. LPN #2 did not check placement prior to flushing. On 09/06/23 at 2:50 PM, during an interview, LPN #2 confirmed she forgot to check placement prior to flushing. She stated she should have checked to make sure it was still in place, as it could have been dislodged and caused complications like aspiration pneumonia or sepsis if the fluid went into the abdominal cavity. On 09/06/23 at 5:00 PM, in an interview with Registered Nurse (RN) #1/ Charge Nurse, she stated nurses should always check placement prior to flushing peg tubes with water. She stated nurses could cause organ damage by not checking placement. On 09/06/23 at 5:27 PM, in an interview with Director of Nursing (DON), she confirmed that LPN #2 should have checked placement before flushing the peg tube. She stated if a peg tube is not in place, it could cause resident pain and rupture an organ. She stated she expects nurses to always check placement before flushing or feeding. A record review of the Admission Record of Resident #9 revealed an admitted [DATE], with diagnoses that include Chronic Obstructive Pulmonary Disease, Essential Hypertension, and Schizophrenia. Record review of the Order Summary Report, with active orders as of 9/7/23, revealed an order dated 6/23/2023 Enteral Feed Order: . Flush with 200 ml of water qid (Four times a day). A record review of Resident #9's Quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 7/31/23 revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment.

Based on observation, interviews, record review and facility policy review the facility failed to ensure a dignified living environment for a resident who had signs regarding her care posted in view of visitors and other residents for one (1) of 15 sampled residents. Resident #23 Findings Include: Review of the facility's Resident Rights, revised 6/1/23, revealed .7. Privacy and confidentiality. The resident has a right to .confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care . On 09/05/23 at 2:49 PM, during an observation of Resident #23, there was a handwritten sign located on her personal refrigerator, within view of other residents and visitors, which indicated Thickened Liquids. On 09/06/23 at 9:30 AM, during an observation of Resident #23, the sign indicating thickened liquids was observed on the resident's personal refrigerator in her room. On 9/7/23 at 10:00 AM, Resident #23 was observed in bed and there was a visitor at the Residents roommate's bedside. The sign regarding Thickened Liquids was posted in the view of the visitor. Record review of the Admission Record revealed the facility admitted Resident #23 to the facility on [DATE] with diagnoses that included Dementia. Record review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated her cognition was moderately impaired. Record review of the Order Summary Report revealed Resident #23 had a Physician's Order, dated 06/15/2023, for NAS (No Added Salt) diet Mechanical Soft texture, nectar consistency. During an interview on 09/07/23 at 8:50 AM, with the Director of Nursing (DON), she stated she did not know there were signs posted in resident rooms with medical information related to the resident. She said they do not post signs because of Health Insurance Portability and Accountability Act (HIPPA) and the resident may not want everybody to know what kind of care they are getting.

Based on observation, staff interviews, record review and facility policy review, the facility failed to keep the call light within the resident's reach for two (2) of three (3) observations. Resident #8. Findings include: Review of the facility's policy titled, Call Lights: Accessibility and Timely Response, with revised date of 08/02/22, revealed, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room . On 09/05/23 at 01:43 PM, an observation of Resident #8 revealed the resident was lying in bed with the head of the bed elevated. The resident's call light was lying on the floor. On 09/05/23 at 02:44 PM, an observation revealed a Certified Nursing Assistant (CNA) in Resident #8's room, having a conversation with the resident. Upon entry into the resident's room after the CNA left, revealed the call light remained on the floor. On 09/05/23 at 02:46 PM, an observation and interview with Resident's #8 in his room revealed his call light was located on the floor and not within his reach. Housekeeper #1 entered the resident's room, saw that the call light was not within reach of the resident and picked it up and placed next to the resident. On 09/05/23 at 03:19 PM, in an interview with Housekeeper #1, she revealed that the call light is the responsibility of all employees. She confirmed that it was found on the floor and that it should have been within the residents' reach. The housekeeper revealed that due to the resident's limitations, his call light should be available to him at all times. On 09/05/23 at 4:18 PM, Resident # 8 was observed lying in his bed with his eyes closed. The resident's call light was laying on top of his bedside table on the left side of his bed. Resident #8 demonstrated he was able to reach his call light. Resident # 8 stated he could reach it today, but states when he can't reach it, he just yells for assistance. On 09/06/23 at 09:23 AM, during an interview, the Director of Nurses (DON) revealed that call lights are the responsibility of all employees, but especially nursing staff because it's the warning system to alert them of something being wrong. The DON revealed the call light system is a part of resident care and is a key to quick response. A record review of the Admission Record of Resident # 8 revealed the resident was admitted by the facility on 8/14/2020, with the diagnoses that included Dysphagia Following Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Chronic Obstructive Pulmonary Disease, Unspecified and Obstructive Sleep Apnea. A record review of Resident # 8's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/19/2023, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on staff interviews, record review, facility investigation review and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of Resident #1 on 2/07/22. The facility was not aware Resident #1 had exited the facility until the Director of Nurses at the hospital next door, approximately one hundred (100) yards away, notified the facility. This concern was identified for one (1) of four (4) sampled residents. The State Agency (SA) conducted a Complaint Survey for CI MS # on 2/15/22 through 2/18/22 and substantiated CI MS # related to an elopement, when the facility failed to provide adequate supervision to prevent Resident #1's elopement from the facility. On 2/07/22 at approximately 6:48 PM Resident #1 was missing, unsupervised and away from the facility for approximately thirty-six (36) minutes. The facility staff were not aware Resident #1 had exited the facility until the Director of Nurses at the hospital telephoned on 2/07/22 at 7:24 PM. Resident #1 was escorted for assessment at the hospital emergency department by facility staff prior to returning to the facility with staff, where he was immediately placed on one-on-one supervision. On 2/07/22 and 2/08/22, the facility Maintenance Technician installed devices in all facility windows to prevent the windows from opening more than six (6) inches. Based on the facility's implementation of corrective actions on 2/07/22 through 2/08/22, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed as of 2/08/22. The SA notified the facility's administrator of the Past Non-compliance (PNC) Immediate Jeopardy (IJ) on 2/17/22 at 11:55 AM. Findings Include: Record review of the facility policy titled ELOPEMENTS, dated January 2012, revealed POLICY STATEMENT: This facility will make every effort to protect the safety of all residents in the facility . Record review of the facility policy titled Safety and Supervision of Residents, dated July 2017, revealed Our facility strives to make the environment as free from accidents are facility-wide priorities .Individualized, Resident-Centered Approach to Safety .3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices . Record review of the facility policy titled Wandering and Elopements, dated June 2021, revealed .Resident supervision is a core component of the systems approach to safety . Record review of the 'Facility Investigation prepared by the facility Director of Nurses (DON), dated 2/07/22, revealed the last staff observation of Resident #1 prior to the elopement was at 6:48 PM on 2/07/22; the facility received a telephone call from the hospital Director of Nurses at approximately 7:24 PM on 2/07/22 who notified her that a resident was at the hospital and had told the hospital DON that he had left the facility through a window. The 'Facility Investigation revealed staff 'made rounds' and determined all residents were accounted for except Resident #1, who's room window blinds and window were up. The investigation revealed that the DON, Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA) #1 had taken the facility van to the hospital, located Resident #1 in the lobby, escorted him to the hospital Emergency Department for assessment where he was noted to have no injuries. The report revealed Resident #1 was returned to the facility at 9:25 PM by the DON, LPN #1 and CNA #1 and was assessed by facility nurses and interviewed by the Administrator and DON. Resident #1's Care Plan was updated and the resident was reassessed for elopement risk. The report recorded that Resident #1 was transferred to a different room, a 'Wander Guard' bracelet was placed on the resident and the staff began one-on-one observation. The Resident Representative (RR) was notified on 2/08/22 at 11:12 AM. The report included that an appointment had been made for Resident #1 for a psychological assessment. The Facility Investigation stated the facility Quality Assessment and Performance Improvement (QAPI) committee held a meeting on on 2/08/22, attended by the facility Medical Director during which the facility policies related to elopement were reviewed. On 2/15/22 at 7:24 PM, observation revealed the facility was situated on a street with the only neighboring building being the local hospital. SA counted eight (8) vehicles traveling the street in front of the facility during a five (5) minute period from 7:18 PM through 7:23 PM. There was a water drainage ravine approximately ten to twelve (10-12) feet deep which ran between the facility and the hospital next door with a very large culvert running under the street between the buildings. The parking lot was well lit with eight (8) outdoor streetlights and lights over the doors. The facility had a clear, clean, well-maintained sidewalk which ran along the front of the building between the building and parking lot. The parking lot was a flat, well-maintained [NAME] and free of holes or tripping hazards. The hospital was located approximately one hundred (100) yards up a slight incline from the facility with a well-lit parking lot and a well-maintained sidewalk along the front of the facility. On 2/15/22 at 7:40 PM, observation and an interview with Resident #1 revealed the resident was resting on his bed, watching television with a Certified Nurse's Aide sitting at the bedside. The resident was alert and oriented to self and his surroundings and able to communicate well verbally. He stated he remembered walking to the hospital during the night but could not recall which night. He stated he remembered feeling fearful and left through the window but could not remember what he had been frightened about. He stated he went to the hospital and recalled going to the hospital emergency department. He stated he had not been injured during the elopement. On 2/15/22 at 8:08 PM, SA conducted an interview with the facility Administrator, who stated Licensed Practical Nurse (LPN) #1 answered a telephone call from the Director of Nurses (DON) at the hospital 100 yards from the facility, during which the hospital DON reported a facility resident was at the hospital unaccompanied. The Administrator reported the facility staff were not aware Resident #1 had exited the facility until the Director of Nurses at the hospital telephoned. The administrator stated the facility 'Elopement Procedure' was initiated immediately. She stated the staff notified her immediately and she notified the facility Maintenance Technician. She stated she and the Maintenance Technician immediately reported to the facility, and arrived at 8:31 PM. She stated the facility DON was already at the facility at the time of the incident. The Administrator stated she was not aware that the windows opened completely prior to Resident #1's elopement. She stated immediately following her arrival at the facility on the night of the elopement (2/07/22) she instructed the facility Maintenance Technician to install window stops on all of the windows, every single one. She said the Maintenance Technician began the process on the night of 2/07/22 and completed the process on 2/08/22. The Administrator stated that all residents were evaluated for elopement risk upon admission. She said Resident #1 had been evaluated as not at risk for elopement. She reported the facility was licensed for 60 beds and had a census of 54 residents. The Administrator confirmed she attended the QAPI committee meeting on 2/8/22. On 2/15/22 at 8:20 PM, observation revealed the room from which Resident #1 eloped was on the front of the facility facing the street. The bottom windowsill was two (2) feet above the floor and there was a room air conditioner/heater unit in the window. There was a window blind on the window. The window looked out onto the sidewalk which ran alongside and against the facility outside wall. The sidewalk led to perpendicular sidewalk which ran across the front of the facility between the building and the parking lot. The facility was surrounded by flat lawn which slanted downward toward and into the drainage ravine between the facility and the hospital. The window would open five (5) inches. On 2/15/22 at 8:50 PM, an interview with CNA #1 revealed he was working the PM shift on 2/07/22 and was present at the time of the elopement. He confirmed the elopement procedure was immediately initiated upon notification of the location of Resident #1. He stated he rode in the (facility) van with the nurse to get the resident. He stated upon arrival at the hospital he and LPN #1 and the DON entered the lobby of the hospital and saw Resident #1 sitting in a chair, calmly talking with an orderly. He said Resident #1 was wearing shoes, pants, two shirts and a baseball cap. CNA #1 stated he accompanied LPN #1 and the DON to drive Resident #1 around to the emergency room at the same hospital where the resident was assessed by emergency department staff. CNA #1 confirmed Resident #1 had no apparent injuries and voiced no complaints at the time. CNA #1 said he accompanied LPN #1, the DON and the resident back to the facility where the resident had a monitoring bracelet applied, another assessment by facility nurses, and was placed on one-on-one supervision. CNA #1 confirmed Resident #1 remained on one-on-one supervision and all windows in the facility were fitted with devices to prevent them from opening more than six (6) inches. On 2/16/22 at 10:00 AM, an interview with the facility DON revealed that she was at the facility on 2/07/22 when she received notification that a resident had been located unattended at the hospital next door. She confirmed that the facility elopement procedure was immediately initiated. She stated, Right away we identified it was (Resident #1) because the window blind was still up and the window was still open and he was not in his room. She stated that at approximately 7:25 PM, LPN #1 drove the facility van and she and CNA #1 were in accompaniment as they drove to the hospital next door, approximately one hundred (100) yards away. The DON confirmed that when she entered the hospital lobby Resident #1 was calmly sitting in a chair talking with a hospital orderly and LPN #2, without voiced complaint or apparent injury. She said Resident #1 had been dressed in shoes, pants, two shirts and a baseball cap. She stated LPN #2 went back to the facility and she (the DON), LPN #1 and CNA #1 took Resident #1 in the facility van around the building to the entrance of the emergency department where Resident #1 was assessed by the hospital emergency department staff with no negative findings reported. The DON stated she, LPN #1 and CNA #1 then transported Resident #1 back to the facility in the facility van where he was assessed by facility nurses, a 'Wander Guard' bracelet was applied to the resident, and he was placed on one-on-one supervision. She confirmed Resident #1 remained on one-on-one supervision. She stated an elopement evaluation was completed for Resident #1 upon return to the facility and he was evaluated as high risk for elopement and the facility immediately began to implement elopement precautions for Resident #1. She reported that the staff attempted notification of the Resident Representative (RR) without success and the Social Worker (SW) notified the RR on 2/08/22 at 11:12 AM. On 2/16/22 at 2:00 PM, observation and interview with the facility Maintenance Supervisor revealed he had participated in application of 'window stop', which were devises to prevent the windows from opening more than six (6) inches were applied to all windows in the building. He confirmed the completion of the installment of the devices was achieved on 2/08/22. Observation revealed all windows in the facility were equipped with 'window stops' and the windows opened no more than six (6) inches. On 2/16/22 at 2:35 PM an interview with LPN #1 revealed she was working the 7:00 PM shift at the facility on 2/07/22 when she received notification that a resident had been located unattended at the hospital next door. She confirmed that the facility elopement procedure was immediately initiated. She stated staff identified Resident #1's window blind was still up and the window was still open and he was not in his room. She stated that at approximately 7:25 PM, she drove the facility van and she and CNA #1 and the DON drove to the hospital next door, approximately one hundred (100) yards away. LPN #1 confirmed that when she entered the hospital lobby Resident #1 was calmly sitting in a chair talking with a hospital orderly and LPN #2, without voiced complaint or apparent injury. She said Resident #1 had been dressed in shoes, pants, two shirts and a baseball cap. She stated LPN #2 went back to the facility and she, the DON and CNA #1 took Resident #1 in the facility van around the building to the entrance of the emergency department where Resident #1 was assessed by the hospital emergency department staff with no negative findings reported. LPN #1 stated she, the DON and CNA #1 then transported Resident #1 back to the facility in the facility van where he was assessed by facility nurses, a 'Wander Guard' bracelet was applied to the resident, and he was placed on one-on-one supervision. She confirmed Resident #1 remained on one-on-one supervision. She stated an elopement evaluation was completed for Resident #1 upon return to the facility and he was evaluated as high risk for elopement and the facility immediately began to implement elopement precautions for Resident #1. On 2/16/22 at 3:09 PM, a telephone interview with LPN #2 revealed she was working the PM shift on 2/07/22 and was present at the time of the elopement. She confirmed elopement procedure was immediately initiated upon notification of the location of Resident #1. She stated she ran outside and looked around and then ran to the hospital to be with him (Resident #1). He stated upon arrival at the hospital she entered the lobby of the hospital and saw Resident #1 sitting in a chair, calmly talking with an orderly; she said Resident #1 had been wearing shoes, pants, two shirts and a baseball cap. LPN #2 confirmed Resident #1 had no apparent injuries and voiced no complaints at the time. LPN #2 confirmed CNA #1, LPN #1 and the DON brought the resident back to the facility where the resident had a monitoring bracelet applied, was assessed by facility nurses, and was placed on one-on-one supervision. LPN #2 confirmed all windows in the facility were fitted with devices to prevent them from opening more than six (6) inches. On 2/16/22 at 4:11 PM, a telephone interview with the Resident Representative (RR) for Resident #1 revealed she had been contacted of the elopement by the facility. She stated she was surprised Resident #1 had exited the facility out of the window because he had never shown any similar behavior before. She stated the elopement had concerned her, but she was planning to be admitted to the same facility on 2/25/22 and share a room with Resident #1. She stated she felt assured that with one-on-one supervision he would be safe at the facility. On 2/17/2022 at 11:55 AM, the State Agency (SA) notified the Administrator that the facility failed to provide supervision for Resident #1, who left the facility unnoticed and unsupervised on 2/7/2022 at approximately 6:48 PM and was located at the local hospital which was approximately 36 minutes later. This was cited as an Immediate Jeopardy (IJ) Past Noncompliance (PNC). The IJ Template was provided to the Administrator. Record review of the Admission Record revealed Resident #1 was admitted by the facility on 2/01/22 with diagnoses that included Chronic [CONDITION(S)], Pressure Ulcer of Sacral Region and Hypertension. Record review of the Admission BIMS (Brief Interview for Mental Status) Evaluation-V2.1 dated 2/2/22 revealed Resident #1's BIMS score was 3.0 which indicates severe cognitive impact. Record review of the 'Elopement Evaluation' dated 2/01/22 for Resident #1 revealed he was evaluated as 'Negative' for risk of elopement. Corrective Action Plan On 2/17/2022 at 11:55 AM the State Agency (SA) notified the Administrator that the facility failed to provide supervision for Resident #1, who left the facility unnoticed and unsupervised on 2/7/2022 at approximately 6:48 PM and was located at the local hospital which was approximately 36 minutes from the last observation of a staff member. This was sited as an Immediate Jeopardy (IJ) Past Noncompliance (PNC). The IJ Template was provided to the Administrator. On 2/7/2022 at 7:24 PM, [NAME] Care Center of [NAME], (BCCM) received a phone call from the local hospital informing them that a Resident from BCCM was at the hospital. 1. Activation of the Elopement procedure was initiated immediately by the Director of Nurses (DON), which involves 2 staff members exiting the facility to inspect surrounding grounds and all other staff to begin room by room search for the missing resident. The DON discovered that Resident #1 had exited the facility through his room window. All other Residents were accounted for and verified by the DON at 7:40 PM. 2. LPN #1 exited the facility at 7:25 PM and ran to the hospital and remained with Resident #1 until the DON arrived at approximately 7:46 PM. Upon arrival LPN #1 noted Resident #1 to be fully dressed with coat and hat. The DON and LPN #2 drove the van to the hospital at 7:45 PM and took Resident #1 to the emergency room (ER) for evaluation. 3. The Administrator was notified at 7:29 PM and at this time it was noted to be 46 degrees outside with no wind or rain present. The Administrator contacted the Maintenance staff at 7:35 PM to report to the facility for inspection of the windows. The Medical Director was notified at 10:15 PM. Multiple attempts were made to notify the Responsible Party, but were not successful until 10:00 AM on 2/8/2022 due to her phone malfunction. 4. Upon arriving at the facility at 8:31 PM, Maintenance #1 inspected the windows and applied a safety stop to Resident #1's window to prevent opening more than 6 inches. 5. The ER Physician conducted an evaluation of Resident #1 at approximately 8:21 PM, with no injuries noted. The DON and staff returned to the facility with Resident #1 at 9:25 PM. 6. The Administrator and DON conducted an interview with Resident #1 at 9:28 PM. Resident #1 was moved to room 202A at 10:09 PM and placed on 1:1 staff observation which continues until re-evaluation on 2/25/2022. 7. The Administrator applied a safety stop to the window in room 202A at 10:09 PM. The DON applied a Wander Guard Bracelet to Resident #1 at 10:10 PM. 8. Staff education was initiated by the Administrator at 10:15 PM to include Wander Guard System, Wandering and Elopement Policy, Exit Seeking Procedures, Abuse, Neglect and Reporting. Staff interviews were initiated by Administrator at 8:45 PM to determine if any Exit Seeking behavior had occurred with Resident #1 prior to his exiting the facility unsupervised. No exit seeking behavior had been witnessed by facility staff. 9. The Administrator notified the SA and Attorney Generals Office at approximately 10:00 PM on 2/7/2022. 10. On the morning of 2/8/2022 at 8:00 AM, the Quality Assessment and Assurance Committee (QAA) to include the Medical Director met and reviewed the policies related to Wandering and Elopements, Abuse, Neglect and Reporting and the Exit Seeking Procedures and recommended to add Resident Rights to the education. No revisions to the policies were recommended. The QAA Committee recommended installing Safety Stops to all windows in the facility. All staff was educated on these policy and procedures prior to working. 11. Maintenance staff #1 and #2, completed installation of Safety Stops to all windows in the facility at approximately 2:00 PM on 2/8/2022. 12. Elopement Evaluations were completed by the DON, Resident Care Coordinator and Staff Development Nurse beginning at approximately 10:00 AM 2/8/2022 for all Residents and the Plan of Care updated accordingly for Resident #1 and Resident #2. The Elopement Binder was revised to include Resident #1 and Resident #2 as at risk for elopement at this time as well. 13. The QAA Committee met at 1:30 pm on 2/8/2022 to review the intervention progress and implemented a weekly window inspection to be completed by Maintenance #2 and to be documented on the Window Safety Stop Maintenance Log for 4 weeks and monthly there after. Any concerns found would be reported to the QAA committee for recommendations. The Window Safety Stop Maintenance Log will be submitted at least quarterly for the Medical Director and QAA Committee's suggestions or recommendations for sustaining compliance. VALIDATION The SA validated the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observations, facility record review and interview. 1. SA validated through record review and interviews with the Administrator, DON, LPN #1 and LPN #2 and CNA #1 the activation of the Elopement procedure was initiated immediately by the Director of Nurses (DON), which involves 2 staff members exiting the facility to inspect surrounding grounds and all other staff to begin room by room search for the missing resident. The DON discovered that Resident #1 had exited the facility through his room window. All other Residents were accounted for and verified by the DON at 7:40 PM. 2. SA validated through record review and interviews with the Administrator, DON, LPN #1 and LPN #2 that LPN #1 exited the facility at 7:25 PM and ran to the hospital and remained with Resident #1 until the DON arrived at approximately 7:46 PM. Upon arrival LPN #1 noted Resident #1 to be fully dressed with coat and hat. The DON and LPN #2 drove the van to the hospital at 7:45 PM and took Resident #1 to the emergency room (ER) for evaluation. 3. SA validated through record review and interview with the Administrator that the Administrator was notified at 7:29 PM and at this time it was noted to be 46 degrees outside with no wind or rain present. The Administrator contacted the Maintenance staff at 7:35 PM to report to the facility for inspection of the windows. The Medical Director was notified at 10:15 PM. Multiple attempts were made to notify the Responsible Party but were not successful until 10:00 AM on 2/8/2022 due to her phone malfunction. 4. SA validated through observation, record review of the 'Facility Investigation' and interview with the Maintenance Supervisor, Administrator, DON that upon arriving at the facility at 8:31 PM, Maintenance #1 inspected the windows and applied a safety stop to Resident #1's window to prevent opening more than 6 inches. 5. SA validated through record review and interview with LPN #1, CNA #1 and the DON that the ER Physician conducted an evaluation of Resident #1 at approximately 8:21 PM, with no injuries noted. The DON and staff returned to the facility with Resident #1 at 9:25 PM. 6. SA validated through record review of the 'Facility Investigation that the Administrator and DON conducted an interview with Resident #1 at 9:28 PM. Resident #1 was moved to room 202A at 10:09 PM and placed on 1:1 staff observation which continues until re-evaluation on 2/25/2022. 7. SA validated through interview with the Maintenance Supervisor and the DON that the Administrator applied a safety stop to the window in room 202A at 10:09 PM. The DON applied a Wander Guard Bracelet to Resident #1 at 10:10 PM. 8. SA validated through record review of the In-Service Training Record with attached sign-in sheets with 'In-service topic' stated Elopement-Wandering, and interview with the Administrator that staff education was initiated by the Administrator at 10:15 PM to include Wander Guard System, Wandering and Elopement Policy, Exit Seeking Procedures, Abuse, Neglect and Reporting. Staff interviews were initiated by Administrator at 8:45 PM to determine if any Exit Seeking behavior had occurred with Resident #1 prior to his exiting the facility unsupervised. No exit seeking behavior had been witnessed by facility staff. 9. SA validated through record review of the confirmation of receipt of report from the SA dated 2/07/22 and interview with the Administrator that the Administrator notified the SA and Attorney Generals Office at approximately 10:00 PM on 2/7/2022. 10. SA validated through review of the QAPI meeting summary and interview with the Administrator that on the morning of 2/8/2022 at 8:00 AM, the Quality Assessment and Assurance Committee (QAA) to include the Medical Director met and reviewed the policies related to Wandering and Elopements, Abuse, Neglect and Reporting and the Exit Seeking Procedures and recommended to add Resident Rights to the education. No revisions to the policies were recommended. The QAA Committee recommended installing Safety Stops to all windows in the facility. All staff was educated on these policy and procedures prior to working. 11. SA validated through interview with the Maintenance Supervisor and the Administrator and record review of the 'Facility Investigation' and observation that maintenance staff #1 and #2, completed installation of Safety Stops to all windows in the facility at approximately 2:00 PM on 2/8/2022. 12. SA validated through record review of the 'Elopement Binder' and 'Elopement Evaluations' for all current residents and interview with the DON that Elopement Evaluations were completed by the DON, Resident Care Coordinator and Staff Development Nurse beginning at approximately 10:00 AM 2/8/2022 for all Residents and the Plan of Care updated accordingly for Resident #1 and Resident #2. The Elopement Binder was revised to include Resident #1 and Resident #2 as at risk for elopement at this time as well. 13. SA validated through record review of the QAA committee summary that the QAA Committee met at 1:30 PM on 2/8/2022 to review the intervention progress and implemented a weekly window inspection to be completed by Maintenance #2 and to be documented on the Window Safety Stop Maintenance Log for 4 weeks and monthly there after. Any concerns found would be reported to the QAA committee for recommendations. The Window Safety Stop Maintenance Log will be submitted at least quarterly for the Medical Director and QAA Committee's suggestions or recommendations for sustaining compliance. Based on all the steps taken by the facility and have been successfully completed, the facility alleges the Immediate Jeopardy was removed as of 2/8/2022 and this represents a Past Noncompliance.