Every finding on record at Belmont Bay Rehabilitation and Healthcare Center

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to perform a transfer with a mechanical lift per the manufacturer's recommendation for one of three residents in the survey sample, Resident #1 (R1). The findings include:For R1, facility staff failed to spread the legs (open the legs) of a mechanical lift while being lifted off the bed. R1 was admitted to the facility with diagnoses that included but were not limited to cerebral palsy (1), paraplegia (2) and intellectual disabilities (3). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 08/15/2025, R1 scored 3 (three) out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions. Section GG. Functional Abilities coded R1 as being dependent for Chair/bed-to-chair transfer. On 10/29/2025 at approximately 8:05 a.m., an observation of R1's transfer using a (Name of Mechanical Lift) 500 from the bed to a wheelchair was conducted in R1's room. CNA (certified nursing assistant) #2 and CNA #3 placed the mechanical lift sling under R1. CNA #3 positioned the lift under the bed with the arm and spreader bar above R1, attached the loops of the sling to the hooks on the spreader bar. CNA #2 informed R1 that she was going to be lifted off the bed and transferred to the wheelchair. As CNA #3 was lifting R1 up off the bed using the lift, an observation of the base of the lift revealed the legs were in a closed position. Continued observations revealed CNA #3 moving the lift away from the bed toward the wheelchair, opening the legs of the lift straddling the wheelchair, a lift leg on either side of the wheelchair, then lowering R1 into the wheelchair. The comprehensive care plan for R1 dated 08/12/2016 documented in part, Focus. (R1) has the potential for fall r/t (related to) immobility, secondary to paraplegia (3), Incontinence. Date Initiated: 08/12/2016, (R1) has ADL (activities of daily living) Self Care Performance Deficit r/t Cerebral palsy, intellectual disability, paraplegia. Under Interventions it documented in part, Mechanical Lift (4) - Hoyer. Date Initiated: 08/02/2018, TRANSFERS: I require total mechanical lift and 2 (two) person assist for transfers. Date Initiated: 04/25/2024. The (Name of a (Name of Mechanical Lift) 500 Owner's Manual documented in part on page 6 (six), SAFETY INSTRUCTIONS. Please pay careful attention to the following important information regarding the care, maintenance, and operation of the (Name of Mechanical) 500 Lift. Carefully read these instructions before assembling the lifter, or attempting to lift any user with the device. PLEASE NOTE THE FOLLOWING: During lifting or lowering, whenever possible, always keep the base of the lift in the widest position. On 10/29/2025 at approximately 9:00 a.m. an interview was conducted with CNA #3 regarding the procedure when transferring a resident using a mechanical lift from the bed to a wheelchair. She stated that the sling is checked to make sure there are no holes or tears in it and the loops are secure, check the battery on the lift to make sure it is fully charged and the lift is working, bring the lift into the resident's room, make sure there is another person in the room to help, a CNA is on either side of the resident's bed, inform the resident what the CNAs are going to do, place the sling under the resident, move the mechanical lift under the resident's bed, attach the loops of the sling on the hooks on the lift, recheck to make sure the sling is correctly attached to the hooks so they do not come off, tell the resident to hug themselves so they keep their hands and arms inside the sling, slowly raise the resident, move the lift with the resident to the wheelchair, lower the resident onto the wheelchair. After being informed of the observation of the position of the mechanical lift legs when R1 was being lifted off the bed, CNA #3 was asked about the position of the mechanical lift legs when raising and lowering a resident. CNA #3 stated that the legs on the lift should be closed when raising and lowering a resident. On 10/29/2025 at approximately 10:16 a.m. an interview was conducted with CNA #2 regarding the procedure when transferring a resident using a mechanical lift from the bed to a wheelchair. She stated that the sling is checked holes or tears and make sure the lift is working, put the lift under the resident's bed, lock the wheels, put the wheelchair in position and lock the breaks before lifting the resident, attach the loops of the sling to the hooks on the lift, raise the resident, unlock the wheels, move the lift with the resident to the wheelchair, open the legs on the lift to go around the wheelchair and lower the resident into the chair. After being informed of the observation of the position of the mechanical lift legs when R1 was being lifted off the bed, CNA #2 was asked about the position of the mechanical lift legs when raising and lowering a resident. CNA #2 stated that the legs on the lift should be closed when raising and lowering a resident. On 10/29/2025 at approximately 10:42 a.m. an interview was conducted with ASM (Administrative staff member) #3, assistant director of nursing, regarding a mechanical lift. ASM #3 stated that he conducted the initial and annual training for mechanical lift operations for all nursing staff. When about the position of the legs on a mechanical lift, he asked when raising and lowering a resident he stated the legs should be open. The facility policy Lifting Machine, Using a Mechanical documented in part, Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training instructions. On 10/30/2025 at approximately 8:20 a.m., ASM #1, executive director, ASM #2, director of nursing, and ASM #4, clinical director of operations, were made aware of the above findings. No further information was provided prior to exit. References:(1) A group of disorders that affect a person's ability to move and to maintain balance and posture. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/cerebralpalsy.html. (2) The symptom of paralysis that mainly affects your legs. This information was obtained from the website: https://my.clevelandclinic.org/health/symptoms/23984-paraplegia. (3) Refers to a group of disorders characterized by a limited mental capacity and difficulty with adaptive behaviors such as managing money, schedules and routines, or social interactions. This information was obtained from the website: https://www.report.nih.gov/NIHfactsheets/ViewFactSheet.aspx?csid=100 (4) A patient lift used by caregivers to safely transfer patients. It can be used for lifting patients from the floor or onto a healthcare bed. The lift also can assist in other surface-to-surface patient transfers, such as moving from a bed to a bath or chair. This information was obtained from the website: https://transfermaster.com/blog/what-is-a-hoyer-lift/ (5) A supportive fabric seat used with a mechanical lift to help safely move a person who cannot stand or bear weight on their own. The sling wraps under and around the individual and attaches to the lift (hydraulic, manual, or electric), which then raises or lowers them into a new position. This information was obtained from the website:

Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to provide assessments and supervision for smoking for three of 50 residents in the survey sample, Residents #80, (R80), R85 and R45. For R80, the facility staff failed to ensure that smoking materials were not stored in the resident's room. For R85 and R45, the facility staff failed to conduct a safety assessment for smoking. The facility's deficient practice placed the facility's residents at risk for burns, fire, and respiratory distress. This resulted in a determination of Immediate Jeopardy (IJ), cited at a level J. After Immediate Jeopardy was removed, the scope and severity were lowered to a level 2 (two) isolated, D. The findings include: For R80, the facility staff failed to safely secure a cigarette lighter and a vape pen (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 04/12/2024, R80 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R80 was cognitively intact for making daily decisions. On 06/05/20/2024 at approximately 8:50 a.m., an interview was conducted with R80 in her room. When asked if she smoked R80 stated that she uses a vape pen and smoked cigarettes. When asked where the vape pen, lighter and cigarettes were stored R80 reached under the pillow on her bed and showed the surveyor a vape pen. She then opened the seat on her rolling walker, reached in and pulled out a cigarette lighter and showed it to the surveyor. When asked about cigarettes, R80 point to a large clothing bag next to the bed and stated she kept her cigarettes in the bag. R80 stated she did not have any cigarettes at the time. R80 further asked the surveyor not to inform the administrator that she had retained her smoking materials. The comprehensive care plan for R80 dated 11/23/2023 documented in part Focus. I smoke r/t (related to) cigarette use. Date Initiated: 10/11/2023. Under Interventions/Tasks it documented, Educate me on the adverse effects of nicotine use as well as the importance, benefits, and available methods of smoking cessation. Nicotine patch. Date Initiated: 04/17/2024. I have been provided with education on e-cigarette/vaporizer safety, including battery and charger safety. Reinforce as needed. Date Initiated: 06/05/2024. I may smoke safely with supervision. Date Initiated: 11/22/2023. I need to smoke in backyard area and not patio. Date Initiated: 11/22/2023. I understand that for my safety, the facility will store my nicotine products and my lighter. Date Initiated: 10/11/2023. The facility's Admission Agreement for R80 documented in part, Smoking: The Center will comply with state and federal law as it pertains to smoking. The safety of Patients and employees is the Center's first priority. Patients agree to follow the Center's smoking policy (a copy which has been provided to them). Each Patient wishing to smoke will be evaluated for safety purposes. If permitted to smoke, the Patient understands that he/she will be allowed to smoke in designated areas at designated times. The Patient understands that he or she will not be permitted to retain smoking materials in their personal possession or room. Further review of the document revealed it was signed by R80 on 10/25/2022. The facility's Smoking Safety Evaluation for R80 dated 04/17/2024 documented in part, 1. Does the resident currently smoke or vape? Yes. 2. Method of nicotine consumption? a. cigarette. 3. How frequently does the resident smoke or vape? Daily .16. Evaluation Generated Care Plan Interventions: I understand that for my safety, the facility will store my nicotine products and my lighter. The Health Status Note for R80 dated 04/17/2024 documented in part, A Nicotine patch was re-offered to the resident. Resident stated that she wants to remain a cigarette smoker. The Nursing Assistant Director of Nursing explained that (Name of Facility) is a non-smoking facility but the facility will continue to find a way to accommodate the resident cigarette smoking needs while the facility social workers continue working to find another placement for the resident. Smoking schedules were already arranged with the resident. Education was provided to the resident on the health risks associated with cigarette smoking and the rights of the resident to continue being a smoker. Resident is her own responsible party with a Bims score of 15 and verbalised [sic] understanding of the education provided. All the interventions put in place by the facility to accommodate the resident's desire to smoke cigarettes while in the facility were explained to the resident and the resident verbalised [sic] understanding. Resident stated that she doesn't need a smoking apron, cigarette holder, flameless lighter or any other special equipment to smoke cigarettes. The attending physician, (Name of Physician) made aware of the resident's intention to continue smoking cigarettes. The Assistant Director of Nursing also provided emotional support to the resident. The Psychological Note for R80 dated 04/22/2024 documented in part, Plan: The Resident was advised not to use drugs in or around the facility and not to distribute unauthorized items to other residents. The Social Service Note for R80 dated 05/01/2024 documented, SW (social worker) spoke with the resident's mother about the resident's plans to be discharged as she stated that she will be leaving the facility to live at an address that she refuses to give to the SW. She is moving with a friend/man since this is a non-smoking facility. The resident stated that she wants to be able to smoke and do what she wants to do. On 06/05/2024 at 10:19 a.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #3, regional VP of operations, were notified of Immediate Jeopardy (IJ). On 6/5/24 at 12:57 p.m., an interview was conducted with CNA (certified nursing assistant) #3. When asked to describe the facility's smoking policy CNA #3 stated that smoking was not allowed. When asked where smoking materials are stored if a resident does smoke CNA #3 stated that she never had it happen but would go to management if she saw anything. When asked if she found smoking materials in a resident's room CNA #3 stated she would take the items to the supervisor. When asked what would happen if a resident had smoking materials in their room CNA #3 stated that due to the danger to the rest of the residents it could cause a fire, putting the roommate in danger. When asked what was the likelihood that could happen CNA #3 stated it could happen. On 6/5/24 at 12:58 p.m., an interview was conducted with LPN (licensed practical nurse) #6 regarding resident smoking. She stated that the policy was there was no smoking. When asked that if a resident did smoke, where are smoking materials maintained? She stated that they would be kept at the front desk or by activities. When asked what she would do if she found a resident to have smoking materials on them or in their room, she stated she would remove the materials, report it to the supervisor and document it. When asked what could happen if the resident has those materials in their room, she stated that the resident could start a fire. When asked what was the likelihood that could happen, she stated very likely. On 6/5/24 at 1:00 p.m., an interview was conducted with LPN #3 regarding resident smoking. When asked to describe the facility's smoking policy LPN #3 stated the facility used to allow smoking but now is smoke free. When asked where smoking materials are stored if a resident does smoke LPN #3 stated they are at the front desk, the receptionist desk. When asked if she found smoking materials in a resident's room LPN #3 stated she Normally I report it to my immediate supervisor. When asked what would happen if a resident had smoking materials in their room LPN #3 stated there is a chance of catching on fire. When asked what was the likelihood that could happen LPN #3 stated it's a small chance but it it's higher if there is oxygen in use. On 6/5/24 at 1:00 p.m. LPN #7 was interviewed regarding resident smoking. She stated that the policy was that the facility was a non-smoking facility. When asked that if a resident did smoke, where are smoking materials maintained? She stated that they would be kept at the front desk or by activities. When asked what she would do if she found a resident to have smoking materials on them or in their room, she stated that she would let the supervisor know and educate the resident that it is not safe to keep the materials, especially a lighter. When asked what could happen if the resident has those materials in their room, she stated that it is a danger to them and the facility as a whole. She stated that there is a risk of fire. When asked what was the likelihood that could happen, she stated it was a great risk that it could happen. On 06/05/24 at 1:03 p.m., an interview was conducted with CNA #2 regarding resident smoking. When asked to describe the facility's smoking policy CNA #2 stated the facility is a no smoking zone and no one is supposed to smoke at the facility especially on the floor. When asked where smoking materials are stored if a resident does smoke CNA #2 stated the activities director keeps the smoking materials. When asked if she found smoking materials in a resident's room CNA #2 stated she would report it to her supervisor. When asked what would happen if a resident had smoking materials in their room CNA #2 stated there is a possibility of a fire. When asked what was the likelihood that a fire could happen CNA #2 stated it's likely. On 6/5/24 at 1:05 p.m. CNA #6 was interviewed regarding resident smoking. She stated that the policy was there is no smoking. When asked that if a resident did smoke, where are smoking materials maintained? She stated maybe with the nurse. When asked what she would do if she found a resident to have smoking materials on them or in their room, she stated she would report it to the supervisor. When asked what could happen if the resident has those materials in their room, she stated that they could start a fire. When asked what was the likelihood that could happen, she stated that it was a big likelihood that something could happen. On 06/05/2024 at approximately 1:05 p.m., an interview was conducted with OSM (other staff member) 9, director of social services. When asked to describe the facility's procedure for residents who smoke OSM #9 stated the facility was a non-smoking facility. She stated that for residents who smoked and wanted to quit the facility would provide them with a nicotine patch the help them stop smoking, for the residents who did not want to stop smoking, the facility would conduct a care plan meeting to try and persuade the resident to stop and would also try to find a facility that allowed residents to smoke and transfer them if a facility was available. She further stated that if the resident was at the facility and smoked, a CNA (certified nursing assistant) would accompany the resident outside of the facility, off facility property, behind the facility to smoke. OSM #9 stated that the facility had schedule smoking times three times a day. When asked where the resident's smoking materials were stored, she stated that that the smoking materials were kept at the receptionist's desk. When asked if she was aware that R80 smoked cigarettes and used a vape pen and stored a lighter and vape pen in her room OSM #9 stated no. When asked if there was the likelihood of an adverse effect of a resident keeping their smoking materials on their person or in their room, she stated it is likely that the resident could start a fire. On 06/05/24 at 1:06 p.m., an interview was conducted with CNA #4 regarding resident smoking. When asked to describe the facility's smoking policy CNA #2 stated the facility is a non-smoking building no residents or staff can smoke. When asked where smoking materials are stored if a resident does smoke CNA #4 stated she did not know. When asked if she found smoking materials in a resident's room CNA #4 stated she would report it to her supervisor. When asked what would happen if a resident had smoking materials in their room CNA #4 stated some residents on oxygen and there's a chance of fire. When asked what was the likelihood that a fire could happen CNA #4 stated it's a high possibility if someone is caught smoking in the facility. On 06/05/2024 at approximately 1:20 p.m., an interview was conducted with OSM (other staff member) 10, social services assistant. When asked to describe the facility's procedure for residents who smoke OSM #10 stated the facility was a non-smoking facility and had not seen any residents smoking. When asked if she was aware that R80 smoked cigarettes and used a vape pen and stored a lighter and vape pen in her room OSM #10 stated no. When asked if there was the likelihood of an adverse effect of a resident keeping their smoking materials on their person or in their room, she stated it is likely that the resident could start a fire. On 06/05/2024 at approximately 1:47 p.m., an interview was conducted with RN (registered nurse) #1. When asked to describe the facility's procedure for residents who smoke RN #1 stated the facility was a non-smoking facility but if a resident is identified as someone who smokes they try to encourage them to quit and offer the resident a nicotine patch to help the resident stop smoking. RN #1 further stated that if the resident wants to continue smoking, the staff keep the resident's smoking materials, and the resident is allowed to smoke off the facility grounds. When asked where the resident's smoking materials were stored RN #1 stated he did not know. On 06/05/2024 at approximately 2:02 p.m., an interview was conducted with OSM (other staff member) #11, receptionist. When asked to describe the facility's procedure for residents who smoke OSM #11 stated she keeps all the resident's smoking materials, cigarettes, lighters and /or vape pens, in a locked file cabinet in the facility's business office. She stated that when a resident wants to smoke, they come to the front desk (receptionist's desk in the facility lobby) and OSM #11 give the resident(s) their cigarettes, lighters and /or vape pens and when the resident(s) come back into the facility she takes the smoking items back and locks them in the cabinet. When asked if she knew the residents in the facility who smoked, OSM #11 stated (Name of R80, Name of R85, Name of R114 and Name of R45). When asked if she was aware of any residents who kept their smoking materials on their person or in their room, she stated no. When asked if there was the likelihood of an adverse effect of a resident keeping their smoking materials on their person or in their room, she stated that it is likely that the resident could share cigarettes or vape pens with other residents or likely of injury and a fire. On 06/05/2024 at 2:16 p.m., the Immediacy Plan was Accepted. The plan documented, 1. Smoking paraphernalia will be removed from the room of resident #80. 2. BIMS assessment to be completed to determine resident's cognitive state as it relates to comprehension of facility smoking policy. 3. Smoking safety evaluation to be completed for resident #80. 4. Resident to be reeducated on facility smoking policy. 5. Resident to be reeducated on the location of designated smoking areas. 6.A head-to-toe skin assessment will be conducted on resident #80 and variances will be reported to the physician. 7. Facility staff will be educated on community smoking policy. In addition to designated smoking areas. Items on the above checklist will be completed by 3:00 pm June 05, 2024. On 06/05/2024 at approximately 2:53 p.m., an interview was conducted with OSM #14, activities director. When asked to describe the facility's procedure for residents who smoke OSM #14 stated she stated the residents would obtain and leave their smoking materials at the receptionist's desk. When asked if she knew the residents in the facility who smoked, OSM #14 stated (Name of R80, Name of R85, Name of R114 and Name of R45). When asked if she was aware of any residents who kept their smoking materials on their person or in their room, she stated no. When asked if there was the likelihood of an adverse effect of a resident keeping their smoking materials on their person or in their room, she stated that it is likely that another resident could take the smoking materials from the resident's room or likely of injury and a fire. After multiple resubmissions, the facility presented the following IJ removal plan was accepted on 06/06/2024 at 8:00 a.m. Plan for Removal: 1.Resident #80 had a smoking re-evaluation on 6/5/24 by the licensed nurse for her ability to smoke safely and handle smoking materials. At that time the resident was also re-educated on the facility's smoking policy to include location of the designated smoking area, the storage of the smoking materials and approved smoking times. Resident #80 was offered a patch for smoking cessation which she declined. A skin evaluation was also completed by the licensed nurse with no new findings. The resident physician was also made aware of the findings of the evaluation, with no new orders noted at this time. The resident's care plan was also updated to include permission for safety rounds to validate that smoking materials are not on her person or in the resident's room. Completed 6/5/2024. 2. BIMS assessment to be completed to determine resident's cognitive state as it relates to comprehension of facility smoking policy. Completed 6/5/2024. 3. Licensed Nursing Home Administrator/designees with permission completed interviews, a visual audit and/or a search of current resident rooms for smoking materials. Any variances will be removed with the resident's knowledge for safe keeping and the resident re-educated. The physician and/ or psychosocial services will be updated as indicated. 4. Immediate Actions/Education: Nursing Administration completed an audit of current residents to validate smoking evaluations were completed and accurate per policy. Any identified variances were immediately corrected, and evaluation was completed. Completed 6/5/2024. Adhoc Resident council meeting conducted on 6/5/24 to review the facility smoking policy. Completed 6/5/24. Administrator sent an email to resident representatives on the facility smoking policy. Completed 6/5/2024. Voice friend sent to all facility staff regarding the smoking policy, designated smoking areas. Completed 6/5/2024. All Staff will be educated on smoking policy, designated smoking area, and storage of the smoking materials and approved smoking times. 36% completed 6/5/2024 and 100% completed by 6/6/2024 at 10AM. Staff will not be able to work until they are educated on smoking policy, designated smoking area, and approved smoking times. 36% completed 6/5/2024 and 100% completed by 6/6/24 at 10AM. All Staff will be educated in visually inspecting rooms during care and in-room visits for the presence of smoking material on the resident's person or at the bedside and the reporting requirements. Staff noting any variances will immediately report to the charge nurse and physician for follow-up. 36% completed 6/5/2024 and 100% completed by 6/6/2024 10AM. Resident #80 has an updated trauma-informed care evaluation and care plan mapping the pathway for individualized psychosocial care. 6/5/2024. Social Service designee will review current residents who smoke and / or have a history of non-compliance with smoking materials to validate that residents identified with similar concerns have been evaluated and care plans up to date and implemented. Resident rooms reviewed for Oxygen in use signs. Completed 6/5/2024. 5. Ongoing Compliance will be monitored by: 9/5/2024: General environment observation will be accessed during routine care delivery or ambassador rounds; such as the closets, bedside tables, and drawers for smoking materials daily for one week, then three times a week for 3 weeks, weekly for 4 weeks then monthly for one month. Any variance will be reported to the Supervisor on duty for immediate follow-up and then to the Administrator. Review of PCC smoking evaluation for new admissions and readmissions for completion, compliance and patterns/trends in resident responses or capabilities five days a week for three months. Any variance will be reported to the RN Supervisor on duty for immediate follow-up. The Administrator will be responsible for the execution and implementation of this abatement plan. The facility policy Smoking Policy - Residents documented, Policy Statement. This facility has established and maintains safe resident smoking practices. Policy Interpretation and Implementation. 1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. 3. Approved area for smoking location: Back left section of patio area. 4. Smoking permitted in the approved location at the following times: 9:30 am, 1:30 pm, 6:30 pm. 5. Smoking is not allowed inside the facility under any circumstances. 6. Residents approved to smoke will have all materials (lighters, cigarettes, e-cigarettes) stored at the front desk of the facility. All items will be returned to the receptionist for storage upon completion of smoking activities. Smoking materials will be stored in a locked drawer at the receptionist's desk. Residents will be required to sign all materials in/out for tracking purposes. 7. Electronic cigarettes and smokeless tobacco are permitted in designated areas only. 8. Oxygen use is prohibited in smoking areas. 9. Metal containers, with self-closing cover devices, are available in smoking areas. 10. Ashtrays are emptied only into designated receptacles. 11. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of tobacco consumption; b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 12. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 13. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 14. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 15. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 16. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member. 17. Residents are not permitted to give smoking items to other residents. 18. Staff members and volunteer workers are not permitted to purchase and/or provide any smoking items for residents. 19. This facility maintains the right to confiscate smoking items found in violation of our smoking policies. 20. Confiscated resident property is itemized and ultimately returned to the resident, or his or her legal representative. 21. If the facility policy changes to one that prohibits smoking (including electronic cigarettes), residents who are currently allowed to smoke will be provided an area to smoke which maintains the quality of life and safety for smoking residents, while considering the health and well-being of non-smoking residents. 22. Residents admitted after the Tobacco-Free Environment policy is adopted are informed of the policy on admission. Electronic Cigarettes 23. Electronic cigarettes (e-cigarettes, vapes) are not considered smoking devices with respect to the risk of ignition, but they are considered a risk for residents related to: a. potential health effects for the smoker, such as respiratory illness or lung injury which may present with symptoms of breathing difficulty, shortness of breath, chest pain, mild to moderate gastrointestinal illness, fever or fatigue; b. second-hand aerosol exposure; c. nicotine overdose by ingestion or contact with the skin; and d. explosion or fire caused by the battery. 24. To prevent accidents associated with e-cigarettes and to respect the rights of resident who do not want to be exposed to second-hand aerosol, residents are permitted to use e-cigarettes with supervision and in designated smoking areas only. 25. Residents who wish to use e-cigarettes are assessed for their ability to safely handle the devices (including batteries and refill cartridges) on an individual basis. 26.Residents who wish to use e-cigarettes are instructed on battery safety and tips to avoid battery explosions per FDA recommendations. Instruction specific to e-cigarette safety is documented in the resident care plan. On 06/06/2024 at 10:10 a.m., the survey team, through observations, interviews, and documentation review, verified the removal plan had been fully implemented by the facility. On 06/06/2024 at 11:45 a.m., ASM #1, the administrator, was informed the removal plan had been verified and the IJ had been removed. No further information was provided prior to exit. 27660 2. For Resident #85 (R85), the facility staff failed to complete a smoking assessment on a resident who upon interview, stated he was a smoker. An interview was conducted with R85 on 6/5/24 at 2:30 p.m. When asked if he smoked, R85 stated he smokes a little bit. R85 was asked where he smokes, R85 stated he goes across the street at the doctor's office. Where do you keep your smoking materials, R85 stated he keeps them on himself. A second interview was conducted with R85 on 6/5/24 at 2:45 p.m. When asked if he smokes, R85 stated he likes to smoke around 9:30 a.m., before dinner and then before they lock up the front doors. When asked if his smoking materials were on his person, he stated they were not on him but are nearby. This writer explained the danger to others if they would get a hold of the lighter, R85 stated, Yes, there are many people in here that you wouldn't want to get a hold of a lighter. When asked where he smokes, R85 stated he goes up the hill to the doctor's office. He further stated that they told him there was a designated smoking spot but thinks it's somewhere in the back parking lot. On most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/2/24, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The admission assessment, dated, 1/24/24 documented in part, Smoking Safety Evaluation: History of Smoking - Does the resident currently smoke or vape? No. Further review of the clinical record failed to evidence any smoking assessments completed after 1/24/24. Review of the progress notes from 1/24/24 to 6/5/24, failed to evidence any documentation related to smoking. The comprehensive care plan dated, 6/4/24, documented, Focus: I smoke Cigarettes. An interview was conducted with CNA (certified nursing assistant) #3 on 6/5/24 at 12:57 p.m. When asked what the smoking policy was in the facility, CNA #3 stated, there is no smoking allowed. CNA #3 was asked if a resident does smoke, where are the smoking materials kept. CNA #3 stated she's never had that happen, but if she sees anything, she would go to management. What do you do if you find a resident with smoking material on the resident or in their room, CNA #3 stated she would take the items to the supervisor. CNA #3 was asked what would happen if a resident has smoking materials in their room, CNA #3 stated, she would take them to her supervisor. When asked what could happen if a resident has smoking materials in their room, CNA #3 stated it is a danger to the rest of the residents, it could cause a fire, putting the roommate in danger. CNA #3 was asked what the likelihood or possibility of a fire is, she stated, it could happen. An interview was conducted with LPN (licensed practical nurse) #3 on 6/5/25 at 1:00 p.m. When asked what the smoking policy was in the facility, LPN #3 stated it used to be allowed but now it is smoke free. LPN #3 was asked if a resident does smoke where are the smoking materials kept, LPN #3 stated, they are kept at the front desk, receptionist desk. The receptionist is here until 8:00 p.m. When asked what she would do if she found smoking materials on a resident or in their room, LPN #3 stated normal she would report it to my immediate supervisor. LPN #3 was asked what could happen if a resident has smoking materials in their room, LPN #3 stated if the resident was smoking in the room, there is a chance of catching on fire. When asked what the possibility is or likelihood of a fire, LPN #3 stated it's a small chance but it's higher if there is oxygen in use. An interview was conducted with RN (registered nurse) #2 on 6/6/24 at 10:40 a.m. When asked who completes the smoking assessments, RN #2 stated the social worker and nursing staff. When are smoking assessments done, RN #2 stated they are done on admission, quarterly and if a resident desires to smoke. RN #2 further stated that the admissions office can ask questions regarding smoking upon admission. ASM #1, the administrator, ASM #3, the regional vice president of operations, ASM #5, the regional director of case management, ASM #6, the regional nurse consultant, ASM #8, regional director of social services, ASM #9, regional nurse consultant, and ASM #10, director of risk management, were made aware of the above concern on 6/6/24 at 12:16 p.m. 42106 3. For Resident #45 (R45), the facility staff failed to assess the resident for safe independent smoking. Resident #45 was admitted to the facility with diagnoses that included but were not limited to cerebral infarction (1) and diabetes mellitus (2). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 5/13/2024, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of the MDS documented no tobacco use. The comprehensive care plan documented in part, The resident is a smoker. Resident educated on facilities nonsmoking policy. Date Initiated: 07/22/2022. Under Interventions it documented in part, .Instruct resident about the facility policy on smoking: locations, times, safety concerns. Date Initiated: 07/22/2022 . Review of the clinical record documented a smoking safety evaluation dated 1/13/2024 and 4/13/2024 which documented in part, .Does the resident currently smoke or vape? No. On 6/5/2024 at approximately 2:02 p.m., an interview was conducted with OSM (other staff member) #11, receptionist. When asked to describe the facility's procedure for residents who smoke, OSM #11 stated that she kept the resident's smoking materials, cigarettes, lighters and /or vape pens, in a locked file cabinet in the facility's business office. She stated that when a resident wanted to smoke, they came to the front desk (receptionist's desk in the facility lobby) and she gave the resident(s) their cigarettes, lighters and /or vape pens and when the resident came back into the facility she took the smoking items back and locked them in the cabinet. When ask [TRUNCATED]

Based on observation, staff interview, and facility document review, the facility staff failed to follow the prescribed menu in one of one kitchen. The findings include: On 6/3/24 at 4:41 p.m., observation was made of tray line service for the dinner meal. After reviewing the menu, the observation revealed there was no garden pasta salad. Instead, the pasta salad consisted only of pasta, and included no vegetables. There was no seasonal soup available for residents. There was no lettuce or tomatoes available for resident sandwiches. Approximately two-thirds of the way through the meal service, the facility ran out of croissants, and served white bread; and ran out of tomato and onion salad, and served tossed salad. On 6/3/24 at 1:27 p.m., OSM (other staff member) #1, the regional food services director, and OSM #6, a regional dietary manager, were interviewed. OSM #1 stated the cook should print daily production sheets at least 24 hours in advance. That way, if any items from the menu are missing, the facility staff have the opportunity to get them. He stated the facility cook was not aware that the pasta salad recipe called for vegetables. OSM #1 stated the facility dietary manager had not printed the shopping list for the week, and had run out of some items such as the croissants. OSM #6 stated the prescribed menu should always be followed. On 6/4/23 at 4:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of operations, were informed of these concerns. A review of the facility policy, Menus, revealed, in part: Menu cycles will include standardized recipes .Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to serve palatable food in one of one kitchen. The findings include: On 6/3/24 at 5:15 p.m., a test tray was requested at the conclusion of dinner service. Two surveyors and OSM (other staff member) #1, the regional food services director, tested all the food served to residents. The pureed tomato and onion salad, and the pureed egg salad, had no flavor, and were sticky in texture. OSM #1 agreed these two items were not appetizing or palatable. On 6/3/24 at 1:27 p.m., OSM (other staff member) #1, the regional food services director, and OSM #6, a regional dietary manager, were interviewed. OSM #1 stated the cook should taste all of the food before serving it to any residents. On 6/4/23 at 4:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of operations, were informed of these concerns. A review of the facility policy, Food: Quality and Palatability, revealed, in part: The Dining Services Director and Cook(s) are responsible for food preparation .Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to serve food at the consistency ordered by the physician for one of 50 residents in the survey sample, Resident #26. The findings include: For Resident #26 (R26), the facility staff served the resident a plate of pureed food, instead of food at a regular texture, as ordered by the physician. On 6/3/24 at 1:08 p.m., R26 was observed sitting up in his bed with the overbed table across the bed; the overbed table contained R26's meal tray. The meal tray contained spaghetti noodles and tomato sauce. R26 had spaghetti noodles in multiple places on his shirt. He was observed attempting to feed himself the spaghetti, but spilled it onto his shirt. He stated he did not really care for spaghetti, and asked if the surveyor could get him something else to eat. The facility staff was alerted of the resident's request. At 1:31 p.m., R26 was observed sitting up in his bed with a new meal tray. The meal tray contained three different types of pureed food. Neither the resident nor the surveyor could identify what the food was. A review of R26's clinical record revealed the following order dated 3/15/24: Consistent Carbohydrate / NAS (no added salt) diet Level 4- Regular texture, Thin consistency. On 6/3/24 at 1:27 p.m., OSM (other staff member) #1, the regional food services director, and OSM #6, a regional dietary manager, were interviewed. OSM #1 stated a resident should be served the consistency of food that has been ordered by the physician. He stated a pureed diet is a downgrade of consistency, and requires a physician order to change. On 6/4/23 at 4:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of operations, were informed of these concerns. A review of the facility policy, Meal Distribution, revealed, in part: The nursing staff will be responsible for verifying meal accuracy. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to serve food according to a resident's preference for four of 50 residents in the survey sample, Residents #4, #22, #66, and #68 The findings include: For Residents #4, #22, #66, and #68, the facility failed to serve what the residents had chosen for the dinner meal on 6/3/24. On 6/3/24 at 4:41 p.m., observation was made of tray line service for the dinner meal. For Resident #4, the resident's meal ticket indicated the resident wanted tomato and onion salad, savory summer soup, egg salad on a croissant, and lettuce and tomato for the sandwich. The resident's dinner tray instead contained a tossed salad, chicken noodle soup, no lettuce and tomato, and egg salad on white bread. For Resident #22, the resident's meal ticket indicated the resident wanted tomato and onion salad, lettuce and tomato for his sandwich, and two servings of ice cream. The resident's dinner tray instead contained marinated green beans, no lettuce and tomato, and only one serving of ice cream. For Resident #66, the resident's meal ticket indicated the resident wanted garden pasta salad, and lettuce and tomato for his sandwich. The resident's dinner tray instead contained plain pasta salad (with no vegetables), and no lettuce and tomato for the sandwich. For Resident #67, the resident's meal ticket indicated the resident wanted tomato and onion salad, and lettuce and tomato for his sandwich. The resident's dinner tray instead contained marinated green beans, and no lettuce and tomato for the sandwich. On 6/3/24 at 1:27 p.m., OSM (other staff member) #1, the regional food services director, and OSM #6, a regional dietary manager, were interviewed. OSM #6 stated someone should be stationed at the end of the serving line to double check the trays to make sure resident preferences are honored. She stated she always encourages staff to read the meal ticket from top to bottom, and to make sure the food on the tray matches the meal ticket. On 6/4/23 at 4:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of operations, were informed of these concerns. A review of the facility policy, Dining and Food Preferences, revealed, in part: The individual tray assembly ticket will identify all food items appropriate for the resident .based on .preferences. A review of the facility policy, Meal Distribution, revealed, in part: All meals will be assembled in accordance with the individualized diet order, plan of care, and preferences. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to store and serve food in a sanitary manner in one of one facility kitchen. The findings include: On 6/3/24 at 11:15 a.m., initial observation was made in the kitchen. The walk in refrigerator contained one bottle of pancake syrup, one package of sliced turkey, one package of unsliced turkey, and one package of ham that were all open but undated. The smaller cook's refrigerator contained two bottles of ketchup, one container of relish, and one jar of applesauce that were all open but undated. On 6/3/24 at 4:41 p.m., observation was made of tray line service for the dinner meal. OSM #3, the cook, was wearing gloves. With gloves on, he touched contaminated surfaces including serving utensil handles, the steam table surface, the cutting board, and the outside of plastic bags which held croisants. He then used the same gloves to grasp potato chips and touch the croissants as he served resident plates. OSM #5, a dietary aide, also wore gloves. With gloves on, he touched contaminated surfaces including the meal trays, the serving line, and meal carts. He then used the same gloves to grasp the end of eating utensils that would be in contact with residents' mouths. On 6/3/24 at 1:27 p.m., OSM (other staff member) #1, the regional food services director, and OSM #6, a regional dietary manager, were interviewed. OSM #1 stated all items should have an in, date, an out date, and a label indicating the open date. He stated items that remain open and unused can become contaminated. He stated it is important to know when items have been opened in order to either use them or discard them before they risk contamination. OSM #6 stated no dirty gloved hand should ever touch a resident's food or silverwear. On 6/4/23 at 4:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of operations, were informed of these concerns. A review of the facility policy, Food Storage: Cold Foods, revealed, in part: All foods will be stored wrapped or in covered containers, lageled and dated, and arranged in a manner to prevent cross contamination. A review of the facility policy, Food: Preparation, revealed, in part: All staff will practice proper hand washing techniques and glove use .Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful .contamination. No further information was provided prior to exit.

2. For R73, the facility staff failed to uphold the resident's dignity by cleaning his fingernails. R73 was admitted to the facility with diagnoses that included but were not limited to hemiparesis (1) and hemiplegia (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/09/2024, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating R73 was moderately impaired of cognition for making daily decisions. Under Section GG Functional Abilities and Goals. Subsection I. Personal Hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) it coded R73 as 01(zero-one)- Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. On 06/03/24 at approximately 2:06 p.m., an observation of R73's fingernails on the right -hand wear observed with dirt under the nails. On 06/04/24 at approximately 8:50 a.m., an observation of R73's fingernails on the right -hand wear observed with dirt under the nails. On 06/04/24 at approximately 12:00 p.m., an observation of R73's fingernails on the right-hand wear observed with dirt under the nails. The facility's ADL (activities of daily living) tracking sheets for R73 dated June 2024 documented in part, - Personal Hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). 01- Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Further review of the ADL sheet coded R73 zero-one (01) on 06/03/2024 and 06/04/2024 during the 7:00 a.m. to 3:00 p.m. shift, indicating R73's fingernails were cleaned. The facility's progress notes for R73 dated 06/01/2024 through 06/05/2024 failed to evidence documentation of ADL refusal. On 06/04/2024 at approximately 1:38 p.m., an interview was conducted with CNA (certified nursing assistant) #7. When asked to describe the procedure for providing ADL (activities of daily living) care for a resident CNA #7 stated ADL care is done every day and it included bed bath, brushing teeth, providing mouth wash, if male resident, shaving them, brushing/combing their hair, trimming and cleaning their finger nails if needed, change their brief, gown or assisting them with dressing, changing the bedding, washing their face and hands and assisting them with toileting if needed. When asked if she was assigned to provide ADL care to R73 on 06/03/2024 CNA #7 stated yes. When asked if resident's hands were washed before each meal CNA #7 stated yes. After observing R73's fingernails, CNA #7 stated R73's fingernails were dirty and needed cleaning. After informed of the observations of R73's fingernails as stated above CNA #7 was asked if it was dignified for R73 to have dirty fingernails. CNA #7 stated it was not dignified. 06/04/2024 at approximately 1:50 p.m., an interview was conducted with R73. When asked how it made him feel not having his fingernails cleaned R73 sated he felt dirty. When asked if he was able to clean his own fingernails R73 stated no. The facility's policy Dignity documented in part, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are groomed as they wish to be groomed (hair styles, nails, facial hair, etc.) . On 06/06/2024 at approximately 12:14 ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional vice president of operations, ASM #4, director of infection prevention, ASM #5, regional director of case management, and ASM #6, regional nurse consultant, ASM #8, regional director of social services, and ASM #9, regional nurse consultant, were made aware of the above findings. No further information was provided prior to exit. References: (1) Paralysis is the loss of muscle function in part of your body. This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) Paralysis is the loss of muscle function in part of your body. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread This information was obtained from the website: https://medlineplus.gov/paralysis.html. 32642 Based on observation, staff interview, and facility document review, the facility staff failed to maintain a resident's dignity for two of 50 residents in the survey sample, Resident #50 and Resident #73. The findings include: 1. For Resident #50 (R50), the facility staff failed to treat the staff in a dignified manner when they did not serve him lunch at the same time as his roommate, Resident #23 (R23). R50 refused to be interviewed during the survey. On 6/3/23 at 1:15 p.m., R50 was observed sitting beside his bed in his wheelchair. He was staring absently to the right side of the room, where R23 sat in a wheelchair. R23 was eating his lunch. R50's lunch tray was observed on top of his chest of drawers, with all containers covered and full. At 1:32 p.m., R23 had finished eating his lunch; R50's tray was still on top of the chest of drawers. At 1:48 p.m., a staff member went into the room, put R50's tray on his overbed table, and began to feed R50. On 6/4/24 at 3:33 p.m., LPN (licensed practical nurse) #1 and CNA (certified nursing assistant) #1 were interviewed. When asked the process for distributing meal trays when one resident can feed himself and the roommate requires feeding, CNA #1 stated there really is no formal process. She stated the staff distributes the trays as they are arranged in the meal cart that comes from the kitchen. If a resident needs to be fed, the staff put the tray for that resident in the room, then feed the resident when the staff member gets to it. When asked if it promotes a dependent resident's dignity to have to wait until after his roommate has finished a meal before the dependent resident has the opportunity to eat, LPN #1 stated: No. I wouldn't want that. On 6/4/23 at 4:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of operations, were informed of these concerns. A review of the facility policy, Dignity, revealed, in part: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document, and clinical record review, the facility staff failed to maintain a clean, home-like environment for one of 50 residents in the survey sample, Resident #23. The findings include: For Resident #23 (R23), the facility failed to maintain a home-like environment in the bathroom, where a hole in the dry wall surrounded the toilet pipe, multiple tiles were chipped of the baseboard, the floor was stained, and the bathroom had a strong urine odor. On 6/3/24 at 3:58 p.m., R23 was interviewed. He stated he had concerns about the cleanliness of his bathroom. In the bathroom, four tiles had chipped off from the baseboard area, and were lying beside the back of the toilet. The tile floor was stained with dark areas, especially in the four corners. There was a circular hole in the drywall surrounding the area where the toilet piping went into the wall behind the toilet. There was a strong smell of old urine. When asked if he felt the condition of the bathroom contributed to a home-like environment for him, he stated it did not. On 6/4/24 at 3:33 p.m., OSM (other staff member) #7, the environmental services manager, and OSM #8, the maintenance director, were interviewed. OSM #7 stated the housekeepers clean each room daily. He stated the room cleaning includes sanitizing the bathroom high-touch surfaces and mopping the floor. OSM #8 stated he inspects several rooms each day, but does not go into each room daily. He stated if there are maintenance needs, the staff members enter maintenance requests into the maintenance software, and his staff completes the repairs. OSMs #7 and #8 observed R23's bathroom with the surveyor. OSM #7 stated the stains on the bathroom floor will not come clean, and the bathroom did not smell clean. OSM #8 stated he had not seen the condition of the drywall behind the toilet before. Both agreed that the bathroom was not a home-like environment. On 6/4/23 at 4:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of operations, were informed of these concerns. A review of the facility policy, Homelike Environment, revealed, in part: The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include .institutional odors. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a written notification upon transfer for one of 50 residents in the survey sample, Resident #27. The findings include: The nurse's note dated, 3/23/24 at 3:49 p.m., documented in part, Resident noted with left sided facial droop, resident c/o (complained of) left facial side numbness. VS (vital signs) done. PA (physician assistant) gave order to send to hospital for stroke, resident is own RP (responsible party). Review of the scanned documents, sent to the hospital with the resident, failed to evidence a written notification was provided to the resident upon transfer. A request was made for the evidence of the written notification on 6/4/24 at 12:21 p.m. On 6/4/24 at 4:50 p.m. ASM (administrative staff member) #3, regional vice president of operations, stated they did not have the written notification. An interview was conducted with RN (registered nurse) #2 on 6/5/24 at 10:40 a.m. When asked when a resident is transferred to the hospital what documents are sent with the resident, RN #2 stated, the face sheet, medication list, progress note, physician history and physical, code status, care plan goals, and written notice of transfer. The facility policy, Transfer or Discharge, Facility-Initiated documented in part. 4. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements). ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, ASM #4, regional director of infection prevention, ASM #5, regional director of case management, and ASM #6, regional nurse consultant, were made aware of the above concern on 6/4/24 at 4:55 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure accurate MDS assessments for one of 50 residents in the survey sample; Resident #79. The findings include: For Resident #79, the facility staff failed to accurately code the admission MDS (Minimum Data Set) assessment dated [DATE] regarding the administration of insulin. The 4/13/24 admission MDS assessment was coded as the resident being on insulin, having received seven insulin injections during the seven day look back period. The resident was not on any prescribed insulin. A review of the above MDS assessments revealed the following: In Section N - Medications, was documented, Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. In the box was typed 7 for seven days. The next part, Insulin documented, Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. In the box was typed 7 for seven injections of insulin. A review of the clinical record failed to reveal any evidence that the resident had a diagnosis of diabetes or ever had any orders for insulin. On 6/04/24 at 2:27 PM, an interview was conducted with LPN #2 (Licensed Practical Nurse), the MDS nurse. She stated that the MDS was miscoded and that the resident was not and had not been on any insulin. A review of the RAI Manual (Resident Assessment Instrument) dated October 1, 2023, on page 1-4 was documented, The RAI process has multiple regulatory requirements. Federal regulations .require that (1) the assessment accurately reflects the resident's status . The facility policy, Comprehensive Assessments was reviewed. This policy documented, 1. The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity using the Resident Assessment Instrument specified by CMS . On 6/4/24 at 4:47 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing and ASM #3 the Regional Director of Operations were made aware of the findings. No other information was provided by the end of the survey.

Based on observation, staff interview, clinical record review, it was determined that the facility staff failed to follow the comprehensive care plan for three of 50 residents in the survey sample, Residents #73 (R73), R413 and R80. The findings include: 1.For R73, the facility staff failed to follow the comprehensive care plan to keep fingernails clean. R73 was admitted to the facility with diagnoses that included but were not limited to: hemiparesis (1) and hemiplegia (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/09/2024, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating R73 was moderately impaired of cognition for making daily decisions. Under Section GG Functional Abilities and Goals. Subsection I. Personal Hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) it coded R73 as 01(zero-one)- Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. On 06/03/24 at approximately 2:06 p.m., an observation of R73's fingernails on the right -hand wear observed with dirt under the nails. On 06/04/24 at approximately 8:50 a.m., an observation of R73's fingernails on the right -hand wear observed with dirt under the nails. On 06/04/24 at approximately 12:00 p.m., an observation of R73's fingernails on the right-hand wear observed with dirt under the nails. The comprehensive care plan for R73 dated 12/02/2023 documented in part, Focus. (Name of R73) has ADL Self Care Performance Deficit r/t (related to) muscle wasting and atrophy, secondary to CVA (stroke) with left side weakness. Date Initiated: 12/02/2023. Under Interventions/Tasks it documented in part, (R73) required extensive to total assistance of 1-2 (one to two) staff members for all ADDL care. Date Initiated: 12/31/2023. The facility's ADL tracking sheets for R73 dated June 2024 documented in part, - Personal Hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). 01- Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Further review of the ADL sheet coded R73 zero-one (01) on 06/03/2024 and 06/04/2024 during the 7:00 a.m. to 3:00 p.m. shift, indicating R73's fingernails were cleaned. The facility's progress notes for R73 dated 06/01/2024 through 06/05/2024 failed to evidence documentation of R73 refusing ADL care. On 06/04/2024 at approximately 1:38 p.m., an interview was conducted with CNA (certified nursing assistant) #2. When asked to describe the procedure for providing ADL (activities of daily living) care for a resident CNA #2 stated ADL care is done every day and it included bed bath, brushing teeth, providing mouth wash, if male resident, shaving them, brushing/combing their hair, trimming and cleaning their finger nails if needed, change their brief, gown or assisting them with dressing, changing the bedding, washing their face and hands and assisting them with toileting if needed. When asked if she was assigned to provide ADL care to R73 on 06/03/2024 CNA #2 stated yes. When asked if resident's hands were washed before each meal CNA #2 stated yes. After observing R73's fingernails, CNA #2 stated R73's fingernails were dirty and needed cleaning. 06/04/2024 at approximately 1:50 p.m., an interview was conducted with R73. When asked if he was able to clean his own fingernails R73 stated no. On 06/06/2024 at approximately 10:50 a.m., an interview was conducted with LPN (licensed practical nurse) #4. When asked about the purpose of a resident's care plan she stated that it tells how to take care of the resident. When asked if the care plan was followed if the if R73's fingernails were not being cleaned LPN #4 stated no. On 06/06/2024 at approximately 12:14 ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional vice president of operations, ASM #4, director of infection prevention, ASM #5, regional director of case management, and ASM #6, regional nurse consultant, ASM #8, regional director of social services, and ASM #9, regional nurse consultant, were made aware of the above findings. No further information was provided prior to exit. References: (1) Paralysis is the loss of muscle function in part of your body. This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) Paralysis is the loss of muscle function in part of your body. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread This information was obtained from the website: https://medlineplus.gov/paralysis.html. 2. For (R413), the facility staff failed to follow the comprehensive care plan for the administration of oxygen according to the physician's orders. R413 was admitted to the facility with diagnoses that included but were not limited to respiratory failure (1). R413's MDS (minimum data set) assessment was in process at the time of the survey, therefore R413's data was not available. The facility's Admission/Readmission Evaluation dated 05/24/2024 for R413 documented in part, A. Cognitive/Neurological. 1. Mental Status: a. Alert. 2. Oriented to: a. Person, b. Place, c. Time, d. Situation. On 06/04/2024 at approximately 8:12 a.m., an observation of R413revealed they were lying in bed receiving oxygen by nasal cannula. An observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two-and-a-half and three liters per minute. On 06/05/24 at approximately 7:34 a.m., an observation of R413 revealed they were lying in bed receiving oxygen by nasal cannula. An observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and two-and-a-half liters per minute. The physician's order for R413 documented in part, Oxygen at 3L/ (three liters per) minute via (by) nasal cannula. every shift for SOB (shortness of breath). Order Date: 06/02/2024. Start Date: 06/02/2024. The comprehensive care plan for R413 dated 06/03/2024 documented in part, Focus. (Name of R413) has altered respiratory status r/t (related to) COPD (chronic obstructive pulmonary disease), respiratory failure, CHF (congestive heart failure). Date Initiated: 06/03/2024. Under Interventions/Tasks it documented in part Administer oxygen as ordered. Date Initiated: 06/03/202. On 06/04/2024 at approximately 1:55 p.m., an interview was conducted with LPN (licensed practical nurse) #4. When asked how she reads the flow meter on a resident's oxygen concentrator to determine the amount of oxygen a resident receives, LPN #4 stated that the float ball in the oxygen flow meter is either on or below the liter line. When asked to clarify how to read the flow meter LPN #4 stated that she was not sure where the float ball should be in the flow meter. The service manual for R413's oxygen concentrator by (Name of Manufacturer) documented in part, 1. Turn the flowrate knob to the setting prescribed by your physician or therapist. To properly read the flowmeter, locate the prescribed flowrate line on the flowmeter. Next, turn the flow knob until the ball rises to the line. Now, center the ball on the L/min (liter per minute) line prescribed. On 06/06/2024 at approximately 10:50 a.m., an interview was conducted with LPN (licensed practical nurse) #4. When asked about the purpose of a resident's care plan she stated that it tells how to take care of the resident. When asked if the care plan was followed if the if the oxygen was not set according to the physician's orders LPN #4 stated no. On 06/06/2024 at approximately 12:14 ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional vice president of operations, ASM #4, director of infection prevention, ASM #5, regional director of case management, and ASM #6, regional nurse consultant, ASM #8, regional director of social services, and ASM #9, regional nurse consultant, were made aware of the above findings. No further information was provided prior to exit. 3. For (R80), the facility staff failed to follow the comprehensive care plan for the safe storge of smoking materials. R80 was admitted to the facility with diagnoses that included but were not limited to PTSD (post traumatic stress disorder) (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 04/12/2024, R80 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R80 was cognitively intact for making daily decisions. On 06/05/20/2024 at approximately 8:50 a.m., an interview was conducted with R80 in her room. When asked if she smoked R80 stated that she uses a vape pen and smoked cigarettes. When asked where the vape pen, lighter and cigarettes were stored R80 reached under the pillow on her bed and showed the surveyor a vape pen. She then opened the seat on her rolling walker, reached in and pulled out a cigarette lighter and showed it to the surveyor. When asked about cigarettes, R80 point to a large clothing bag next to the bed and stated she kept her cigarettes in the bag. R80 stated she did not have any cigarettes at the time. The facility's Smoking Safety Evaluation for R80 dated 04/17/2024 documented in part, 16. Evaluation Generated Care Plan Interventions: I understand that for my safety, the facility will store my nicotine products and my lighter. The comprehensive care plan for R80 dated 11/23/2023 documented in part Focus. I smoke r/t (related to) cigarette use. Date Initiated: 10/11/2023. Under Interventions/Tasks it documented, Educate me on the adverse effects of nicotine use as well as the importance, benefits, and available methods of smoking cessation. Nicotine patch. Date Initiated: 04/17/2024. I have been provided with education on e-cigarette/vaporizer safety, including battery and charger safety. Reinforce as needed. Date Initiated: 06/05/2024. I may smoke safely with supervision. Date Initiated: 11/22/2023. I need to smoke in backyard area and not patio. Date Initiated: 11/22/2023. I understand that for my safety, the facility will store my nicotine products and my lighter. Date Initiated: 10/11/2023. On 06/06/2024 at approximately 10:50 a.m., an interview was conducted with LPN (licensed practical nurse) #4. When asked about the purpose of a resident's care plan she stated that it tells how to take care of the resident. When asked if the care plan was followed if R80 stored smoking materials in her room, LPN #4 stated no. On 06/06/2024 at approximately 12:14 ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional vice president of operations, ASM #4, director of infection prevention, ASM #5, regional director of case management, and ASM #6, regional nurse consultant, ASM #8, regional director of social services, and ASM #9, regional nurse consultant, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to provide ADL(activities of daily living) care for one of 50 residents in the survey sample, Resident #73 (R73). For R73, the facility staff failed to clean his fingernails. R73 was admitted to the facility with diagnoses that included but were not limited to: hemiparesis (1) and hemiplegia (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/09/2024, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating R73 was moderately impaired of cognition for making daily decisions. Under Section GG Functional Abilities and Goals. Subsection I. Personal Hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) it coded R73 as 01(zero-one)- Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. On 06/03/24 at approximately 2:06 p.m., an observation of R73's fingernails on the right -hand wear observed with dirt under the nails. On 06/04/24 at approximately 8:50 a.m., an observation of R73's fingernails on the right -hand wear observed with dirt under the nails. On 06/04/24 at approximately 12:00 p.m., an observation of R73's fingernails on the right-hand wear observed with dirt under the nails. The facility's ADL tracking sheets for R73 dated June 2024 documented in part, - Personal Hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). 01- Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Further review of the ADL sheet coded R73 zero-one (01) on 06/03/2024 and 06/04/2024 during the 7:00 a.m. to 3:00 p.m. shift, indicating R73's fingernails were cleaned. The facility's progress notes for R73 dated 06/01/2024 through 06/05/2024 failed to evidence documentation of R73 refusing ADL care. On 06/04/2024 at approximately 1:38 p.m., an interview was conducted with CNA (certified nursing assistant) #7. When asked to describe the procedure for providing ADL (activities of daily living) care for a resident CNA #7 stated ADL care is done every day and it included bed bath, brushing teeth, providing mouth wash, if male resident, shaving them, brushing/combing their hair, trimming and cleaning their finger nails if needed, change their brief, gown or assisting them with dressing, changing the bedding, washing their face and hands and assisting them with toileting if needed. When asked if she was assigned to provide ADL care to R73 on 06/03/2024 CNA #7 stated yes. When asked if resident's hands were washed before each meal CNA #7 stated yes. After observing R73's fingernails, CNA #7 stated R73's fingernails were dirty and needed cleaning. 06/04/2024 at approximately 1:50 p.m., an interview was conducted with R73. When asked how it made him feel not having his fingernails cleaned R73 sated he felt dirty. When asked if he was able to clean his own fingernails R73 stated no. The facility's policy Activities of Daily Living (ADLs), Supporting documented in part, Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care). On 06/06/2024 at approximately 12:14 ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional vice president of operations, ASM #4, director of infection prevention, ASM #5, regional director of case management, and ASM #6, regional nurse consultant, ASM #8, regional director of social services, and ASM #9, regional nurse consultant, were made aware of the above findings. No further information was provided prior to exit. References: (1) Paralysis is the loss of muscle function in part of your body. This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) Paralysis is the loss of muscle function in part of your body. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread This information was obtained from the website: https://medlineplus.gov/paralysis.html.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services for one of 50 residents in the survey sample, Resident #413. For (R413), the facility staff failed to maintain the oxygen flow rate at three liters per minute according to the physician's orders. R413 was admitted to the facility with diagnoses that included but were not limited to respiratory failure (1). R413's MDS (minimum data set) assessment was in process at the time of the survey, therefore R413's data was not available. The facility's Admission/Readmission Evaluation dated 05/24/2024 for R413 documented in part, A. Cognitive/Neurological. 1. Mental Status: a. Alert. 2. Oriented to: a. Person, b. Place, c. Time, d. Situation. On 06/04/2024 at approximately 8:12 a.m., an observation of R413revealed they were lying in bed receiving oxygen by nasal cannula. An observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two-and-a-half and three liters per minute. On 06/05/24 at approximately 7:34 a.m., an observation of R413 revealed they were lying in bed receiving oxygen by nasal cannula. An observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and two-and-a-half liters per minute. The physician's order for R413 documented in part, Oxygen at 3L/ (three liters per) minute via (by) nasal cannula. every shift for SOB (shortness of breath). Order Date: 06/02/2024. Start Date: 06/02/2024. The comprehensive care plan for R413 dated 06/03/2024 documented in part, Focus. (Name of R413) has altered respiratory status r/t (related to) COPD (chronic obstructive pulmonary disease), respiratory failure, CHF (congestive heart failure). Date Initiated: 06/03/2024. Under Interventions/Tasks it documented in part Administer oxygen as ordered. Date Initiated: 06/03/202. On 06/04/2024 at approximately 1:55 p.m., an interview was conducted with LPN (licensed practical nurse) #4. When asked how she reads the flow meter on a resident's oxygen concentrator to determine the amount of oxygen a resident receives, LPN #4 stated that the float ball in the oxygen flow meter is either on or below the liter line. When asked to clarify how to read the flow meter LPN #4 stated that she was not sure where the float ball should be in the flow meter. The service manual for R413's oxygen concentrator by (Name of Manufacturer) documented in part, 1. Turn the flowrate knob to the setting prescribed by your physician or therapist. To properly read the flowmeter, locate the prescribed flowrate line on the flowmeter. Next, turn the flow knob until the ball rises to the line. Now, center the ball on the L/min (liter per minute) line prescribed. On 06/06/2024 at approximately 12:14 ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional vice president of operations, ASM #4, director of infection prevention, ASM #5, regional director of case management, and ASM #6, regional nurse consultant, ASM #8, regional director of social services, and ASM #9, regional nurse consultant, were made aware of the above findings. No further information was provided prior to exit. References: (1) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a complete and accurate clinical record for one of 50 residents in the survey sample; Resident #79. The findings include: For Resident #79, the facility staff failed to ensure an accurate clinical record. The facility staff developed a comprehensive care plan for a diagnosis of diabetes. The resident was not diabetic. A review of the admission MDS (Minimum Data Set) assessment dated [DATE] regarding the administration of insulin coded as the resident being on insulin, having received seven insulin injections during the seven day look back period. The resident was not on any prescribed insulin. In Section N - Medications, was documented, Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. In the box was typed 7 for seven days. The next part, Insulin documented, Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. In the box was typed 7 for seven injections of insulin. A review of the clinical record failed to reveal any evidence that the resident had a diagnosis of diabetes or ever had any orders for insulin. A review of the comprehensive care plan revealed one dated 4/22/24 for (Resident #79) has DX (diagnosis) Diabetes Mellitus. Interventions included one dated 4/22/24 for Diabetes medication as ordered by doctor. Monitor and document side effects and effectiveness. The resident was not on any diabetic medication. Another intervention dated 4/22/24 documented, Monitor glucose as ordered. The resident did not have an order to monitor glucose because she did not have diabetes. On 6/04/24 at 2:27 PM, an interview was conducted with LPN #2 (Licensed Practical Nurse), the MDS nurse. She stated that the clinical record was not accurate because the resident should not have been care planned for diabetes as the resident was not diabetic. The facility policy Charting and Documentation was reviewed. This policy documented, .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate On 6/4/24 at 4:47 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing and ASM #3 the Regional Director of Operations were made aware of the findings. No other information was provided by the end of the survey.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to follow infection control practices during the medication administration for one of six residents in the medication administration observation, Resident #32 (R32). For R32, the facility staff failed to dispose of medications that were spilled out onto the top of the medication cart and were administered. On 06/04/2024 at approximately at approximately 8:04 a.m., an observation of LPN (licensed practical nurse) #7 during the medication pass was conducted. Observations of PLN #7 revealed she removed six medication bubble packs for R32 from the middle drawer of the medication cart and placed them on top of the medication cart. After verifying then medications with the eMAR (electronic medication administration record), LPN #7 obtained a small plastic medication cup from the end of the medication cart and placed it in front her on the top of the medication cart next the stack of bubble packs for R32. LPN #7 dispensed one-50mg (milligram) pill of hydralazine (1) and one-20mg pill of furosemide (2). As LPN #7 was moving the medication bubble packs, the medication cup containing the hydralazine and furosemide pills onto the top of the medication cart. LPN #7 obtained a plastic spoon, scooped up the two pills and placed them back in the medication cup. She proceeded to put R32's remaining medications into the same cup and administer them to R32. Further observation revealed R32 ingesting all the medications that LPN #7 placed into the medication cup. On 06/04/2024 at approximately 12:30 p.m., an interview was conducted with LPN #7 regarding the administration of the medications to R32 that spilled onto the medication cart. LPN #1 stated she recalled picking up the pills, putting back in the medication cup and administering them to R32. LPN #7 stated that she should have discarded the pills that spilled out of the medication cup because the top of the medication cart was not 100% clean and the medication could have been contaminated. The facility's policy Administering Medications documented in part, 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. On 06/04/2024 at approximately 4:50 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional vice president of operations, ASM #4, director of infection prevention, ASM #5, regional director of case management, and ASM #6, regional nurse consultant, were made aware of the above findings. No further information was provided prior to exit. References: (1) Used to treat high blood pressure. Hydralazine is in a class of medications called vasodilators. It works by relaxing the blood vessels so that blood can flow more easily through the body. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682246.html. (2) Used to treat edema (fluid retention; excess fluid held in body tissues) caused by various medical problems, including heart, kidney, and liver disease. This information was obtained from the website: Furosemide: MedlinePlus Drug Information

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to preserve resident dignity when serving meals in one of one facility kitchen. The facility staff served the 7/19/22 lunch meal on disposable Styrofoam containers for all residents, and gave disposable eating utensils to the final seven residents served from the tray line. The findings include: On 7/19/22 at 1:29 p.m., OSM (other staff member) #1, the dietary manager, was observed as he served all resident lunches from the tray line in the facility's only kitchen. OSM #1 served each and every meal on a disposable Styrofoam container. The food was placed on one side of the container, and the other side of the container was folded over to create a cover. Two stacks of facility dishware were observed in a dish cart adjacent to the tray line. Additionally, the last seven Styrofoam containers served were paired with disposable plastic eating utensils. OSM #1 stated: I don't know where the [stainless steel] forks are going. We just don't have enough for everybody. On 7/19/22 at 1:46 p.m., OSM #2, the dietary manager at a sister facility, who had also observed the lunch tray line service, was interviewed. She stated OSM #1 was serving on Styrofoam because they are short staffed. She stated if the facility staff did not serve on disposable dishware, there is no way they would ever be able to turn the dishware around on time to get the dinner meal out at a decent time. She stated there was not enough staff at the facility to wash the dishware. When asked if serving the residents on disposable dishware for staff convenience promoted a sense of resident dignity, she said it did not. On 7/20/22 at 5:17 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. A review of the facility policy, Resident Rights, revealed, in part: A resident shall be treated with dignity and respect. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to maintain confidentiality of residents' medical records for 4 of 33 residents in the survey sample, Residents #7, #88, #25 and #96. The findings include: 1. The facility staff failed to maintain confidentiality of Resident #7's (R7) durable DNR (do not resuscitate) order. The order was posted on the wall in R7's room. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], the resident's cognitive skills for daily decision making was coded as severely impaired. On [DATE] at 2:46 p.m., an observation of R7's room was conducted. The resident's durable DNR order was posted on the wall behind the resident's bed. The order documented R7's name, the date the form was signed and the following: I, the undersigned, state that I have a [NAME] fide physician/patient relationship with the patient named above. I have certified in the patient's medical record that he/she or a person authorized to consent on the patient's behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respiratory arrest .I hereby direct any and all qualified health care personnel, commencing on the effective date noted above, to withhold cardiopulmonary resuscitation (cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, and related procedures) from the patient in the event of the patient's cardiac or respiratory arrest. I further direct such personnel to provide the patient other medical interventions, such as intravenous fluids, oxygen, or other therapies deemed necessary to provide comfort care or alleviate pain . On [DATE] at 3:24 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated the purpose of a DNR order is to alert nurses to not initiate CPR (cardiopulmonary resuscitation) on a resident if there is an emergency where CPR is needed. LPN #4 stated a DNR order contains confidential information and she usually gets the DNR from the chart. LPN #4 stated she didn't know who made the decision to place residents' DNR orders on the wall in residents' rooms but she would find out. On [DATE] at 4:01 p.m., another interview was conducted with LPN #4. LPN #4 stated that during the time of COVID, some residents were rapidly declining so the former executive director made the decision to post DNR orders on the wall in residents' rooms so nurses would know when to withhold CPR. LPN #4 stated a confidential document should not be posted on the wall in residents' rooms. On [DATE] at 5:37 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Clinical/Medical Records documented, Information contained in the resident's clinical record, regardless of the form or storage method, is considered confidential. The Center has the property right to the clinical record, but the resident has the protected right of information. No further information was presented prior to exit. 2. The facility staff failed to maintain confidentiality of Resident #88's (R88) durable DNR (do not resuscitate) order. The order was posted on the wall in R88's room. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. On [DATE] at 2:44 p.m., an observation of R88's room was conducted. The resident's durable DNR order was posted on the wall behind the resident's bed. The order documented R88's name, the date the form was signed and the following: I, the undersigned, state that I have a [NAME] fide physician/patient relationship with the patient named above. I have certified in the patient's medical record that he/she or a person authorized to consent on the patient's behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respiratory arrest .I hereby direct any and all qualified health care personnel, commencing on the effective date noted above, to withhold cardiopulmonary resuscitation (cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, and related procedures) from the patient in the event of the patient's cardiac or respiratory arrest. I further direct such personnel to provide the patient other medical interventions, such as intravenous fluids, oxygen, or other therapies deemed necessary to provide comfort care or alleviate pain . On [DATE] at 3:24 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated the purpose of a DNR order is to alert nurses to not initiate CPR (cardiopulmonary resuscitation) on a resident if there is an emergency where CPR is needed. LPN #4 stated a DNR order contains confidential information and she usually gets the DNR from the chart. LPN #4 stated she didn't know who made the decision to place residents' DNR orders on the wall in residents' rooms but she would find out. On [DATE] at 4:01 p.m., another interview was conducted with LPN #4. LPN #4 stated that during the time of COVID, some residents were rapidly declining so the former executive director made the decision to post DNR orders on the wall in residents' rooms so nurses would know when to withhold CPR. LPN #4 stated a confidential document should not be posted on the wall in residents' rooms. On [DATE] at 5:37 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 3. The facility staff failed to maintain confidentiality of medical information for Resident #25 (R25). The facility had posted on the wall behind the resident's bed, a DDNR (durable do not resuscitate) form. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of [DATE], the resident scored a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. Observation was made of R25's room on [DATE] at approximately 12:50 p.m. A DDNR form was posted above the bed in a plastic sleeve. A second observation was made on [DATE] 9:15 a.m. the DDNR form was still posted above the resident's bed. The order documented R25's name, the date the form was signed and the following: I, the undersigned, state that I have a [NAME] fide physician/patient relationship with the patient named above. I have certified in the patient's medical record that he/she or a person authorized to consent on the patient's behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respiratory arrest .I hereby direct any and all qualified health care personnel, commencing on the effective date noted above, to withhold cardiopulmonary resuscitation (cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, and related procedures) from the patient in the event of the patient's cardiac or respiratory arrest. I further direct such personnel to provide the patient other medical interventions, such as intravenous fluids, oxygen, or other therapies deemed necessary to provide comfort care or alleviate pain . The comprehensive care plan dated [DATE] documented in part, Focus: (R25) wishes to be DNR (do not resuscitate). The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:24 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated the purpose of a DNR order is to alert nurses to not initiate CPR (cardiopulmonary resuscitation) on a resident if there is an emergency where CPR is needed. LPN #4 stated a DNR order contains confidential information and she usually gets the DNR from the chart. LPN #4 stated she didn't know who made the decision to place residents' DNR orders on the wall in residents' rooms but she would find out. On [DATE] at 4:01 p.m., another interview was conducted with LPN #4. LPN #4 stated that during the time of COVID, some residents were rapidly declining so the former executive director made the decision to post DNR orders on the wall in residents' rooms so nurses would know when to withhold CPR. LPN #4 stated a confidential document should not be posted on the wall in residents' rooms. ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3 the director of clinical services were made aware of the above concern on [DATE] at 5:23 p.m. No further information was provided prior to exit. 4. The facility staff failed to maintain confidentiality of medical information for Resident #96 (R96). The facility had posted on the wall behind the resident's bed, a DDNR (durable do not resuscitate) form. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of [DATE], the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. Observation was made of R96's room on [DATE] at approximately 12:45 p.m. A DDNR form was posted above the bed in a plastic sleeve. A second observation was made on [DATE] 10:18 a.m. The DDNR form was still posted above the resident's bed. The order documented R96's name, the date the form was signed and the following: I, the undersigned, state that I have a [NAME] fide physician/patient relationship with the patient named above. I have certified in the patient's medical record that he/she or a person authorized to consent on the patient's behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respiratory arrest .I hereby direct any and all qualified health care personnel, commencing on the effective date noted above, to withhold cardiopulmonary resuscitation (cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, and related procedures) from the patient in the event of the patient's cardiac or respiratory arrest. I further direct such personnel to provide the patient other medical interventions, such as intravenous fluids, oxygen, or other therapies deemed necessary to provide comfort care or alleviate pain . The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan dated, [DATE], does not address the resident's status for resuscitation. On [DATE] at 3:24 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated the purpose of a DNR order is to alert nurses to not initiate CPR (cardiopulmonary resuscitation) on a resident if there is an emergency where CPR is needed. LPN #4 stated a DNR order contains confidential information and she usually gets the DNR from the chart. LPN #4 stated she didn't know who made the decision to place residents' DNR orders on the wall in residents' rooms but she would find out. On [DATE] at 4:01 p.m., another interview was conducted with LPN #4. LPN #4 stated that during the time of COVID, some residents were rapidly declining so the former executive director made the decision to post DNR orders on the wall in residents' rooms so nurses would know when to withhold CPR. LPN #4 stated a confidential document should not be posted on the wall in residents' rooms. ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3 the director of clinical services were made aware of the above concern on [DATE] at 5:23 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff when 4 out of 33 residents in the survey sample were transferred to the hospital; Residents #37, #40, #350 and #1. The findings include: 1. The facility staff failed to evidence provision of required resident information to a receiving facility at the time of discharge for Resident #37. Resident #37 was transferred to the hospital on 6/27/22. Resident #37 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/21/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfer, dressing, hygiene and bathing; supervision for locomotion and independence for eating. Section O-special procedures/treatments coded the resident as [CONDITION(S)] no. A review of the comprehensive care plan dated 2/26/22, which revealed, FOCUS: The resident is on Hemodialysis via Left arterial-venous Fistula related to [CONDITION(S)]. Transferred to hospital for clogged AV shunt 6/27/22. INTERVENTIONS: Communicate with [CONDITION(S)] facility as needed. [CONDITION(S)] 3 times/week: Tuesday, Thursday & Saturday. Further review of the clinical record failed to evidence any documentation of any documents; medication list, resident information and care plan goals, having been sent to the hospital upon transfer. A review of the facilities Acute Care Transfer Document Checklist (INTERACT version 4.0 tool), Copies of Documents sent with Resident/Patient (check all that apply): dated 2014 transfer form are enclosed 3.face sheet 4.current medication list or current MAR (medication administration record) 5.SBAR (Situation, Background, Assessment, and Recommendation) and/or other change in condition progress includes the following: Documents recommended to accompany resident/patient: 1.Resident/Patient transfer form 2.Personal belongings identified on resident/patient note if completed 6.Advance Directives 7.Advance Care Orders. Send these documents if available: 1.most recent history and physical 2.recent hospital discharge summary 3.recent MD/NP/PA (physician/nurse practitioner/physician assistant) and Specialist orders 4.Flow sheets 5.relevant lab results 6.relevant x-rays and other diagnostic test results 7.SNF/NF (skilled nursing facility/nursing facility) capabilities checklist. EMERGENCY DEPARTMENT: Please ensure that these documents are forwarded to the hospital unit if this resident/patient is admitted . This checklist was on the front of an envelope which is to contain the forms and includes a tear off front page which reveals, Tear off front page to keep with the resident's medical record. An interview was conducted on 7/20/22 at 9:30 AM with LPN (licensed practical nurse) #3. When asked what information is provided to the hospital upon transfer of a resident, LPN #3 stated, I'll get you a sample of what we send with the resident to the acute care facility. It is a transfer document checklist and we tear off the top copy, it should go to medical records. An interview was conducted on 7/20/22 at 2:12 PM, with OSM (other staff member) #6, the medical records coordinator. When asked if she has copies of the transfer document checklist, and shown the transfer document checklist, OSM #6 stated, No we do not get a copy of that for the medical records. I do not know what they do with it. I bet they send all of it to the hospital with the resident. On 7/20/22 at approximately 5:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. ASM #1 asked what top form and was shown the transfer document checklist envelop with the tear off front page. A review of the facilities Transfer/Discharge Notification and Right to Appeal policy dated 9/2017, revealed the following: Contents of the Notice: The written notice must include the following: The reason for transfer or discharge; The effective date of transfer or discharge; The location to which the resident is transferred or discharged ; A statement of the resident's appeal rights including the name, address (mailing and email), and telephone number of the entity which receives such request; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; The name, address (mailing and email) and telephone number of the State Long-Term Care Ombudsman. Orientation for Transfer or Discharge: The Center must provide and document sufficient preparation and orientation, in a form and manner that the resident understands, to ensure safe and orderly transfer or discharge. No further information was provided prior to exit. 2. The facility staff failed to evidence provision of required resident information to a receiving facility at the time of discharge for Resident #40. Resident #40 was transferred to the hospital on 3/22/22, 4/1/22, 4/12/22 and 4/26/22. Resident #40 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/28/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfer, dressing and hygiene; supervision for eating and total dependence for bathing. Further review of the clinical record failed to evidence any documentation of any documents; medication list, resident information and care plan goals, having been sent to the hospital upon transfer. A review of the comprehensive care plan dated 2/19/22, which revealed, FOCUS: The resident has (chronic) pain related to Depression, Diabetes, and back pain. ER evaluation related to pain per resident's request 3/22/22. ER evaluation related to pain per residents request 4/1/2022. 4/12 sent to ER for unrelieved pain per resident. 4/15 medication adjustment related to unrelieved pain. 4/26/22 Sent to ER for chest pain. INTERVENTIONS: Evaluate the effectiveness of pain interventions (q shift) Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. A review of the facilities Acute Care Transfer Document Checklist (INTERACT version 4.0 tool), Copies of Documents sent with Resident/Patient (check all that apply): dated 2014 transfer form are enclosed 3.face sheet 4.current medication list or current MAR (medication administration record) 5.SBAR (Situation, Background, Assessment, and Recommendation) and/or other change in condition progress includes the following: Documents recommended to accompany resident/patient: 1.Resident/Patient transfer form 2.Personal belongings identified on resident/patient note if completed 6.Advance Directives 7.Advance Care Orders. Send these documents if available: 1.most recent history and physical 2.recent hospital discharge summary 3.recent MD/NP/PA (physician/nurse practitioner/physician assistant) and Specialist orders 4.Flow sheets 5.relevant lab results 6.relevant x-rays and other diagnostic test results 7.SNF/NF (skilled nursing facility/nursing facility) capabilities checklist. EMERGENCY DEPARTMENT: Please ensure that these documents are forwarded to the hospital unit if this resident/patient is admitted . This checklist was on the front of an envelope which is to contain the forms and includes a tear off front page which reveals, Tear off front page to keep with the resident's medical record. An interview was conducted on 7/20/22 at 9:30 AM with LPN (licensed practical nurse) #3. When asked what information is provided to the hospital upon transfer of a resident, LPN #3 stated, I'll get you a sample of what we send with the resident to the acute care facility. It is a transfer document checklist and we tear off the top copy, it should go to medical records. An interview was conducted on 7/20/22 at 2:12 PM, with OSM (other staff member) #6, the medical records coordinator. When asked if she has copies of the transfer document checklist, and shown the transfer document checklist, OSM #6 stated, No we do not get a copy of that for the medical records. I do not know what they do with it. I bet they send all of it to the hospital with the resident. On 7/20/22 at approximately 5:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. ASM #1 asked what top form and shown the transfer document checklist envelop with the tear off front page. A review of the facilities Transfer/Discharge Notification and Right to Appeal policy dated 9/2017, revealed the following: Contents of the Notice: The written notice must include the following: The reason for transfer or discharge; The effective date of transfer or discharge; The location to which the resident is transferred or discharged ; A statement of the resident's appeal rights including the name, address (mailing and email), and telephone number of the entity which receives such request; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; The name, address (mailing and email) and telephone number of the State Long-Term Care Ombudsman. Orientation for Transfer or Discharge: The Center must provide and document sufficient preparation and orientation, in a form and manner that the resident understands, to ensure safe and orderly transfer or discharge. No further information was provided prior to exit. 3. The facility staff failed to evidence provision of required resident information to a receiving facility at the time of discharge for Resident #350. Resident #350 was transferred to the hospital on 1/11/22. Resident #350 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an ARD (assessment reference date) of 12/6/21, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfer, dressing and hygiene; supervision for eating and total dependence for bathing. Further review of the clinical record failed to evidence any documentation of any documents; medication list, resident information and care plan goals, having been sent to the hospital upon transfer. A review of the comprehensive care plan dated 12/18/21, which revealed, FOCUS: The resident has an ADL (activities daily living) self-care performance deficit related to limited mobility and stroke. INTERVENTIONS: Provide assist with all ADLs. A second focus dated 12/30/21, which revealed FOCUS: The resident does not cooperate with care related to adjustment to nursing home, personal choice: refuses medication and refuses to allow staff to change soiled dressing and brief, refusing shower, refused medication prior to wound care and refuses to be turned and repositioned by staff. INTERVENTIONS: Allow the resident to make decisions about treatment regime to provide a sense of control. If possible, negotiate a time for ADLs so that the resident participates in the decision making process. A review of the facilities Acute Care Transfer Document Checklist (INTERACT version 4.0 tool), Copies of Documents sent with Resident/Patient (check all that apply): dated 2014 transfer form are enclosed 3.face sheet 4.current medication list or current MAR (medication administration record) 5.SBAR (Situation, Background, Assessment, and Recommendation) and/or other change in condition progress includes the following: Documents recommended to accompany resident/patient: 1.Resident/Patient transfer form 2.Personal belongings identified on resident/patient note if completed 6.Advance Directives 7.Advance Care Orders. Send these documents if available: 1.most recent history and physical 2.recent hospital discharge summary 3.recent MD/NP/PA (physician/nurse practitioner/physician assistant) and Specialist orders 4.Flow sheets 5.relevant lab results 6.relevant x-rays and other diagnostic test results 7.SNF/NF (skilled nursing facility/nursing facility) capabilities checklist. EMERGENCY DEPARTMENT: Please ensure that these documents are forwarded to the hospital unit if this resident/patient is admitted . This checklist was on the front of an envelope which is to contain the forms and includes a tear off front page which reveals, Tear off front page to keep with the resident's medical record. An interview was conducted on 7/20/22 at 9:30 AM with LPN (licensed practical nurse) #3. When asked what information is provided to the hospital upon transfer of a resident, LPN #3 stated, I'll get you a sample of what we send with the resident to the acute care facility. It is a transfer document checklist and we tear off the top copy, it should go to medical records. An interview was conducted on 7/20/22 at 2:12 PM, with OSM (other staff member) #6, the medical records coordinator. When asked if she has copies of the transfer document checklist, and shown the transfer document checklist, OSM #6 stated, No we do not get a copy of that for the medical records. I do not know what they do with it. I bet they send all of it to the hospital with the resident. On 7/20/22 at approximately 5:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. ASM #1 asked what top form and shown the transfer document checklist envelop with the tear off front page. A review of the facilities Transfer/Discharge Notification and Right to Appeal policy dated 9/2017, revealed the following: Contents of the Notice: The written notice must include the following: The reason for transfer or discharge; The effective date of transfer or discharge; The location to which the resident is transferred or discharged ; A statement of the resident's appeal rights including the name, address (mailing and email), and telephone number of the entity which receives such request; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; The name, address (mailing and email) and telephone number of the State Long-Term Care Ombudsman. Orientation for Transfer or Discharge: The Center must provide and document sufficient preparation and orientation, in a form and manner that the resident understands, to ensure safe and orderly transfer or discharge. No further information was provided prior to exit. 4. The facility staff failed to provide the required documents to the receiving facility for a transfer to the hospital on 5/4/2022 for Resident #1 (R1). On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 7/7/2022, the resident was coded as having both short and long term memory difficulties. The Change In Condition form dated 5/4/2022 at 12:35 p.m. documented in part, On arrival at the facility, report received from the outgoing nurse, rounds done, treatment nurse went to Resident room to do (their) treatment and observed resident twitching and jerging (sic) she alerted writer, writer rush to the room vs done 132/94 (blood pressure),90 (heart rate),98.0 (temperature) o2 (oxygen) sat (saturation) 88- 90. MD (medical doctor) notified. The form further documented, new order in place to transfer resident to hospital ER (emergency room ) via 911 (emergency ambulance service). At 0720 (7:20 a.m.) 911 call, at 0730 (7:30 a.m.) 911 arrived at the facility, at 0745, 911 left the facility with the resident via stretcher. Report given to KD (initials of) the ER nurse, RP (responsible party) made aware resident sister in law and brother. Further review of the clinical record failed to evidence any documentation of any documents; medication list, resident information and care plan goals, having been sent to the hospital upon transfer. A request was made on 7/20/2022 at approximately 12:30 p.m. for the documents. As of 7/21/2022 at 10:00 a.m. the facility did not provide any further documentation of the documents sent to the hospital with the resident. An interview was conducted with LPN (licensed practical nurse) #5 on 7/21/2022 at 7:40 a.m. When asked what documents the nurses send to the hospital when a resident is transferred, LPN #5 stated they send the face sheet, care plan, SBAR (change in condition form), an infection control sheet that includes immunization status, medication list and bed hold notice. When asked where that is documented, LPN #5 stated in the clinical record and on the envelope with the resident's information in it. When asked if she tore off the first copy of the multiple copies on the envelope to keep at the facility, LPN #5 stated she did not remember tearing anything off. ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3 the director of clinical services were made aware of the above concern on 7/21/2022 at 10:00 a.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of written RP (responsible party) and/or ombudsman notification was provided for 4 of 33 residents, Residents #37, #40, #29 and #1. The findings include: 1. The facility staff failed to evidence provision of written RP notification was provided for Resident #37. Resident #37 was transferred to the hospital on 6/27/22. Resident #37 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/21/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfer, dressing, hygiene and bathing; supervision for locomotion and independence for eating. Section O-special procedures/treatments coded the resident as [CONDITION(S)] no. A review of the comprehensive care plan dated 2/26/22, which revealed, FOCUS: The resident is on Hemodialysis via Left arterial-venous Fistula related to [CONDITION(S)]. Transferred to hospital for clogged AV shunt 6/27/22. INTERVENTIONS: Communicate with [CONDITION(S)] facility as needed. [CONDITION(S)] 3 times/week: Tuesday, Thursday & Saturday. An interview was conducted on 7/20/22 at 7:45 AM with LPN (licensed practical nurse) #3. When asked what evidence of RP or ombudsman notification is provided upon transfer of a resident to the hospital, LPN #3 stated, we call the family, the doctor and do not know that we send anything to them. We do not do anything with the ombudsman. An interview was conducted on 7/20/22 at 2:33 PM with OSM (other staff member) #3, the director of social services. When asked what evidence of RP or ombudsman notification is provided upon transfer of a resident to the hospital, OSM #3 stated, the ombudsman notification is by your chair for your residents. An interview was conducted on 7/21/22 at 7:41 AM, with LPN #5. When asked what evidence of RP or ombudsman notification is provided upon transfer of a resident to the hospital, LPN #3 stated, we call the family, we do not give them anything in writing. We do not do anything with the ombudsman. On 7/20/22 at approximately 5:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. A review of the facility's policy Family Notification dated 11/2014, revealed the following, All significant family contact will be documented. This should include discussion of transfer, discharges, problem with care or roommate, significant changes in family support systems, etc. No further information was provided prior to exit. 2. The facility staff failed to evidence provision of written RP notification was provided for Resident #40. Resident #40 was transferred to the hospital on 3/22/22, 4/1/22, 4/12/22 and 4/26/22. Resident #40 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/28/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfer, dressing and hygiene; supervision for eating and total dependence for bathing. A review of the comprehensive care plan dated 2/19/22, which revealed, FOCUS: The resident has (chronic) pain related to Depression, Diabetes, and back pain. ER evaluation related to pain per resident's request 3/22/22. ER evaluation related to pain per residents request 4/1/2022. 4/12 sent to ER for unrelieved pain per resident. 4/15 medication adjustment related to unrelieved pain. 4/26/22 Sent to ER for chest pain. INTERVENTIONS: Evaluate the effectiveness of pain interventions (q shift) Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. An interview was conducted on 7/20/22 at 7:45 AM with LPN (licensed practical nurse) #3. When asked what evidence of RP or ombudsman notification is provided upon transfer of a resident to the hospital, LPN #3 stated, we call the family, the doctor and do not know that we send anything to them. We do not do anything with the ombudsman. An interview was conducted on 7/20/22 at 2:33 PM with OSM (other staff member) #3, the director of social services. When asked what evidence of RP or ombudsman notification is provided upon transfer of a resident to the hospital, OSM #3 stated, the ombudsman notification is by your chair for your residents. An interview was conducted on 7/21/22 at 7:41 AM, with LPN #5. When asked what evidence of RP or ombudsman notification is provided upon transfer of a resident to the hospital, LPN #3 stated, we call the family, we do not give them anything in writing. We do not do anything with the ombudsman. On 7/20/22 at approximately 5:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. A review of the facility's policy Family Notification dated 11/2014, revealed the following, All significant family contact will be documented. This should include discussion of transfer, discharges, problem with care or roommate, significant changes in family support systems, etc. No further information was provided prior to exit. 3. The facility staff failed to provide the resident and/or responsible party with a written notification for the reason for transfer to the hospital on 5/4/2022 for Resident #1 (R1). On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 7/7/2022, the resident was coded as having both short and long term memory difficulties. The Change In Condition form dated 5/4/2022 at 12:35 p.m. documented in part, On arrival at the facility, report received from the outgoing nurse, rounds done, treatment nurse went to Resident room to do (their) treatment and observed resident twitching and jerging (sic) she alerted writer, writer rush to the room vs done 132/94 (blood pressure),90 (heart rate),98.0 (temperature) o2 (oxygen) sat (saturation) 88- 90. MD (medical doctor) notified. The form further documented, new order in place to transfer resident to hospital ER (emergency room ) via 911 (emergency ambulance service). At 0720 (7:20 a.m.) 911 call, at 0730 (7:30 a.m.) 911 arrived at the facility, at 0745, 911 left the facility with the resident via stretcher. Report given to KD (initials of) the ER nurse, RP (responsible party) made aware resident sister in law and brother. Further review of the clinical record failed to evidence any documentation of a written notification to the resident and/or responsible party for the reason for the transfer to the hospital. A request was made on 7/20/2022 at approximately 12:30 p.m. for the documentation of a written notification. On 7/21/22 8:34 a.m., OSM (other staff member) # 3, the social worker. OSM # 3 presented a form, Virginia Involuntary Transfer/Discharge Notice. with R1's name. The form documented the resident's name, date of transfer and an X was documented next to: The facility can no longer meet the resident's medical needs. OSM # 3 stated, they don't give the Transfer/Discharge form to the resident and/or RP (responsible party), they use this form to notify the ombudsman. ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3 the director of clinical services were made aware of the above concern on 7/21/2022 at 10:00 a.m. No further information was provided prior to exit. 4. The facility staff failed to provide the resident and/or responsible party with a written notification for the reason for the transfer to the hospital on 7/18/2022 for Resident #29 (R29). On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/15/2022, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is moderately cognitively impaired for making daily decisions. The nurse's note dated 7/18/2022 at 2:31 p.m. documented, Patient c/o (complained of) chest pain around 11:40am. MD (medical doctor) was notified. Order received to send Patient to ER for further evaluation via 911. 911 was called and came in around 11:48am. Medication list, care plan, transfer form, face sheet, recent labs advance directive and bed hold policy for were given to paramedics. Report was called in to (name of Charge Nurse). Emergency contact (name of emergency contact) is oriented to the transfer. Further review of the clinical record failed to evidence any documentation of a written notification to the resident and/or responsible party for the reason for the transfer to the hospital. A request was made on 7/20/2022 at approximately 12:30 p.m. for the documentation of the written notification. On 7/21/22 8:34 a.m., OSM (other staff member) # 3, the social worker. OSM # 3 presented a form, Virginia Involuntary Transfer/Discharge Notice. with R29's name. The form documented the resident's name, date of transfer and an X was documented next to: The facility can no longer meet the resident's medical needs. OSM # 3 stated, they don't give the Transfer/Discharge form to the resident and/or RP (responsible party), they use this form to notify the ombudsman. OSM #3 stated, R29 was their own RP so we wouldn't call anyone. This form would not be given to resident. ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3 the director of clinical services were made aware of the above concern on 7/21/2022 at 10:00 a.m. No further information was provided prior to exit.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined that the facility staff failed to provide supervision and failed to ensure safety precautions were in place to prevent an elopement that resulted in a hospitalization for one of six residents in the survey sample, Resident #1. The facility staff failed to provide adequate supervision and failed to initiate interventions to mitigate the risk of elopement for Resident #1, a newly admitted resident. On 4/13/17 during the 11 p.m. - 7 a.m., (night) shift, Resident #1 attempted to exit the facility through a fire exit door and was intercepted by CNA (certified nursing assistant) #1 and LPN (licensed practical nurse) #3. The facility staff failed to ensure adequate supervision of Resident #1 after this incident. The staff failed to apply a wanderguard and failed to implement 15 minute SAFETY checks, which resulted in Resident #1 eloping from the facility. The resident went missing on 4/13/17 at approximately 12:00 p.m. Resident #1 was listed as a missing person with the local police department until 4/14/17 at 10:08 a.m. when he was found face down in a ditch on the side of the road. He was transported to the hospital emergency room and admitted with the [DIAGNOSES REDACTED]. The findings include: Resident #1 was admitted to the facility at 3:10 p.m. on 4/12/17 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was not completed as the resident had just entered the facility. Review of the nurse's admission assessment dated and timed on 4/12/17 at 3:10 p.m. documented that the resident was sometimes understood and usually understands others and that the resident was oriented to self and place. It was documented that the resident required assistance of one person for transfers and supervision of staff for ambulation. In Section N titled, Safety there was a section titled, Elopement Risk Evaluation it was documented, - 1. Is resident cognitively impaired? No. - 2. Is resident independently mobile (ambulatory or wheelchair)? No. - 3. Does resident have poor decision making skills? No. - 4. Has resident demonstrated exit-seeking behavior? No. - 5. Does resident wander oblivious to safety needs? No. - 6. Does resident have a history of elopement? If yes, # of times, if known. No. - 7. Does resident have the ability to exit the facility? No. In the section titled, Fall Risk Evaluation it was documented, LOC (level of consciousness)/MENTAL STATUE Alert -- (oriented x (times) 3 (indicating the resident was oriented to person, place and time). GAIT BALANCE Balance problem when walking. 1 Requires use of assistive devices (i.e., cane, w/c (wheelchair), walker, furniture) 1. Total score of 10 or more deems resident at risk. The resident's fall risk score was two indicating the resident was a low fall risk. The nurse's handwritten note on the assessment documented in part, He is alert and oriented x2 (oriented to self and place). He has bruises on his lower bilateral legs and left hand. He has another bruise on his right leg. Review of the interim care plan initiated on 4/12/17 documented, 2. Falls/Safety/Elopement Risks. Goal: Resident will remain free of injuries and falls. Evaluate for unsteady gait. Ambulation devices as necessary. Instruct Resident on appropriate safety measures. Assess cognitive status as ability to ask for assistance. Assess Resident footwear for fit and non-skid soles. (*Note- there were no updates documented on the interim care plan indicating Resident #1 had attempted to exit the facility through a fire exit door on the morning of 4/13/17 at approximately 6:15 a.m., during the 11 p.m.- 7 a.m., (night) shift. ) Review of the form titled TRANSFER/MOBILITY STATUS CRITERIA dated on 4/12/17 documented, TRANSFER STATUS (circle one) 1. CONSIDER. Limited assistance; resident highly involved in activity; receives physical help in guided maneuvering of limbs or other nonweight-bearing assistance. Able to transfer on their own, but needs hands-on support when moving from a sitting or standing position. LIFTING AID TO BE USED Gait belt with assist on one if support of individual is unreliable, then use two-person support. Review of the nurse's note dated 4/13/17 on the 11:00 pm. to 7:00 a.m. shift documented, LEVEL OF CONSCIOUSNESS documented that Resident #1 was alert and oriented to self, place and time. In the section titled, MOOD STATUS it was documented that the resident was happy, pleasant and smiling. In the section titled BEHAVIOR PROBLEMS there were no behaviors documented. The nurse's note dated on 4/13/17 at 8:35 a.m. documented, Noted ambulating in hallway for a while and back in bed. Stayed in bed for a while during shift. Adjusting well to unit. Resident also asked (sic) writer he wants to leave the place and go the bank to get money to come and pay you all (sic) Was redirected personally. Unit manager made aware resident is exit (illegible) Q (every) 15 min (minute) (check mark) initiated on resident. Review of the nurse's note dated and timed 4/14/17 7:28 p.m. documented, Late entry for events that occurred on 4/13/17 at apporox (sic, approximately) 12 noon CNA (certified nursing assistant) informed nursing staff not seeing resident in room (room number). ED (executive director) notified, staff search (sic) for Resident room to room Inside and out side the facility and out side the community, MD (medical doctor) on the unit was notified, by nursing gave verbal order to continue searching for Resident, ED notified police and notified family, ED page for elopement over head (on the intercom). The facility staff and police and family continue to search for Resident in the community Resident has not returned to the facility at this time 7:05 p.m. Review of the form titled, PHYSICIAN'S EVALUATIONS OF RESIDENT'S CAPACITY TO MAKE HEALTH CARE DECISIONS OR PROVIDE INFORMED CONSENT dated 4/13/17 documented, Is incapacitated to make health care decisions. This was signed by two physicians. Review of the facility related incident (FRI) document dated 4/14/17 and sent to the appropriate reporting agency documented, Approximately 12 noon (name of CNA) went to serve (name of resident) his lunch tray and he wasn't able to be found. We looked for him throughout the facility and on the grounds and after 10 mins (minutes) of searching the interior and exterior the police and family were notified. The search continues outside of the facility. Resident remains missing. Review of the first EMS (emergency medical services) team's notes dated 4/14/17 at 10:08 a.m. documented, INITIAL. PT FOUND POSITION LYING ON STOMACH; LOC (level of consciousness) ORIENTATION ORIENTED X 2. PHYSICAL NO TRAUMA. 10:15 a.m. VITALS 151/104 (normal 120/80). Review of the second EMS (emergency medical services) team's notes dated on 4/14/17 at 10:10 a.m. documented in part, Patient was found lying prone (on his abdomen) on the side of the road in a ditch by two joggers. Patient is alert but slightly disoriented X2 .Upon closer inspection, the patient is a missing person who has been missing since yesterday. His portrait is posted on (name of hospital) ED (emergency department). PD (police department) called and is on route. Patient has no complaints and states he was just sleeping on the side of the road. He does not seem to understand why 911 was called Patient does not know how long he has been on the side of the road PD arrives and confirms that he is the missing person. PD will follow up at the hospital. SKIN/BODY TEMP (temperature) 93.1 F (Fahrenheit) (normal temperature is 98.6). Review of the emergency room events log documented, 04/14/17 1031 (10:31 a.m.) Patient arrived in ED. 04/14/17 1614 (4:14 p.m.) Patient admitted . Review of the emergency room nurse's notes dated and timed 4/14/17 at 10:43 a.m. documented, found outside face down on the ground by joggers. Pt (patient) was reported missing from (name of nursing facility) for a few days. Pt states he doesn't want to go back to (name of facility). EMS did a temporal (temperature) (2), unable to get an oral temp right now. EMS did a blood glucose -- 217 (3). Review of the emergency room records dated 4/14/17 at 12:30 p.m. documented, [DIAGNOSES REDACTED]. admitting [DIAGNOSES REDACTED]. Patient Background (why are they here?) found down outside. Patient Vitals for past 24 hrs (hours): Temp 04/14/17 1129 (11:29 a.m.) 94.9 (degrees) F; 04/14/17 1312 (1:12 p.m.) 97.2 (degrees) F; 04/14/17 1500 (3:00 p.m.) 98.5 (degrees) F. Review of the emergency room nurse's note on 4/14/17 at 3:11 p.m. documented, Removed Gaymar (7) warmer; patient temp is now 98.5 oral. Review of the Admission History and Physical dated 4/15/17 at 5:09 p.m. documented, Pt is now being admitted after he was found found(sic) face down on the ground by joggers. 1. AMS (altered mental status); 2. Acute on (sic) chronic renal failure; 3. DHN (dehydration); 4. Hypernatremia (8); 5. Uncontrolled DM -2 (diabetes mellitus type 2); 6. Elevated BNP (9) .likely from diastolic dysfunction, ARF (acute renal failure); 7. Anemia; 8. Cognitive impairment; 9. Abnormal ECG (10); Oriented to person and place; Agitated. On 4/17/17 at 2:45 p.m. a request was made for the facility's policy on elopement and resident fifteen minute safety checks. A policy on elopement was received on 4/17/17 at 3:04 from ASM (administrative staff member) #2, the interim director of clinical services. When asked about a policy for the fifteen minute checks, ASM #2 stated, We don't have a policy for that. It's just something we do when we have a resident who wanders. The Clinical Guideline - Elopement policy, Developed: 9/1/16 and revised 11/23/16, documented, If a resident is identified as being at risk complete an Elopement Risk Alert and obtain a full body photograph. Initiate interventions to mitigate risk of elopement. If utilizing wander monitoring system device check placement of the device every shift and functionality every day. Document individualized interventions in the resident Care Plan and Kardex ASM (administrative staff member) #1, the executive director also provided a copy of the facility investigation on 4/17/17 at approximately 2:45 p.m. Review of the investigation completed by the facility for Resident #1 documented statements from staff. A review of LPN (licensed practical nurse) #3, the night nurse who cared for Resident #1, statement documented, On 4/13/17 @ about 2 am, resident ambulated to nurses station and when asked what he wanted, stated I'm going to sit right there (pointing to chairs by nurses station. Seen eating candy and was advised against eating all that candy due to his [DIAGNOSES REDACTED]. Had a quiet night At about 6:30 am writer heard the fire exit door alarm go off and went to that direction (North). Noted resident's aide with resident in hallway. Resident had a piece of paper in hand and aide was telling him I told you I will give it to you when I finish. Writer asked what it was and resident requested the address of the facility. And when asked what it was for, resident told writer he wanted to go to the bank to cash some money to come and pay his bill. Resident was redirected and was told not to worry about the bill and that it had been taken care of. Resident was then placed at the nurses station for constant observation. Review of CNA #1, the aide who cared for Resident #1, statement documented, On 4-13-2017 while doing my last rounds I heard the alarm going off between 6:00 am/6:30 am. I was in the middle of cleaning a resident, however I immediately ran out to the back and there I caught (name of Resident #1) on the 1st landing of the steps. Ms. (name of LPN #3) came there after (sic). We then returned him to his room. He was wanting the address to the building. I didn't give it to him. Review of RN (registered nurse) #1, the unit manager, statement documented, 4/17/17. Events on 4/13/17: About or around 820 (8:20) A (a.m.) I was @ (at) the nsg (nursing) station on even side when the charge nurse (name of LPN #3 (the night nurse)) had reported to the Unit that (Name of resident (Resident #1)) will need a wanderguard because he was exit seeking during the night. The Unit Manager (writer RN #1 is referring to herself) was in a situation that morning when charge nurse on 11-7 (11:00 p.m. to 7:00 a.m.) was on odd side stating I must have someone to count with me because I have a dental apt (appointment) and I cannot stay - I have to leave. Unit Manager (writer RN #1 is again referring to herself in third person) had to check schedule and noted that RN had c/o (called out). So @ this point I had to receive a report from Charge Nurse and do narcotic count at this time I was the Charge Nurse for the ODD side instead of Unit Manager. 11-7 Charge Nurse could have told me about this resident being exit seeking and needing a wanderguard but with all events that I was dealing with - It was an oversight. (*Note in the statement above when the writer is referring to Unit Manager, she is referring to herself in third person. Also note the writer RN #1 (Unit Manager) states LPN #3 (the night nurse) reported Resident #1 needed a wanderguard as he (Resident #1) was exit seeking during the night, and provides conflicting information further on in her statement). Review of LPN #2, the day nurse who cared for Resident #1, statement documented, 4/13/17. This writer arrived from 11-7 (11:00 p.m. to 7:00 a.m.) nurse, the writer told the CNA at 710 (7:10) am for Resident in (room number) to please monitor Resident (Resident #1) for fall and the CNA took the resident at 711 (7:11) am to the room he ate breakfast in the room. 915 (9:15) am Tolerated meds (medications) well, no falls noted, around 12 pm CNA (name of aide) came to the writer told me she can not (sic) find this Resident (name of resident) all staff look room to room for this Resident and we can not (sic)find him, we went up the road at 1211 (12:11) pm looking all over still can not (sic) see Resident, staff continue to look around for this Resident, ED (executive director) notified police, and family. Review of CNA #4, the day aide who cared for Resident #1, statement documented, 4/13/17. To Whom it May Concern. I (name) came to work and (name of facility) new patient (name of Resident #1) had been right at the front desk on the second floor. The nurse (name of nurse) told me to make sure (name of resident (Resident #1)) go for cigarettes. At breakfast he ate and after that I didn't see him. When lunch came around I went looking for (name of resident) and couldn't find him. An interview was conducted on 4/17/17 at 4:55 p.m. with LPN (licensed practical nurse) #2, the nurse assigned to Resident #1 on the 7:00 a.m. to 3:00 p.m. shift on 4/13/17. When asked what occurred on the day Resident #1 went missing, LPN #2 stated, Around 9:00 (a.m.) or 9:30 (a.m.) I gave him (Resident #1) his medications. I brought him to the nurse's station because I was not able to watch him. When asked why he needed to be watched, LPN #2 stated, I took report from the hospital the day before and I knew he was a fall risk. I left him at the nurse's station. There was someone there but I didn't tell them to watch him. When asked if that was the last time she saw the resident, LPN #2 stated, Yes, ma'am. When asked if she had received report from the night nurse, LPN #2 stated she had. When asked if she was told about the resident trying to elope and that he was to be on 15 minute safety checks, LPN #2 stated, the nurse may have told me about the elopement. If she told me I'm sorry about it. When asked what occurred next, LPN #2 stated, Around 12 (noon) the nursing aide came to me and told me she could not find (name of Resident #1.) I called administration. We looked everywhere. Staff looked downstairs. We looked in our cars and went to (name of local store). We went everywhere. An interview was conducted on 4/18/17 at 10:50 a.m. with CNA (certified nursing assistant) #2, the aide who was assigned to do the 11:00 a.m. resident checks. When asked what occurred during her rounds, CNA #2 stated, We do hourly checks everyday. Mine was at 11:00 a.m. I was busy so when I started it (the rounds) it was 11:30, I started at my end which is room 201 and when I looked in (room number of Resident #1) no one was in there. I ran down to the dining room area. Sometimes they stay there and socialize. He wasn't there so I ran back to the therapy area. He wasn't there. I went and told (name of CNA #4, the resident's aide). She said he went smoking. Smoking was at 9:30 a.m. CNA #4 told me she was busy. So we started looking everywhere. When asked what happened next, CNA #2 stated, We told the nurse. Every department was looking for him. When asked what time the nurse was notified, CNA #2 stated it was around noon. When asked if she had received any education since Resident #1's elopement, CNA #2 stated, Yes, the administrator and the director of nursing gave us an inservice to know what to do when a new person or any resident goes missing. When asked what staff was to do, CNA #2 stated, I should have run straight to the nurse. All the time we should be careful, especially when they're new because many people didn't know who we were even looking for. When asked about 15 minute safety checks, CNA #2 stated, What you do is every 15 minutes you have to go to the person and make sure the person is there. When asked if this was documented, CNA #2 stated, Yes, we have a paper we document our 15 minute checks. The unit manager or the nurse should let us, (the aides); know if they're on 15 minute checks. On 4/18/17 at 9:50 a.m. a message was left for the police office in charge of the case of the missing person. On 4/18/17 at 11:30 a.m. an interview was conducted with other staff member (OSM) #5, the receptionist at the local police department. OSM #5 informed the survey team that the initial call from the facility to the emergency operator came in at 12:56 p.m. The first officer on the scene arrived at 13:42 (1:42 p.m.). OSM #5 stated she would have the police officer call the surveyors when he returned to work on 4/19/17. An interview was conducted on 4/18/17 at 11:33 a.m. with CNA #4, the aide caring for Resident #1. When asked how the resident was when she came in on 4/13/17, CNA #4 stated, He was walking around. He was alert. When asked if he needed assistance with walking, CNA #4 stated, No. It was really busy that day. His roommate told me (name of Resident #1) was trying to leave that day. I don't really listen to him. We call him Mr. eyewitness news. I was getting the roommate ready and (Resident #1) tried to come behind the curtains and get some candy from the roommate so I took (name of Resident #1) out into the hall and put him in a chair and told him to stay there. It takes me awhile to get him (the roommate) ready. It was probably thirty minutes. By the time I came out of the room I looked at the nurses station and I think I saw him there about 9:15 (a.m.) it was so busy. I had another patient to dress and two residents to feed. By that time the 11:00 (a.m.) or 11:30 (a.m.) tray came up. I thought 'I have to get (name of Resident #1)' and I thought he was out smoking. I was thinking he was confident walking around the facility. I went to the lunch room (resident was not there) and then I told (LPN #2, resident's nurse). I started looking in all the rooms, therapy (department) and I came back downstairs. I saw the administrator and I told her I couldn't find my patient. When asked what time that was, CNA #4 stated, Like 12 (noon). When asked if she had been told that Resident #1 was to be on 15 minute safety checks, CNA #4 stated, I came in late. Miss (name of night shift nurse, LPN #3) told me he wanted a cigarette. I had just gotten in and I didn't have time. She didn't tell me he was on 15 minute checks. She (LPN #3) claimed she told me he had a 15 minute watch. When asked if LPN #2 had told her the resident was on 15 minute checks, CNA #4 stated, No because they would have given me a piece of paper to be signed. When asked about the paper, CNA #4 stated, that they had a form that they signed off every 15 minutes. When asked if she had received any education after this incident, CNA #4 stated, Yes. I learned that when they call the resident to go back to their room we go check that room and they are going to give us a card with a picture on it. Now we've been educated if they come in late and nobody's here (to take their picture) we have a picture taken. When asked when the police should be notified of a missing resident, CNA #4 stated, In about ten minutes. An interview was conducted on 4/18/17 at 11:58 a.m. with LPN #3, the night nurse who cared for the resident. When asked what occurred that night, LPN #3 stated, Around 2:00 a.m. he came to the nurse's station and he was eating candy. The aide took him back to his room. About 6:30 (a.m.) he was opening the fire door. He asked the address for the facility so he could go to the bank. I took him to his room and then took him to the desk while I was charting. When the morning shift came in I told them he tried to get out and go to the bank and I told the unit manager (RN (registered nurse) #1) he needed a guard (wanderguard). She (RN #1) said okay. When asked what she had told the day shift staff, LPN #3 stated, I told the oncoming nurse that he opened the back door and to keep an eye on him and do 15 minute checks. I told the nurse and the aide to take him wherever they were going. Need to keep an eye on him. I told the aide he wanted to go downstairs to go smoking and she told him she was going. When asked what the resident's orientation status was, LPN #3 stated, He could make his needs known. He knew who he was and he said he was here to get better. An interview was conducted on 4/18/17 at 1:22 p.m. with CNA #1, the aide assigned to the resident on the night shift. When asked what occurred on that night, CNA #1 stated, I was doing my last rounds for the morning. I was in (Resident #1's) room and I was on the B bed side changing him (the roommate). I heard the alarm going off and I ran to the back door and it was (Resident #1) he went down the first flight. I caught him at the landing. That's when (LPN #3) came. He was asking me for the address for the building and that's all that happened that morning. When asked what time this occurred, CNA #1 stated, It happened (Resident #1 going through the exit door) approximately 6:15ish. We walked him to his room and I had to finish my rounds. When asked if Resident #1 should have been on 15 minute checks, CNA #1 stated, Yes because he's a wanderer. When asked who would have completed the checks, CNA #1 stated, Me or (LPN #3). When asked if she knew who had checked him or completed the checks, CNA #1 stated, No, ma'am. An interview was conducted on 4/18/17 at 2:25 p.m. with ASM (administrative staff member) #2, the director of clinical services. When asked what occurred on 4/13/17 the day Resident #1 eloped, ASM #2 stated, If it had been on the 24 hour report it would have been a red flag because I read the 24 hour report. When asked why the nurse (LPN #3) did not put that information on the 24 hour report, ASM #2 stated, She said she forgot, she had filled it out earlier in the night. When asked if 15 minute checks should have been initiated, ASM #2 stated, Absolutely. When she (LPN #3) said she did 15 minute checks I asked her where it (the document of the 15 minute checks) was and she (LPN #3) could not give it to me so I could not validate it (that the checks had been done). When asked when the resident was last seen, ASM #2 stated, 9:15 (a.m.) and 9:30 (a.m.) based on interviews and statements. When asked who called the police, ASM #2 stated, I called the police. I realized they needed to be called. When asked what time the police were called, ASM #2 stated, I called at 12:50 p.m. When asked if they had reviewed their policy on elopement that day, ASM #2 stated, No, it was a chaotic situation. First of all we were looking for someone we really didn't know well. When asked when the police arrived, ASM #2 stated, Between 1:45 (p.m.) and 2:00 (p.m.). When asked what else she had to say about the situation, ASM #2 stated, There are things we missed that could have prevented this from happening When asked what have they had done since the incident, ASM #2 stated, We have almost done (education) on everybody. We didn't have a picture at that time because medical records took them at that time. Now we have a camera on the second floor unit and after hours the staff takes a picture of the resident. A request for a copy of the 4/12/17 and 4/13/17 24 hour reports was made. An interview was conducted with LPN #1, the nurse who admitted Resident #1 on 4/12/17, on 4/18/17 at 2:55 p.m. When asked how residents were assessed for potential for elopement, LPN #1 stated, You look at the way the patient is behaving. If the person tries to get up and try to find the exit. When asked if she had observed that behavior in Resident #1, LPN #1 stated, Actually I didn't see that behavior. He was in his wheelchair throughout the shift. When asked what his orientation level was, LPN #1 stated, He was alert and oriented times two, to person and to place. He told me he was in a nursing home. When asked if she was worried about anything with Resident #1, LPN #1 stated, Falls. When asked what process staff follows when a resident exhibits elopement behaviors, LPN #1 stated, We assign a person for him. The policy here is that we give the form (the 15 minute check list) to the nurse's aide and every 15 minutes someone has to go in and look at the resident. Review of the 24 hour report for 4/12/17 on the 3:00 p.m. to 11:00 p.m. shift documented, (Name of Resident #1) New resident. admitted @ 3 p.m. from (name of hospital). On 4/13/17 the 11:00 p.m. to 7:00 a.m. shift documented, (Name of Resident #1) New admit. Adjusting. (No) c/o (complaints of). There was no documentation regarding the resident's exit seeking behavior, attempted elopement at approximately 6:15 a.m., through and exit door or risk for elopement. An interview was conducted on 4/18/17 at 3:25 p.m. with ASM (administrative staff member) #1, the executive director. When asked what occurred on 4/13/17 when Resident #1 was missing, ASM #1 stated, About 12 (noon) we were having a job fair. (Name of CNA #4) was getting off the elevator and told me they couldn't find (name of Resident #1). I took the unit manager upstairs and I mistakenly called the code purple. I used it (that code for elopement) in my old building but everyone came running. Everyone got assignments to go look for the resident. I had no idea what (name of Resident #1) looked like. I had called (ASM #2, the director of clinical services) to call the police. She had already called. When asked what time the police were called, ASM #1 stated, I think it was around 12:40 (p.m.) or 12:50 (p.m.). When told the police had been notified at 12:56 p.m., ASM #1 stated, What I learned is that I need to do a timeline. I know it took too long (to notify the police). We have put a plan of corrections together; we assessed 100 per cent of all of the residents for elopement risk and found one. Their care plan was updated. The staff has been educated (about elopement). We were here all weekend working with the staff. An interview was conducted on 4/18/17 at 3:45 p.m. with OSM #1, the staff member sitting at the front desk on 4/13/17. When asked what process staff follows if a resident leaves the building, OSM #1 stated, First I call upstairs to see if they're signed out. When asked if she was at the front desk between 9:15 a.m. and 9:30 a.m. on 4/13/17, OSM #1 stated, she was at the desk until somewhere between 11:30 a.m. and 12:00 p.m. When asked if she remembered seeing Resident #1, OSM #1 stated, No. When asked if visitors signed in, OSM #1 stated they did. When asked if visitors needed to sign out, OSM #1 stated, I ask them if they're leaving for the day and I sign them out. When asked why she didn't do that for Resident #1, OSM #1 stated, I'm doing multiple things at one time so I didn't see him. I could have been working with transport (ambulance service) or making a copy for someone. Anything. An interview was conducted on 4/18/17 at 3:55 p.m. with RN (registered nurse) #1, the unit manager. When asked how staff assessed a resident for elopement risk, RN #1 stated, First of all we do a risk assessment. If they are an elopement risk we get an order for [REDACTED]. When asked what had occurred on the day that Resident #1 eloped, RN #1 stated, It was pretty chaotic that morning. I got bombarded with a lot of things. A lot was going on. The nurse on the odd side (of the nurse's unit) needed to go home. A lot of stuff was going on. Finally I said I had to count off (count the narcotics) and got a report and that was it and then I just worked the floor. When asked if she remembered LPN #3 (night nurse) talking to her about Resident #1 needing a wanderguard and 15 minute checks, RN #1 stated, I don't remember. I'm not denying she told me, I just don't honestly remember. When asked if being told a resident was exit seeking would get her attention, RN #1 stated, I think if she (LPN #3) said it in such a way it might have caught my attention. When asked if she had seen Resident #1 that day, RN #1 stated, No, I did not. When asked when she was made aware that the resident was missing, RN #1 stated, I found out about it about noon. I went upstairs looking. I went from room to room searching personally. I made a phone call to his POA (power of attorney). (LPN #3, the night nurse) said she told me (about Resident #1's exit seeking behavior). I talked to (LPN #2, the day nurse) and she doesn't remember the 11-7 (11:00 p.m. to 7:00 a.m.) nurse telling her anything. On 4/18/17 at 4:20 p.m. ASM #1, the administrator, ASM #3, the director of clinical services and ASM #4, the divisional director of clinical services were made aware of the concern for harm. A telephone interview was conducted with OSM #6, the first officer responding to the emergency call, on 4/20/17 at 8:27 a.m. When asked to describe what the facility staff told him when he arrived at the facility, OSM #6 stated, The nurse stated she had seen him around 7:00 a.m. upstairs, I believe the second floor. He (Resident #1) mentioned he needed to take a smoke break. The staff member told him that he had to wait as they were serving breakfast. Another patient told me he had tried to leave during the night. They did look for him in every room in the building and then expanded their search outside. Once they couldn't find him they called us. During our search we found another resident who was out of the facility who told us he saw a man walking towards Route one around 11:30 a.m. The search was expanded up and down Route one. When asked if he had knowledge of when (Resident #1) was found, OSM #6 stated, I was not involved with that part of the search. Review of the document titled, Final Investigation dated 4/18/17 documented, Our facility and external community search continued until the following day 4/14/17. At 10:36 a.m. the sister contacted the Executive Director and stated her brother was found by the police in the woods asleep, off Dale Blvd and was taken to (name of hospital). The Admissions Director (name) immediately went to the E.R. (emergency room ) where the attending physician stated that he got tired of walking so he laid down and slept in the woods. (Name of Re