Every finding on record at Boynton Beach Rehabilitation Center

Based on policy review, observation, interview and record review, the facility failed to ensure resident rights for 1 of 2 sampled residents (Resident #96), as evidenced by the failure to provide showers in a dignified manner and access to the call bell.The findings included:Review of the policy titled, Procedural Guidelines, Shower, updated 09/2023, documented, in part, For a shower, place shower chair in shower for support.Review of records revealed that Resident #96 was admitted to the facility on [DATE] with diagnoses that include Hemiplegia following Cerebral Infarction affecting Left Non-Dominant side and Right Below Knee Amputation (BKA). Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #96 had a Brief Interview for Mental Status (BIMS) score of 12 on a 0-15 scale indicating moderate cognitive impairment. The current care plan initiated 01/27/26 revealed Resident #96 required Substantial/ Maximal assistance of one for bathing.During an initial interview on 03/24/26 at 10:05 AM, Resident #96 stated that his call bell does not always work because the nurse comes in and takes it out of the wall. Resident #96 was asked why he pushes the call bell, and he stated that he pushes it when he is in pain, cold and wet, and when he is constipated. Resident #96's significant other who visits him daily stated that she has seen the call bell pulled out the wall when she has arrived and when they ask the staff about it, they say someone must have pulled it out. Resident #96 went on to state that when he gets showers twice a week, they put the whole wheelchair in the shower, and he does not use a shower chair, and that the wheelchair is soaking wet.Resident #96 was sitting in his wheelchair with his right leg (BKA) on the pad of the elevated leg rest and his left foot on the footrest of the wheelchair. He had a cushion on the seat of the wheelchair and a cushion on the backrest of the wheelchair that had lateral trunk supports. Resident #96 stated that therapy provided him with cushions since he was leaning to the side and added a padded tray on the left armrest for his left paralyzed arm to rest on.An interview was conducted on 03/25/26 at 3:00PM with Staff C, Certified Nursing Assistant (CNA), who has worked at the facility for 9 years. When Staff C was asked if she assists Resident # 96 with showers she stated she gives him showers during the 3-11 shift on Mondays and Thursdays. She was asked if he sits in a shower chair or a wheelchair and Staff C stated that she gives him a shower while positioned in his wheelchair with the sling under him for the mechanical lift but removes the back cushion and seat cushion so they do not get wet. When asked why she does not have Resident #96 sit in a shower chair she stated it is not safe for him since he moves in the chair and slides down. We went to the shower room and she showed the surveyor the 3 shower chairs and stated that one is too wide and too low for him since he leans to the side, the other two do not have enough support and that he slides down in them and it is not safe to give him a shower while sitting in it. She stated that they transfer him back to the bed using the mechanical lift and remove the sling and make sure he is dried and then dry the wheelchair and use a pad on it to help it dry out. Staff C was asked if the nurse knows that she gives Resident #96 a shower in the wheelchair instead of the shower chair she stated that the nurse's know. She was asked if there are other residents who are showered in their wheelchairs, she stated no, just Resident #96. An interview was conducted on 03/25/26 at 3:30 PM with Staff D, Licensed Practical Nurse (LPN) who has worked at the facility for 4 years and was familiar with Resident #96. She was asked if she knows who gets showers during her shift and she stated yes, they have a shower schedule, and I see them go past with the CNA to the shower room. She was then asked if she knew that Resident #96 was getting his showers while in his wheelchair and she stated that she did not give the CNA permission to use his wheelchair for showers, but the CNA's told her it is safer than using the shower chair. Staff D was then asked if she communicated that CNA's feel it is unsafe to shower Resident #96 in the shower chair and use his wheelchair to anyone else in the facility like the Assistant Director of Nursing (ADON), Director of Nursing (DON) or Therapy and she stated she had not. On 03/26/26 at 7:33 AM Resident #96 was sitting up in his wheelchair in the TV room near the nurse's station. Resident #96 was asked if he was ever given a shower in one of the shower chairs and he stated he did not think he ever had a shower in anything but his wheelchair. He was then asked why he did not want to be showered in his wheelchair, and he stated because it stays wet and it is just not right. He was then asked about his call bell and if it had been working properly and he stated no, they pulled it out of the wall again last night. He was asked how he gets help when the call bell does not work and he stated that he screams for help.On 03/26/26 at 7:41 AM, the call bell in Resident #96's room that was located on the 1/4 siderail on the left side of the bed was activated and the red light on the wall did not light up. Upon further inspection, the call bell was not pushed all the way into the outlet on the wall. The Resident in the bed next to Resident #96 allowed the surveyor to test his call bell that was pushed fully into the outlet on the wall, and the red light did go on.On 03/26/26 at 7:44 AM an interview was conducted with Staff C, CNA and Staff E, LPN who were asked to test Resident #96's call bell that was located on the 1/4 siderail on the left side of the bed and when Staff E pushed the button on the call bell the red light did not go on and she stated that it was working yesterday. Then Staff E and Staff C decided to check the plug at the wall and pushed it in the wall and then it worked. Staff C and Staff E were asked why the call bell wasn't fully plugged into the outlet and Staff C stated that sometimes the cord gets coiled on the side rail and then pulls it partially out of the wall. Staff C and Staff E did not have to adjust the cord since it was not pulling or coiled and once it was pushed back into the outlet it worked. They were asked if Resident #96 pushes his call bell often and Staff E stated, yes, but only when he needs something.An interview was conducted on 03/26/2026 at 8:15 AM with Resident #96's significant other who had arrived for her daily visit and was asked about the call bell and how it was positioned when it did not work and she stated it is pulled out of the outlet just enough to look like it is plugged in but it does not work unless it is pushed all the way in and that sometimes she has found it like that in the morning when she arrives at the facility.Photographic Evidence Obtained.

Based on observation, interview and record review, the facility failed to ensure quality of life for 1 of 5 sampled residents (Resident #108) as evidenced by the failure to assist with positioning in bed for meals.The findings included: Review of the record revealed that Resident #108 was admitted to the facility on [DATE] with diagnoses including Rheumatoid Arthritis. Review of the current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #108 required set- up assistance for eating and partial to moderate assistance for transitioning from lying to sitting in bed. The MDS also revealed that Resident #108 had a Brief Interview for Mental Status (BIMS) score of 15 on a 0-15 scale indicating the resident had intact cognition.During an initial interview on 03/24/26 at 8:10 AM, Resident #108 was asked if she was in a good position to eat her breakfast and she stated, no, but I do not want to bother anyone. Resident #108 had her bedside table over the bed with her breakfast tray on the table and the head of her bed was elevated a small amount making the tray almost level with her shoulders/mouth.An interview was conducted on 03/24/26 at 8:12 AM with Staff A, Certified Nursing Assistant (CNA) who was asked if she delivered Resident #108 her tray this morning and set it up for her and she stated, yes. Staff A was asked if she thought that Resident #108 was in a good position to eat and Staff A went over to Resident #108 and raised the back of the bed a little bit more which did not help since Resident #108 was down low in the bed, and then stated to Resident #108 you're okay, right. During further discussion between Staff A and the surveyor about having 2 people assist with lifting Resident #108 further up in the bed and then raising the head of the bed, Staff A stated that Resident #108 tends to lean to the right side when she is sitting upright in bed and that is why she does not leave her that way. When Staff A left the room, Resident #108 stated that she knew that she needed to have them to pull her up in the bed but they do not do that anymore. Staff from the admissions office and business office stopped by the room and asked Resident #108 if she needed to be repositioned and the surveyor asked them if they typically assist with repositioning residents in bed for meals and they stated they did not. They were asked to have Staff A come back into the room and at 8:20 AM Staff A came back in and the staff member from Admissions assisted Staff A with repositioning Resident #108 up in her bed. After being pulled up in bed, Staff A assisted with raising the head of the bed and the tray table to allow Resident #108 to see her food and eat and drink in a more comfortable position.On 03/25/26 at 7:59 AM, Staff B, Licensed Practical Nurse (LPN) Unit Manager was assisting Resident #108 with her tea was asked if she thought that Resident #108 was in a good position to eat, (Resident #108 was slid down in the bed and the head of the bed was only elevated a small amount and the tray was not close to the resident)and Staff B stated no, but Resident #108 tends to lean to the right when its upright. Staff B asked Resident #108 if she is in a good position to eat and she stated, no. Staff B went and got the nurse and they assisted resident up in the bed and when the surveyor stated you look better now, Resident #108 said oh, thank you so much. Resident #108 stated that if she had something to hold onto, she may be able to reposition herself when she leans to the right. Resident #108 was asked if she had ever asked for side rails and she stated she was told they were illegal. Resident #108 stated she will ask for them and when her nurse came into her room she did request 1/4 siderails and the nurse agreed to put in a request to have Resident #108 assessed for siderails.

Based on record review and interview, the facility failed to follow up on physician ordered urine culture for 1 of 3 sampled residents for urinary tract infections (Resident #4). The findings included:Record review revealed Resident #4 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and required partial/moderate assistance with activities of daily living.A review of Resident #4's orders revealed an order dated 03/19/26 for a urinalysis with culture. Further review of the resident's orders revealed an order for intravenous (IV) antibiotics dated 03/19/26.A review of Resident #4's records on 03/26/26 revealed no results for the ordered urine culture on 03/19/26.An interview was conducted with the Nurse Practitioner (NP) on 03/26/26 at 10:00 AM. The NP stated she expected staff to follow up with the ordered urine culture to identify the specific organism of the infection to ensure Resident #4 was receiving the appropriate antibiotic treatment. If the culture was not able to be done, the NP stated she expected to be notified.An interview was conducted with the Director of Nursing (DON) on 03/26/26 at 12:00 PM. The DON was informed of the above.

Based on policy review, observation, interview and record review, the facility failed to provide assistive devices for 1 of 8 sampled residents, as evidenced by failure to provide 2-handled cup to Resident #108.The findings included:Review of the policy titled, Rehabilitation Space, Equipment, & Supplies, revised on 08/2023, documented in part, 8. Resident specific equipment is issued by the treating therapist who provides instruction in the use of the equipment, and who documents the resident's response to the equipment in the medical record.Review of the record revealed that Resident #108 was admitted to the facility on [DATE] with diagnoses including Rheumatoid Arthritis. Review of Physicians' orders revealed an order dated 10/08/24 for Resident to receive 2 handled cup and scoop plate at all meals.An interview was conducted on 03/24/26 at 8:34 AM when Resident #108 was eating breakfast and had one 2 handled cup filled with orange juice and a regular coffee mug filled with tea. Resident #108 stated that it is difficult for her to drink the tea out of the coffee mug since it only has one handle and does not have a lid with a spout. Resident #108 stated that she has Rheumatoid Arthritis that makes it hard to hold things with her hands and that she has poor vision and likes the two handled cup with the lid when drinking fluids.On 03/25/26 at 7:59 AM, Resident #108 was being assisted with setting up her tray and getting tea by Staff B, Licensed Practical Nurse (LPN) unit manager who put the hot tea in the 2 handled cup that was delivered empty on her tray and the orange juice was in a standard juice cup without any handles. Resident #108 stated that it would be difficult for her to drink the orange juice out of that cup.An interview was conducted on 03/25/26 at 8:22 AM with Staff B who was asked if it was okay that Resident #108 was drinking her tea from a 2 handled cup but her orange juice was in a standard cup and she stated, no, I will ask the kitchen to send her two 2 handled cups from now on. She was then asked if the orange juice is sent from the kitchen shouldn't it be sent on her tray in a 2 handled cup and she agreed that it should be.An interview was conducted with the Culinary Manager on 03/25/26 at 8:34 AM who stated that she did not know that Resident #108 drank tea and that is why she was only sent one empty 2 handled cup. The Culinary Manager was asked if the orange juice is sent from the kitchen, why is it in a standard cup and not in a 2 handled cup and she agreed that it should have been in a 2 handled cup sent from the kitchen.Photographic Evidence Obtained.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with active wounds and a Peripherally Inserted Central Catheter (PICC) line, for 1 of 6 sampled residents on EBP (Resident #3); and facility failed to implement infection control practices for a resident with a urinary catheter, for 1 of 3 sampled residents (Resident #1.) The findings included: 1) Review of the policy titled Enhanced Barrier Precautions Chapter: Infection Prevention and Control revised 06/13/24 documented Enhanced Barrier Precautions are indicated . 2. Wounds, and/or indwelling medical devices even if the resident is not known to be infected or colonized with a Multi-Drug-Resistant Organism (MDRO). Indwelling devices: Indwelling urinary catheters, Gastronomy-feeding tubes, Central lines including PICC, Midline, tracheostomy tubes . Review of the record revealed Resident #3 was admitted to the facility 04/16/25. A Brief Interview for Mental Status (BIMS) evaluation conducted on 04/17/25 documented the Resident had a BIMS score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the care plan dated 04/17/25 documented Resident #3 is at risk for impairment to skin integrity related to Peripheral Artery Disease (PAD), Diabetes Mellitus (DM). 04/16/24 admitted with R great toe wound/infection. Interventions included Enhanced Barrier Precautions. Review of the current orders revealed Resident #3 had a PICC line and active wounds. Further review revealed the Resident's wounds were located on the right great toe and right heel. Resident #3 had active orders for wound treatments and was currently receiving antibiotics. No active EBP orders were revealed upon record review. During an observation conducted on 04/23/25 at 9:59 AM the Wound Care Nurse was seen inside Resident #3's room. No EBP sign or Personal Protective Equipment (PPE) was observed at the Resident's doorway. At 10:13 AM another attempt was made to observe the Resident, the Wound Care Nurse was still in the room with Resident #3. During an observation and interview conducted on 04/23/25 at 11:50AM, no EBP sign or PPE was observed upon entrance or inside the Resident #3's room. When asked if staff wear a gown when they provide direct care she stated, No, I don't think they wear gowns. Resident #3 stated she had a PICC line and two wounds and she was currently being treated with antibiotics. During an interview on 04/23/25 at 12:29 PM, when asked what Residents should be placed on EBP, the Infection Preventionist stated Residents with open wounds, foleys, Intravenous lines (IV) such as midlines and PICC line. When asked why Resident #3 was not on EBP , the Infection Preventionist stated the resident should be on EBP due to the wound and PICC line. She confirmed that it had been her error and thought there was an order. During an interview on 04/23/25 at 1:16 PM, when asked if she was providing care to Resident #3 earlier while in the room, the Wound Care nurse replied No I was just talking to her, she feels comfortable with me. When asked if she knew why the Resident was not on EBP, the Wound Care Nurse stated she didn't know why and thought she was on it. During an interview on 04/23/25 at 1:31 PM the Assistant Director of Nursing (ADON) was made aware of Infection control concerns regarding Resident #3, and the ADON acknowledged with the findings. 2) Review of the Centers for Disease Control and Prevention article titled Summary of Recommendations published 03/25/24 documented, III. Proper Techniques for Urinary Catheter Maintenance . III.B.2. Do not rest bag on the floor. Review of the record revealed Resident #1 was last admitted to the facility 08/26/24.Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. Review of the active orders revealed Resident #1 currently had a suprapubic catheter (a urinary catheter inserted directly into the bladder through a small incision in the lower abdomen, rather than through the urethra.) Review of the Wound PCR Panel revealed that Resident #1 had a positive wound result reported on 03/14/25 to his suprapubic catheter site with suggested treatments. Further review of his record revealed he was treated for this infection with antibiotics. During an observation on 04/23/25 at 9:30 AM, Resident #1's urinary drainage bag was seen resting on the floor. Photographic evidence obtained. During a follow-up observation on 04/23/25 at 12:09 PM, Resident #1's representative was at the bedside feeding the resident. When asked how care was, the representative stated that Resident #1 has had a lot of urinary tract issues lately. When the urinary drainage bag was observed again, it was still resting on the floor. During an interview on 04/23/25 at 12:29 PM, when asked, Upon conducting an initial observation and assessment on a resident who has a urinary catheter, what do you not want to see? The infection preventionist replied I don't want to see a catheter bag on the floor or a catheter above the bladder because that can lead to infection, those two things are very important. When the infection preventionist was shown a picture of Resident #1's catheter bag resting on the floor, she stated she would have to check the policy to see if that was acceptable as it was in a dignity bag. No policy was provided to the surveyor justifying the infection preventionist's comment. During an interview on 04/23/25 at 1:31 PM with the ADON, when made aware of the concerns regarding Resident #1's catheter, the ADON stated it was hard to keep it off the ground due to the bed being in the lowest position. The ADON was made aware two other catheter bags were also observed with the bed in the lowest position and they were not observed resting on the ground. The ADON agreed how it was still an infection control concern due to the recent infection to the same site.

Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, safe, clean, and comfortable interior for 2 of 3 resident units (200 and 300), 1 of 1 physical therapy room, and 1 of 1 main dining room. The findings included: During the initial resident tours conducted by the surveyors on 10/07/24 - 10/08/24, and the Environment Tour conducted with the Director of Maintenance on 10/11/24, the following were noted: 200 Unit: room [ROOM NUMBER]: Large areas of peeling room wallpaper, and numerous small black holes to room floor. room [ROOM NUMBER]: Exterior of wood bed frame in disrepair (A-bed). room [ROOM NUMBER]: Room floor had large cracks in the linoleum, exterior pf wood bed frame in disrepair (A-bed), Room floor stained and in disrepair, exterior of over-bed tables (X 2) stained and rust laden, room walls in disrepair, and exteriors of room dressers (x 2) worn, broken, and in disrepair. room [ROOM NUMBER]: Privacy curtain soiled and stained (A-bed), and room floor numerous small black holes in linoleum. room [ROOM NUMBER]: large area of room floor was peeling up, exterior of bathroom shower handrails (X 2) were stained and rust laden, and exterior of over-bed table was stained and rust laden (B-bed) . room [ROOM NUMBER]: Bathroom floor soiled and heavily stained, and room floor soiled and stained. room [ROOM NUMBER]: Bathroom floor soiled and heavily stained, and exterior of over-bed table stained and rust laden (A-bed). room [ROOM NUMBER]: Bathroom floor soiled and heavily stained, and room waste basket cracked and broken. room [ROOM NUMBER]: Bathroom floor soiled and heavily stained, and exterior of over-bed table stained and rust laden (A-bed). Hallway/Corridor: Large carpet stains outside entrance to room [ROOM NUMBER]. 300 Unit: room [ROOM NUMBER]: Room windows soiled and build-up of green algae. Hallway/Corridor: Heavy urine odor outside of room [ROOM NUMBER]. Community Shower #1: Privacy curtain of toilet area does not promote resident privacy when in use, and 1 of 3 light fixtures not working. Community Shower #2: Two of 3 light fixtures not working. Nourishment Room: Door gasket had large tear and requires replacement. Nurses Station: Exterior of wall vent and surrounding wall area covered with black mold type matter. Skilled Therapy Department: Parallel Bars: The wood floor area of 2 of 2 parallel bars noted to be heavily worn, stained and non-slips strips require replacement. Parallel Bars: The hand and arm stabilization bars of 2 of 2 parallel bars were broken, loose held together with zip ties and in need of immediate replacement. Practice Stair Case: The exterior of the stairs (6) were soiled, stained and the non-skid foot strips require replacement . Storage Room: Four ceiling tiles appeared to have water/leak damage and in need of repair and replacement. Bathroom: Two ceiling tiles appeared to have water/leak damage and in need of repair and replacement Main Dining Room: Windows: Twelve of twelve windows were noted to be soiled and heavy build-up of green-algae matter. Following the tours the findings were again reviewed and confirmed with the Administrator and Director of Maintenance.

Based on observation, interview, and record review, it was determined that the main dining room space was not being properly utilized during meal service for 40 of 40 facility residents. The findings included: During the observation of the lunch meal in the Main Dining Room (MDR) on 10/07/24 at 12 PM, it was noted that the entire dining room space was not being utilized for the meal service. Specifically, approximately only half of the dining space was being utilized for the residents(38 wheelchair bound) . During the meal observation it was noted that 40 residents were in attendance and numerous residents complained and became upset and angry due to having their wheelchairs moved from their table so other residents in wheelchairs could get into the dining area. During the observations, three sampled residents (Resident 's # 40, #57 and #127 ) complained to the surveyor of constantly being moved during meal services (Lunch & Dinner). Staff (A, D, and E) were also noted to state to the surveyor about the difficulty the residents have constantly repositioning/moving during meal services. Further observation noted that the main dining space being utilized for the lunch meal was furnished with 13 dining tables and 36 of the 38 residents in attendance were wheelchair bound. Further observation noted that the space not being utilized for meal were furnished with 3 tables of which only 4 wheelchair bound residents were in attendance. On 10/08/24 at 11 AM, at the request of the surveyor the dining room spaces being utilized for meals were measured by the Director of Maintenance. The measurements noted that the main area was 1200 square feet and the connecting ding area not being utilized was measured at 560 square feet. The Director stated that he did not know why the entire dining area is not being utilized for resident meals and confirmed that there is a problem of space constraints and continuous moving of residents during meals. Continuous observation of the lunch meals on 10/08/24, 10/11/24, and 10/14/24 confirmed the surveyor's findings of residents being continuously moved during meal service and complaining of the issue.

Based on observation, interview, and record review, it was determined that the facility failed to provide 1 (Resident #127) of 1 sampled residents with the right to choose schedules and make choices that include sleeping and waking times. The findings included: On 10/07/24 at 1 PM, an interview was conducted with Resident #127, in the Main Dining Room (MD) concerning issues at the facility. The alert and oriented resident stated that she would like to be able to attend the breakfast meal in the MDR (8:30 AM) but staff will not get her up, provide morning care and dressed until 10 AM after numerous requests. The resident also stated that she is late for Skilled Therapy sessions daily, which are scheduled at 10 AM. She has repeatedly requested from nursing to be ready for the therapy session but this also has not been resolved. Following the interview the surveyor stated to the resident to request from nursing staff to be up and prepared for the breakfast meal in the MDR on 10/08/24. On 10/08/24 at 8:30 AM the surveyor observed the resident in her room who was awake and in bed. Staff had failed again to honor her request to attend the breakfast meal in the MDR and would be again late for her schedule therapy 10 AM appointment. On 10/08/24 at 2 PM the surveyor met with the Director of Nursing and reviewed the resident's issues. The DON stated that the issues would be resolved. A subsequent observation conducted on 10/11/24 at 8 AM noted the resident to be up and dressed and in the wheelchair going to the MDR. The resident stated that she has been ready for the past 2 days at 7:30 AM and has attended the breakfast meal and therapy sessions on time. The resident voiced how happy she was and increased the quality of her life. During the review of the clinical record of Resident #127, it was noted an admitted [DATE] with diagnoses that included Dysphagia, Failure to Thrive, and Lower Leg Wound. Further review of clinical record noted an MDS date 08/02/24 that indicated a BIMS score of 9 (non-cognitive impairment), no mood issues, and independent with eating.

Based on observation, interview, and record review, the facility failed to provide activities on an ongoing basis for 2 of 5 residents reviewed for activities (Resident #62 and #81). The findings included: A review of the facility's policy Activity Program, revised 08/2023, documented: Each center provides an ongoing program of activities designed to meet (in accordance with the comprehensive assessment) the interests and physical, mental, and psychosocial well-being of each resident. Document the resident's participation in activities or refusal to participate in activities in the progress notes as need. 1. Resident #62 was admitted to the facility on [DATE] with diagnoses included Dementia and Stroke. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive impairment and was dependent for activities of daily living. Resident #62 was care planned for person-centered care, with an intervention enjoys participating in their favorite activities. A record review for Resident #62 revealed an Activities Evaluation dated 07/26/24 that documented the resident was able to make needs known, and was staff dependent for participation in activities. The evaluation further documented the resident had interests in sports, music, outdoor activities, conversation/talking, movies/TV, and interested in participation in special event parties/happy hour and ice cream/food socials. The resident needed assistance getting to and from activities via wheelchair. A review of Resident #62's progress notes revealed an activity note dated 06/10/24 at 15:14 that documented: Resident was unavailable for activity programs in bed sleeping today. Further review of Resident #62's records did not reveal any other documentation of the resident's participation or refusal of activities. Resident #62 was observed in his room sleeping in bed in a hospital gown on 10/07/24 at 11:30 AM. The TV was observed off. Resident #62 was observed in his room in bed sleeping in bed in a hospital gown on 10/08/24 at 10:30 AM, and again at 2:00 PM. The TV was off. Resident #62 was observed in his room awake and alert, dressed, sitting up in a recliner chair on 10/11/24 at 11:00 AM. The TV was off. Resident #62 was observed in his room awake and alert, dressed, sitting up in a recliner chair on 10/14/24 at 11:00 AM. The TV was off. An interview was conducted with the Activities Director on 10/14/24 at 12:00 PM. The Activities Director stated a resident's participation in activities was charted in the resident's progress notes. The Activities Director acknowledged the last time Resident #62 participated in activities according to the resident's progress notes was on 06/10/24. 2. Resident #81 was admitted to the facility on [DATE] with diagnoses included Stroke. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive impairment and was dependent for activities of daily living. Resident #81 was care planned for person-centered care with an intervention enjoys participating in their favorite activities. A record review revealed an Activities Evaluation dated 07/24/24 that documented the resident was able to make needs known, and was staff dependent for participation in activities. The evaluation further documented the resident had interests in sports, music, outdoor activities, conversation/talking, and movies/TV. The resident needed assistance getting to and from activities via wheelchair or walker. A review of Resident #81's progress notes revealed an activity progress note dated 07/25/24 at 5:13 PM that documented: Quarterly review: [Resident #81] is mostly in bed resting or sleep in bed, haven't been up to activity programs. Activity staff will continue to encourage resident to attend programs. Further review of Resident #81's records did not reveal any other documentation of the resident's participation or refusal of activities. Resident #81 was observed in her room sleeping in bed in a hospital gown on 10/07/24 at 11:30 AM. The TV was observed off. Resident #81 was observed in her room in bed sleeping in bed in a hospital gown on 10/08/24 at 10:30 AM, and again at 2:00 PM. The TV was off. Resident #81 was observed in her room awake and alert, in bed on 10/11/24 at 11:00 AM. The TV was off. Resident #81 was observed in his room awake and alert, in bed on 10/14/24 at 11:00 AM. The TV was off. An interview was conducted with the Activities Director on 10/14/24 at 12:00 PM. The Activities Director stated a resident's participation in activities was charted in the resident's progress notes. The Activities Director acknowledged the last time Resident #81 had documentation for activities participation was on 07/25/24.

Based on record review and interview, the facility failed to address high blood glucose levels for 1 of 1 sampled resident (Resident #195). The findings included: Resident #195 was admitted to the facility for respite care on 09/20/24- 09/23/24. A review of Resident #195's orders revealed an order dated 09/20/24 for sliding scale insulin Novolog before meals and at bedtime. The resident was to receive 2 units of insulin for blood glucose level of 251-400. A review of Resident #195's blood glucose levels revealed a level of 438 on 09/22/24 at 6:51 AM. Further record review did not reveal any documentation of physician notification of a blood glucose level outside of the parameter of greater than 400. An interview was conducted with the Director of Nursing (DON) on 10/14/24 at 12:00 PM. The DON stated for a sliding scale insulin order, it will usually document to call physician if the blood glucose level is greater than 400. The DON further stated even if there was no order to call for a blood glucose level greater than 400, the nurse should have called as that was the standard of practice.

Based on observations, interviews and record reviews, the facility failed to adequately supervise a resident on enteral feeding who was self-administering fluids, for 1 of 2 residents reviewed with gastrostomy tube feeding (Resident #116). The findings included: Resident #116 was admitted to the facility on [DATE] with diagnoses including Acute Respiratory failure with Hypoxia (low oxygen concentration in the blood), Dysphagia (Swallowing difficulty), and Cognitive communication deficit. Review of annual MDS (Minimum Data Set) Section C, dated 08/14/24 revealed a score of 06 indicating, impaired cognitive function. MDS Section K under Nutritional Approaches revealed yes to a feeding tube (PEG {percutaneous endoscopic gastrostomy-an abdominal opening through a tube that goes straight into the stomach}). Further review of Nursing Care Plan created on 08/23/24, with a target date of 11/18/24, revealed the following foci: decreased nutritional status, and dehydration related to Acute respiratory failure, and head and neck cancer. The documented goals for Resident # 116 were: to tolerate tube feeding flushes as ordered, to be free from signs and symptoms of dehydration, and to be free from significant weight changes. The interventions included: assistance with meals as needed, diet as ordered, observe diet tolerance, and observe for dehydration. Record review of Dietary Progress Notes dated 09/11/24 related to enteral feeding review, revealed resident is NPO (nothing to be given by mouth), that tube feeding provides 2280 kcal (Kilocalorie), 97 g (Grams) of proteins, 2695 ml (Milliliter ) of fluids plus an additional 240 ml of fluid flushes every 4 hours. It documented a weight of 146.8 pounds, and a BMI ( Basal Metabolic Index) of 23, indicating normal. Additional notes revealed that Resident #116 was found taking food from meal carts and hiding milk in nightstand drawer, has failed swallow studies and had PEG tube prior to facility admission. Additional documentation revealed that Resident #116 remains ambulatory and walks around the facility several times a day. A review of orders dated 09/26/24 revealed an NPO diet. On 09/27/24, an order for enteral feed related to Dysphagia was documented as Jevity 90 ml/hr (Milliliter per hour ) for 16 hours, on at 6:00 PM, off at 10 AM. Additional record review of Dietary Progress notes dated 10/11/24 related to enteral feeding, revealed that Resident is NPO, that tube feeding provides 2755 kcal, 118 g of protein, 2714 ml of fluids, plus 240 ml flushes every 4 hours, which indicated greater than 100 percent of estimated nutritional needs. A Jevity feeding at 100 ml/hour for 16 hours, with one can bolus during the day was documented. It further revealed that Resident #116 was status post hospitalization , with some weight loss, and an increased needs related to being mobile, with history of refusing gastrostomy tube feeding, and diuretic treatment. Additional documentation revealed a recorded weight of 128 pounds and a BMI of 20, indicating underweight. In an observation on 10/14/24 10:39 AM, Resident # 116 was observed lying in bed, with head slightly elevated on a pillow. He had a red carton of 8 ounces whole milk between his thighs. He was attaching a [NAME] syringe on an open portal of the gastrostomy tube located on his abdomen and started emptying the contents of the 8 ounces whole milk carton on the [NAME] syringe, pouring down to the gastrostomy tube opening. This surveyor searched for staff for assistance. Two Staff, Staff B, a CNA (Certified Nursing Assistant), and the DON (Director of Nursing), were approaching were asked to go inside Resident #116's room. The DON put on gloves and told the resident that he is not allowed to feed himself through the gastrostomy tube. She disconnected the [NAME] syringe from the gastrostomy tube port then closed it with a cap. She then bagged the milk and took it outside Resident #116's room. In an interview with the DON on 10/14/24 at 10:52 AM, she stated that Resident #116 is not allowed to perform enteral feeding by himself. In an interview with Resident #116 on 10/14/24 at 10:55 AM, he stated he was hungry, and staff do not provide enough food for him, so he decided to feed himself. Resident #116 was observed tapping his abdomen while he was talking to this Surveyor. During an interview with Staff H, a CNA, on 10/14/24 11:10 AM, she stated that Resident #116 goes to the dining room every morning. She added that she does not see him eating, but she sees him going there.

Based on observations, interviews and record reviews, the facility failed to monitor residents' weights for 2 of 9 residents reviewed for Nutrition, Residents #32 and 89. The findings included: The facility's policy, 'Weight Measurements' revised 08/2023, documented: Frequency of measurements and calculations Residents are weighed weekly, monthly or according to physician orders. Residents should be weighed at the same time of day, in similar clothing and using the same scale. Any significant or progressive weight loss or gain is noted and reported to the resident's attending physician, family, or responsible party, and documented in the medical record. Note: All new admits are weighed weekly for 30 days. 1). Resident #89 was admitted to the facility on [DATE]. According to the resident's admission Minimum Data Set (MDS) assessment, dated 08/20/24, Resident #89 had a Brief Interview for Mental Status (BIMS) score of 10, indicating that the resident was 'moderately' cognitively impaired. Resident #89's diagnoses at the time of the assessment included: Hypertension, Renal insufficiency, Diabetes Mellitus, Hyponatremia, Muscle weakness, Lack of coordination, Cognitive communication deficit. Resident #89's orders included: Regular diet, Regular texture, Thin Liquids consistency - 08/29/24 Med Pass 2.0/Ready Care 2.0 two times a day for nutrition support give 120 ml by mouth twice a day - 09/25/24. Resident #89's Care plan for nutrition, initiated on 08/30/24, documented, Resident is at risk for decreased nutritional status & dehydration related to Type 2 DM, Hypertension, meds that may cause Gi upset/edema, liberalized diet to promote po (oral) intakes, need for nutrition supplements, decreased po intakes. Interventions to the care plan included: * Weights as ordered Date Initiated: 08/30/2024 Review of Resident #89's health records showed that there were no orders for weights to be taken. During an interview, on 10/08/24 09:31 AM, with Resident #89, when asked about any concerns with weight loss or weight gain, Resident #89 replied, I have lost weight since I have been here. The food is prepared food - not like mama cooked. Resident #89's weight upon admission was documented as 120 pounds. There were no other weights documented in the resident's electronic health record since the admission weight. During an interview, on 10/11/24 at approximately 8:30 AM, with Staff B, Restorative CNA, when asked about taking residents' weights, Staff B stated that the Restorative CNAs received a list of residents to be weighed based on orders and requests/recommendations from the Diet Tech. After obtaining the weights they are to provide the hand written documentation to the Diet Tech. The Diet Tech then puts the information in the resident's electronic health record. During an interview, on 10/11/24 at 9:40 AM, Staff A, Restorative CNA, Staff A provided this Surveyor with hand-written documentation of residents' weights. Staff A documented Resident #89's weight as 89 pounds for the month of September 2024. When asked, Staff A could not recall the exact date that the weight was taken. Staff A provided this Surveyor with hand-written documentation of weights from 10/10/24. The document showed that Resident #89 weighed 113 pounds. During an interview, on 10/11/24 at 10:03 AM with the Diet Tech, when asked about the facility's policy for obtaining residents' weights, the Diet Tech replied, A lot of times, I put them in the computer. I have not seen the weight for September, but before I put them in the computer, I have to go and make sure. I have not seen it. The Diet Tech further stated that residents are to be weighed on admission and then weekly for the next 4 weeks and monthly thereafter unless otherwise determined, when there is a weight loss, weekly or as indicated. 50370 2). Resident # 32 was admitted on [DATE] with diagnoses including Atrial fibrillation, Cognitive communication deficit, Hypothyroidism, Glaucoma, Dementia, and Anemia. Review of MDS (Minimum Data Set) Section C, dated 09/03/24, revealed a BIMS (Brief Interview of Mental Status) score of 05, indicating impaired cognitive function. Section E 0800, pertaining to rejection of care, revealed a response of zero, indicating the behavior was not exhibited by Resident #32. Further record review of Nursing Progress Notes between 08/01/24 and 10/10/24, revealed Staff E, a Licensed Practical Nurse (LPN) documented as follows: Resident has history of COPD (Chronic Obstructive Pulmonary Disease), and experiences occasional SOB (shortness of breath) with exertion. There were no documentations that Resident #32 refused to be weighed on all the above dates. There were no documentation of Resident #32's Physician was made aware of resident's refusal to be weighed on the above dates. A further review of Nursing Progress Notes dated 09/04/24, revealed a documentation by a Staff I, an RN (Registered Nurse), noting Resident #32 has been very pleasant and weight is stable. IDT (Interdisciplinary team reviewed the POC (Plan of Care) and it was updated. There was no recorded weight on this progress note. Additional Nursing Progress Notes dated 09/12/24, documented by Staff K, LPN, revealed head to toe visual evaluation for skin check completed. Left lower leg wound care done by wound care Nurse and wound care Doctor. There was no documentation of Resident # 32's refusal to be weighed. A record review of Nursing Progress Notes documented by Staff J, a LPN, dated 09/24/24 revealed Resident is stable, no complaint voiced, appetite is good. There was no documentation of Resident #32's refusal to be weighed. Further review of Nursing Progress Notes written by Staff J, LPN, dated 09/26/24 revealed no mood indicators and behaviors displayed by resident. It added that resident #32 has intermittent confusion. Additional notes were Nursing services provided, turned and repositioned, positioning devices applied. There was no documentation of Resident 32's refusal to be weighed. Record review of Nursing care plan dated 09/04/24, revealed the following foci: Resident is at risk for decreased nutritional status, and dehydration, related to past medical history of Sepsis, Dementia, UTI ( Urinary Tract Infection), Advanced age and limited mobility. The goals documented are as follows: Resident will be free from significant weight changes through the review date; Resident will consume adequate foods and fluids to meet estimated nutritional needs through the next review date. The following interventions were documented as follows: Assist with meals as needed, monitor diet tolerance, provide food preferences and substitutions, monitor po ( per orem or by mouth) intake, and weights as ordered. Further record review of quarterly Nutrition Note, dated 09/18/24, revealed Resident #32 refused weight for August and September. There were no documentation that Resident #32's Physician was informed of Resident's refusal to be weighed, and the interventions performed by Staff. A review of Progress Notes dated 10/08/24, revealed a Nutrition follow up documenting that Resident #32 refuses to be weighed for 3 months. It added weight loss was suspected based on appearance and intervention. During the Recertification survey on 10/08/24, Staff D, a Dietary Technician, added an order of Ready care 2.0, 120 ml ( Milliliters) to be offered BID (twice a day). Staff D, Dietary Technician met with the Resident on the same day to discuss Resident #32's dietary preferences and questioned the resident about complaints of Gastro-intestinal upset. A review of Facility policy titled Weight Measurements revised on 08/23, revealed that the purpose of body weight is a value used to monitor the nutritional status of the resident. Additional notes related to frequency and calculations revealed that residents are weighed weekly, monthly, or according to physician orders. Any significant weight loss or gain is noted and reported to the attending physician, family, or responsible party, and documented in the medical record. Page 1 of the document revealed the types of scales and the indications for each usage. Bed scale is appropriate for a non- ambulatory or acutely ill resident who is bed-bound. Page 2 and 3 of the same document revealed various procedures of measuring weight using a standing scale, bed scale, chair scale, and specialty bathing system. During an observation on 10/07/24 at 12:30 PM, Resident #32 did not touch the main entree on her meal tray. She had some drinks from the meal tray. She stated food is not great all the time. She wanted something that she can easily digest. She is not sure if she had been seen by a Dietician. Resident looks thin with long fingers. When asked if she is losing weight, she stated she does not know. In an interview with Staff D, Dietary Technician, on 10/11/24 at 10:06 AM, she stated that Residents are weighed weekly, monthly and or according to physician's orders. When asked how she evaluated Residents nutritional status if they refused to be weighed, she stated that she monitored the daily intake tasks documented by the staff CNAs. When asked if she had visually assessed Resident #32 recently, and if she agreed that this resident weighed 141 pounds, she did not respond. In an observation on 10/11/24 at 2:00 PM, Staff A, CNA, stated that Resident #32 refused to be weighed three times today. During an interview with a Staff E, LPN, on 10/14/24 at 10:50 AM, she stated Resident #32 finally agreed to be weighed on Saturday, 10/12/24. When this Surveyor asked for the weight obtained, Staff E stated she cannot remember. When asked if the result was documented in PCC (Point Click Care), she stated she does not know. When this Surveyor checked PCC on 10/14/24 at 2:30 PM, the last documented weight of 141 pounds was on 07/24/24. During an interview with the Facility's Administrator on 10/14/24 at 2:30 PM, the above information was shared.

Based on observation, interview, and record review, it was determined that 1 (Resident #6) of 1 sampled residents for dialysis review failed to receive services that include meals and snacks and professional standards of practice to ensure dialysis communication reports are properly completed for each dialysis session. The findings included: 1) During an interview and observation of Resident #6 on 10/11/25 at 8 AM noted resident awake and in bed. Alert and oriented and stated to be leaving for dialysis at approximately 9:30 AM and will return approximately 3 PM. She sated that she is given a bagged lunch to take to dialysis center on each appointment however the dialysis center will not let her eat or drink during dialysis. She stated this has been going on for many months and has complained to dialysis staff previously without resolution. She does get hungry and thirsty during dialysis sessions but is denied food and fluids. Resident stated that she leaves the facility 3 times per week at 9:30 AM and returns from dialysis at approximately 3 PM. On 10/11/24 the surveyor discussed the issues with Resident #6 with the facility's Dietetic Technician who stated she was not aware of the issues but stated she was aware the bagged lunch and snacks given to the resident to take to dialysis sessions come back with the resident to the facility untouched and uneaten. The surveyor requested the technician to contact the resident's dialysis facility and request the policy for consuming food and beverages during dialysis. On 10/11/24 the technician submitted the facility's policy fro Eating and Drinking Hot Liquids on Dialysis which documented all forms of eating or drinking are discouraged for potential burns, increased chance of choking, and increased chance of spreading communicable disease due to cross contamination. The policy further documented that patients may snack and/or drink in the waiting room before or after their treatment. Further interview with the facility's Technician noted the dialysis staff stated they are not asking patients (including Resident #6) if they are thirsty or hungry and bring them to the waiting room to eat and drink. The facility's technician stated to dialysis staff that Resident #6 requests to consume food and fluids on dialysis days before and after treatment. 2) During the review of the clinical record of Resident #6, it was noted an admitted [DATE] with diagnoses of End Stage Renal Disease and Diabetes Type 2. Current physician orders dated 12/27/23 documented dialysis every Monday, Wednesday, Friday, with a dialysis chair time of 10 AM on each scheduled day. Further review of the clinical record by the surveyor noted the review of the Communication Forms that are required to be completed by the facility prior to leaving for dialysis and completed by the dialysis facility following the dialysis session. A review of the form noted that the dialysis center was not completing the communication form on a regular basis which included required documentation of the following: Pre-Dialysis Weight Post Dialysis Weight Estimated Dry Weight Pre-Dialysis Blood Pressure Post Dialysis Blood Pressure * Given Food/Fluids Condition on Discharge Back to Facility Follow-up Change to Care Type of Dialysis Access Port Condition of Port Medications Given Lab Values * Meal Sent Signature of Staff Completing Form Further review of Resident #6 Dialysis Communication forms from 07/31/24 through 10/07/24 noted that the dialysis facility failure to complete the documents on the following dialysis dates: 10/04/24 - Not completed by dialysis facility 09/30/24 - Not completed by the dialysis facility. 09/27/24 - Not completed by the dialysis facility. 09/18/24 - Not completed by the dialysis facility. 09/06/24 - Not completed by the dialysis facility. 08/28/24 - Not completed by the dialysis facility. 08/19/24 - Not completed by the dialysis facility. 08/16/24 - Not completed by the dialysis facility. 08/14/24 -Not completed by the dialysis facility. 08/02/24 - Not completed by the dialysis facility. 07/31/24 - Not completed by the dialysis facility. On 10/11/24 the surveyor reviewed the issue of failure to document on the dialysis communication form who confirmed the surveyor's findings and discussed the issues with the facility's Director of Nursing.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate is not 5% or greater, as evidence by 2 errors out of 26 opportunities for a medication error rate of 7.69%, which affected 1 of 4 sampled residents (Resident #74) The findings included: An observation of a medication administration was conducted on 10/08/24 at 9:00 AM on Resident #74 with Staff K, a Licensed Practical Nurse. Staff K administered one Zyprexa (antipsychotic) 7.5 milligrams (mg) tablet and two Tylenol 325 mg for a total of 650 mg, along with other ordered medications. A review of Resident #74's orders revealed an order dated 06/23/23 for Tylenol 650 mg give 2 tablets three time a day. Further review of the resident's orders revealed an order dated 10/02/24 for Zyprexa 5 mg for gradual dose reduction (GDR). An interview was conducted with Staff K on 10/08/24 at 10:30 AM. Staff K acknowledged the Zypexa order was changed to 5 mg on 10/02/24. Staff K produced a packet of Zyprexa 5 mg dated 10/02/24. The packet had not been used. Staff K stated the old packet of Zyprexa 7.5 mg should have been returned to pharmacy. Staff K further acknowledged she administered two Tylenol 325 mg tablets (650 mg) instead of two Tylenol 650 mg tablets (1300 mg). An interview was conducted with the Director of Nursing (DON) on 10/11/24 at 10:00 AM. The DON acknowledged the above.

Based on observation, interview, and record review, it was determined that the facility failed to provide special eating equipment and utensils for 6 (Resident #40, #57, #67, #68, #118, and #134) of 9 residents sampled for nutritional review. The findings included: 1) Observation of the lunch meal conducted on 10/07/24 at 12:15 PM noted the meal tray card of Resident #40 to document 2-Handled Cups, Scoop Plate, and Weighted Utensils with meals. Further observation of the lunch meal noted the resident did not receive beverages in 2-handle cups and was served water in a glass cup and coffee in a ceramic regular coffee mug. Interview with the alert resident at the time of the observation noted to state he often does not receive the 2-handled cups and further stated that beverages are easier to drink from the 2-handle cups. Therapy staff indicated to the surveyor during the meal that the resident did not receive the appropriate cups with the meal and that the resident has been assessed to receive the adaptive eating and drinking equipment. Observation of the breakfast meal in the Main Dining Room on 10/08/24 at 8:45 AM, it was again noted that the resident was served milk and coffee in regular cups. Review of the clinical record of Resident #40 noted an re-admitted [DATE] with current diagnoses of Hemiplegia, Hemiparesis, Diabetes Type 2, and Dysphagia. Current physician orders included Patient to receive Scoop Dish, Weighted Utensils, and and 2-Handled Cup with Lid to facilitate increased independence with self feeding and reduce spillage (07/09/24). Review of Occupational Therapy Treatment of service from 06/27/24 - 07/10/24 documented patient with weight loss but can feed self with use of weighted utensils, scoop dish, and 2-handled cups. Review of current care plans dated 10/08/24 documented the problem of Nutritional Risk that included the intervention of Adaptive equipment as ordered: scoop dish, weighted utensils, and 2-handled cup with meals. 2) Observation of the lunch meal in the Main Dining Room on 10/07/24 at 12:15 PM noted the Resident's #57 meal tray card to document Large Grip Utensils, Scoop Plate, and Sipper Cup with the meal. Further observation noted that the resident was not given Large Grip Utensils with the lunch meal. The resident stated to the surveyor that he often is not issued the Utensils or the scoop plate or sipper cup with meals in the dining room or in room with meals. He further stated that the built-up utensils, scoop plate, and sipper cup allow him to eat more easily and independently. Interviews with therapy staff during the lunch meal observation noted that the resident was not issued the Large Grip Utensils with the meal and has been assessed for the use of the utensils. Review of the clinical record of Resident #57 noted an admitted [DATE] with current diagnoses of Diabetes, Protein-Calorie Malnutrition, and Muscle Weakness. Current physician orders included Large Grip Utensils, Scoop Plate, and Sipper Cup with meals. A review of Occupational Therapy notes from the certification period of 03/21/24 - 05/04/24 documented that Resident #57 has arthritis in both hands with decreased gross grasp and unable to close hands. Patient will benefit from adaptive feeding equipment to facilitate improved self feeding independence. Use of 2-handled mug, built-up utensils, and scoop dish to ensure adequate nutrition and hydration. Review of current care plans dated 09/10/24 documented the problem of Risk for Decreased Nutritional and Dehydration Status with the documented intervention of Adaptive Equipment: Large grip Utensils, Sippy Cup, and cup with handles with every meal. 3) During the observation of the lunch meal in the Main Dining Room on 10/07/24 at 12:15 PM, it was noted Resident's #67 meal tray card to document a Mini Coated Spoon and Scoop Plate with the meal. Further observation noted that the Mini Coated Spoon was not served with the meal and the resident received a regular Built-up Spoon with the meal. It was noted the resident was having difficulty biting and eating the foods with the regular spoon. Interviews with therapy staff during the meal observation were noted to state the resident was not given the appropriate mini coated spoon with the meal and has been assessed for the need of the mini coated spoon. Review of the clinical record of Resident #67 on 10/11/24 noted that the resident was readmitted on [DATE] with current of diagnoses of Depressed Mood, Dysphagia, and Aphasia. Current physician orders noted Patient to use mini-coated spoon and scoop plate with meals dated 05/22/23. Review of Occupational Therapy Discharge Summary from service period of 05/2223 - 06/02/22 documented patient requires mini coated spoon and scoop plate for self feeding. Review of current care plans dated 10/02/24 document the problem of Decreased Nutritional and Hydration Status with the intervention including Adaptive Equipment as ordered : Mini Coated Spoon and Scoop Plate. 4) Observation of the lunch meal conducted on 10/07/24 at 12:15 PM noted the meal tray card of Resident #68 to document 2-Handled Cups, Scoop Plate, and Weighted Utensils with meals. Further observation of the lunch meal noted the resident did not receive beverages in 2-handle cups and was served water in a glass cup and coffee in a ceramic regular coffee mug. Interview with the alert resident at the time of the observation noted to state he often does not receive the 2-handled cups and further stated that beverages are easier to drink from the 2-handle cups. Therapy staff indicated to the surveyor during the meal that the resident did not receive the appropriate cups with the meal and that the resident has been assessed to receive the adaptive eating and drinking equipment. During the observation of the breakfast meal in the Main Dining Room on 10/08/24 at 8:45 AM it was again noted that a serving of milk and orange juice were served in a glass drinking cup . Review of the clinical record of Resident #68 noted re-admitted [DATE] with diagnoses of Seizures, Hemiplegia and Hemiparesis. Current physician orders noted 2-Handle Cups and Scoop Plate with Meals. Review of Occupational Therapy Treatment from service period of 09/22/24 - 11/07/22 documented the addition of adaptive equipment including scoop dish, and large grip utensils to minimize spillage. Review of current care plans dated 7/24/24 documented the problem of Decreased Nutrition and Hydration Status with the intervention of Adaptive Equipment as ordered: 2-handled cup and scoop plate. 5) Review of the clinical record of Resident #118 noted an admitted [DATE] with diagnoses of Anemia, Seizures, and Dysphagia. Current physician orders included Soft and Bite Sized Diet with Mildly Thickened Liquids (08/21/24) , and Patient to use Scoop Plate, Large Grip Utensils, and 2-Handled Cup/Low Flow Restricted Cup with all meals. During the review of Occupational Treatment Encounter for the service period of 05/06/24 - 08/19/24 noted documentation of need for self feeding with lidded cup with 2-handles, large grip utensils, and scoop dish to increase independence with self-feeding and decreased spillage. Review of current care plans dated 09/24/24 documented the problem of Decreased Nutritional Status and Hydration with the documented intervention of Adaptive Equipment as ordered: 2-handled cup, built-up utensils and scoop plate. 6) Observation of the lunch meal conducted on 10/07/24 at 12:15 PM noted the meal tray card of Resident #134 to document 2-Handled Cups, Scoop Plate, and Weighted Utensils with meals. Further observation of the lunch meal noted the resident did not receive beverages in 2-handle cups and was served milk and juice a glass cup. Interview with the alert resident at the time of the observation noted to state he often does not receive the 2-handled cups and further stated that beverages are easier to drink from the 2-handle cups. Therapy staff indicated to the surveyor during the meal that the resident did not receive the appropriate cups with the meal and that the resident has been assessed to receive the adaptive eating and drinking equipment. During the observation of the breakfast meal in the Main Dining Room on 10/08/24 at 8:45 AM it was again noted that a serving of milk and orange juice were served in a glass drinking cup . Review of the clinical record of Resident #134 noted a re-admitted [DATE] with current diagnoses of Gastro Hemorrhage, Respiratory Failure, Diabetes, and Protein-Calorie Malnutrition . Current physician orders noted Patient to use 2-Handled Cup, Scoop Plate, and Weighted Utensils with all meals (09/04/24). Review of current care plans dated 10/08/24 documented the problem of Decreased Nutritional Status with the documented intervention of Adaptive Equipment as ordered; 2-handled cup, scoop plate and weighted utensils.

Based on observation and interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, clean and comfortable environment. The findings included: In room [ROOM NUMBER], the privacy curtain between the beds was stained. In room [ROOM NUMBER], there was an accumulation of trash on the floor next to the Door Bed (A) on multiple occasions, the wall by the restroom was damaged and the over bed table for the Door Bed (A) was beginning to swell. In room [ROOM NUMBER], the privacy curtain between the beds was stained and there was an accumulation of dust in the vents of the air conditioning unit. In room [ROOM NUMBER], the wall by the restroom was damaged, the privacy curtain between the beds was stained, there was an accumulation of trash on the floor, there was an accumulation of unidentifiable brown matter on the grab bar in the restroom. In room [ROOM NUMBER], there was an accumulation of trash on the floor and the floor under the window bed (B) was damaged. In room [ROOM NUMBER], the wall paper around the commode in the restroom was peeling from the wall and the wall at the head of the bed was damaged. In the TV Room on the 200 unit, a portion of the wall under the call light was damaged. The entry door to the Electrical Room on the 200 unit was damaged. The wallpaper by room [ROOM NUMBER] and around the drinking fountain was peeling from the wall. The hand rail by the entrance to the TV Room was damaged in a manner that residents could sustain skin tears when using to assist with mobility. The rubber baseboard and the wall by room [ROOM NUMBER] was damaged. During an Environmental tour of the facility, accompanied by the Director of Maintenance, on 08/10/23 at 10:26 AM, the Director of Maintenance acknowledged the concerns.

Based on observations, interviews, and record review, the facility failed to properly secure medications at the bedside for 3 out of 28 sampled residents (Residents #114, #62, and #120) The findings included: Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals with a revised date of 08/07/23 included under General Storage Procedures: Store all drugs and biologicals in locked compartments, including the storage of Schedule II-VI medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible to residents and visitors. Bedside Medication Storage: Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. Facility should store bedside medications or biologicals in a locked compartment within the resident's room. Review of the facility's policy titled, Self-Administration of Medication with a reviewed date of 04/25/17 included: to respect the wishes of competent residents to self-administer prescribed medications, as allowed by state regulations. To provide an assessment and evaluation process to determine if a resident is capable of self-administration. To provide instructions for those capable of self-administration. To maintain the safety and accuracy of medication administration. If a resident desires to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate, by completing a self-determination of medication assessment. The nurse will interview the resident to determine their ability to identify, prepare, and administer medications. Based on the interdisciplinary team's assessment, a decision is made as to whether or not the resident is a candidate for self-administration. This will be recorded on the self-administration of medication assessment. The nurse will obtain a physician's order for each resident conducting self-administration of medications. Document the self-administration of medication on the resident's comprehensive plan of care. 1. Record review for Resident #114 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy, Type 2 Diabetes Mellitus and Major Depressive Disorder. Review of the Minimum Data Set (MDS) for Resident #114 dated 06/25/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Review of the physician orders for Resident #114 revealed no order for ultra lubricant eye drops, triple antibiotic ointment, 12hour decongestant nasal spray, or ibuprofen. There also was no order for the resident to self-administer medications. During an observation conducted on 08/07/23 at 10:50 AM in Resident #114's room, medications were observed on an overbed table between an empty bed with no linens and the resident's bed. This included ultra lubricant eye drops, 2 tubes of triple antibiotic ointment, and 12hour decongestant nasal spray (Photographic Evidence Obtained). There also was a bottle of ibuprofen in an open bag on the empty bed in Resident #114's room. It was discovered on 08/08/23 that the medications located in Resident #114's room belonged to his roommate. During an interview conducted on 08/07/23 at 10:54 AM with Resident #114 who was asked about the medications at the bedside, he said I don't know. When asked if he uses the eye drops and puts them in his eyes by himself or does the nurse do it, he stated I don't know. When asked about the nasal spray, he stated I don't know. When asked if he uses the triple antibiotic ointment, he said I don't know. 2. Record review for Resident #62 revealed the resident was originally admitted to the facility on [DATE], was sent out to the hospital on 07/31/23 and was readmitted to the facility on [DATE] at 10:40 PM. The resident's diagnoses included: Cataract Bilateral (Both Eyes), and Legal Blindness, Acute Respiratory Failure with Hypoxia, and Anxiety Disorder. Review of the Minimum Data Set (MDS) for Resident #62 dated 07/14/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 14 indicating a cognitive response. Review of the Physician's orders for Resident #62 only revealed 1 order for medication that included it may be self-administrated and it was dated 06/18/23 for Propylene Glycol-Glycerin Ophthalmic Solution 1-0.3 % (Propylene Glycol-Glycerin) Instill 1 drop in both eyes every 8 hours for Dry eye syndrome may be self-administered. Review of the Self-Administration of Medication Evaluation for Resident #62 dated 05/21/22 included: Under Section A Resident Request documented that the resident has requested to self-administer the following medications: Artificial Tears. Under Section D IDT member's determination of a self-administration medication program for this resident: Approved (obtained physician's order). Review of the Care Plan for Resident #62 dated 07/06/18 with a focus on the resident impaired visual function. The goal was for the resident to have no indications of acute eye problems through the review date (10/23/23). The interventions included: MD orders for eye gtts (drops)at bedside. Resident to use himself. Date Initiated: 03/20/2023, observe/document/report to MD the following signs of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray. On 08/08/23 at 9:05 AM, an observation was made of Resident # 62 sitting up in bed. Upon a closer observation the resident had ultra lubricant eye drops, and 2 tubes of triple antibiotic ointment located on his overbed table next to the bed. There also was a 12hour decongestant nasal spray located on a container next to his bed. During an interview conducted on 08/08/23 at 9:07 AM with Resident #62 who was asked about the medications at the bedside, he stated they are all over the counter medications and he uses the triple antibiotic ointment for a rash, and he uses eye drops for dry eyes, and he needs the nasal spray, or he has to wear his bi-pap machine to sleep. During an interview conducted on 08/08/23 at 9:19 AM with Staff B Licensed Practical Nurse (LPN) who was asked about the medications at the bedside for Resident # 62, she stated he just came back from the hospital this morning. When she was informed that the medications were in plain sight on the overbed table yesterday and believed to be the roommate's personal property, she said the room should have been cleaned. When asked if he is supposed to have medications at the bedside, she said no. She went to inform the Resident Care Specialist. During an interview conducted on 08/08/23 at 9:25 AM with the Resident Care Specialist who was asked if Resident # 62 can have medications at the bedside, he said absolutely not. 3. Record review for Resident #120 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on 07/27/22. The diagnoses included: Encephalopathy, Type 2 Diabetes Mellitus, Anxiety Disorder, Obesity, Dysphagia, and Major Depressive Disorder. Review of the Minimum Data Set (MDS) for Resident #120 with a date of 06/12/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. On 08/08/23 at 8:42 AM, an observation was made of Resident #120 sitting up in bed with the overbed table in front of her. Upon closer observation, there was a medication cup containing several medications sitting on the overbed table. During an interview conducted on 08/08/23 at 8:42 AM with Resident #120 when asked about the medication cup with several medications she stated the nurse had just brought them in. During an interview conducted on 08/08/23 at 8:48 with Staff A, Registered Nurse (RN) who had entered the room for Resident #120 and was asked about the medication cup with several medications sitting on the resident's overbed table, she stated she brought the medications in the room for the resident and had been called away and left the medications to return and make sure the resident took the medications. When asked if she is supposed to leave the medications at the bedside unattended, she said no.

Based on record review, interview, and policy review, the facility failed to report a credible allegation of abuse for 2 of 3 sampled residents no later than 2 hours after the allegation by Resident #7, and no later than 2 hours after a known resident to resident altercation between Residents #4 and #5. The facility also failed to report the results of the investigation of the allegation of abuse by Resident #7 to the State Survey Agency within 5 working days of the allegation. The findings included: Review of the policy Abuse & Neglect Prohibition dated 05/23/17 documented, Investigation: 2. The facility will report such allegations to the state, as per state/federal regulation. The Facility will report immediately but no later than 2 hours after forming the suspicion if the events that cause the allegation involve abuse or result in serious bodily injury. 3. The facility will report reportable investigation findings in accordance with State law, including to the state survey agency within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action will be taken. 1) Review of the Nursing Home Federal Reporting Five Day Report, revealed the Social Services Director (SSD) became aware of an allegation of abuse by Staff A, Certified Nursing Assistant (CNA), toward Resident #7, on 05/03/23 at 8:30 AM. This report documented the date and time of the incident as 05/03/23 at 1:00 PM. The narrative of this report documented the event took place on 05/02/23 at approximately 10:30 PM, with facility knowledge the following morning. The report was submitted by the SSD. Review of the Status Log corresponding to this report documented the SSD submitted the Immediate Report on 05/03/23 at 2:56 PM, more than 6 hours after becoming aware of the allegation. Further review of the Status Log documented the SSD submitted the Five Day report on 05/12/23 at 11:01 AM, seven working days after the allegation. During an interview on 06/01/23 at 5:35 PM, the SSD agreed with the incorrectly documented date and time of the incident as compared to the narrative. When asked about the failure to submit the allegation of abuse to the State Agency within 2 hours, the SSD stated she thought that meant to call the Abuse Hotline (Department of Children and Families/DCF) within two hours. The SSD also acknowledged the failure to submit the Five Day report within the mandated timeframe. 2) Review of the Nursing Home Federal Reporting Five Day Report, documented a resident to resident altercation, involving Residents #4 and #5 physically hitting on another on 04/15/23 at 1:25 PM. This report was completed by the Social Services Director (SSD). Review of the corresponding Status Log revealed the Immediate Report was submitted on 04/15/23 at 10:29 PM, nine hours after the resident to resident abuse. During an interview on 06/01/23 at 5:07 PM, the SSD confirmed she had completed and submitted the Immediate report at the above mentioned time.

Based on observation, interview, and record review, the facility failed to ensure a thorough investigation for 2 of 3 abuse allegations, involving Residents #4, #5, and #7. The findings included: 1) Review of the Nursing Home Federal Reporting Five Day Report documented a resident to resident abuse altercation between Resident #4 and #5, on 05/14/23 at 1:25 PM, under the gazebo in the courtyard. This area was the designated smoking area for the facility, but the incident happened at a non-designated smoking time, when no staff were outside to witness the altercation. As per the report, Resident #4 reported to the Social Services Director (SSD) that he had called a female Resident #6 a name, and Resident #5 got up out of his wheelchair and hit him in the mouth causing a small cut, and causing him to fall backwards in his wheelchair. The report documented, other residents and family members came into the building to get staff for assistance. This report and subsequent investigation lacked any evidence of an interview with Resident #5, the alleged attacker, Resident #6, the female victim of verbal abuse, or any other witness, except the Activity Director, who was the first staff member summoned to the incident, or staff who care for each resident. During an interview on 06/01/23 at 10:20 AM, when asked about and altercation with Resident #4 on 04/15/23 under the gazebo in the courtyard, Resident #5 stated Resident #4 was calling Resident #6, a female friend of his, a name, and I told him that wasn't appropriate. I thought (name of Resident #4) was going to hit her, so I rolled forward to put myself between them and (name of Resident #4) slugged me (pointing to his right jaw). Resident #5 explained he ended up with a bruise. Resident #5 volunteered during the interview that Resident #12 was also there, under the gazebo with them during the incident. Resident #5 denied hitting Resident #4, and stated he even tried to help Resident #4 up off the ground, after he had lost his balance and fell , but he couldn't as the resident kept hitting at him. During an interview on 06/01/23 at 10:37 AM, Resident #12 was asked if she observed the altercation out in the courtyard on 04/15/23. Resident #12 confirmed she had been there and explained that Resident #4 was verbally abusive toward the female Resident #6, started to get up and go toward her, so Resident #5 told Resident #4 to stay away from her. Resident #12 stated Resident #4 stood up and slugged Resident #5 in the face. Resident #12 stated Resident #5 did not hit back. Resident #12 explained that Resident #4 ended up falling to the ground, stating it was wet outside and she thought he had slipped, and Resident #5 tried to assist him back up, but Resident #4 kept swinging at him. Resident #12 stated, All the upper people (referring to management) got upset with (name of Resident #5), but it wasn't him. When asked if any of the staff asked her what happened, Resident #12 stated they had not, but she wished they had so she could tell them what really happened. Review of the record revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 13, on a scale of 0 to 15, indicating she was cognitively intact, as per the annual Minimum Data Set (MDS) assessment dated [DATE]. During an interview on 06/01/23 at 10:51 AM, Resident #6, the female victim of verbal abuse, stated Resident #4 was calling me a name, stood up and looked like he was going to hit me. (Name of Resident #5) got between the two of us and (name of Resident #4) punched him. Resident #6 explained that after Resident #4 threw the punch, he fell backward. Resident #6 stated Resident #5 even tried to help Resident #4 get back up. During an interview on 06/01/23 at 2:53 PM, Staff B, Licensed Practical Nurse (LPN), stated she was not working the day of the incident, but she is the regular nurse for Resident #5. The LPN stated Resident #5 has a female friend (Resident #6), and that Resident #5 had told her Resident #4 was calling the female resident names and asked for a cigarette, and Resident #5 was trying to defend her. She did not know who hit who, but stated Resident #4 is very aggressive and started punching at her one day when he wanted cigarettes. When asked about the temperament of Resident #5, the LPN stated he does get vocal and aggressive, especially if he gets alcohol, explaining that there had been instances of someone sneaking alcohol into the facility for him to consume. During an interview on 06/01/23 at 3:02 PM, Staff D, Certified Nursing Assistant (CNA), stated she did not see the incident, but the next day she noted Resident #5 had a bruise to his right jaw. The CNA stated Resident #5 told her that Resident #4 was calling his friend Resident #6 a name, and that was why Resident #4 hit him. During an interview on 06/01/23 at 3:06 PM, Staff C, CNA, stated she did not see the incident, but after the event Resident #5 said that Resident #4 hit him. During an interview on 06/01/23 at 3:48 PM, when asked what happened on 04/15/23 out in the courtyard, the Activity Director explained she was in the dining room finishing up the lunch service, when she was summoned to the courtyard. Upon arrival she saw Resident #4 swinging and fall, then saw Resident #5 swinging. The Activity Director confirmed she saw both residents swinging at each other and fighting. The Activity Director stated she then went to get the nurses of both residents and the weekend supervisor. When asked if there were any other residents under the gazebo at the time of the event, the Activity Director stated Resident #6 (the victim of the verbal abuse), Resident #12, and another resident who was currently in the hospital. When asked if Resident #12 was a credible witness, the Activity Director stated she was. When asked about the other resident who was currently in the hospital, the Activity Director stated she would not remember the event now, but at the time she could have been interviewed. When asked if she was involved in any other way, the Activity Director explained she was present when three police interviewed Residents #4 and #5, separately. Resident #4 informed the police that Resident #5 swung at him and then he swung back. Resident #5 denied the incident to the police at first, then stated Resident #4 hit him, but he did not hit back. The Activity Director stated she and the police then went to the SSD and explained what each resident had said. Further review of the written statement from the Activity Director and the investigation lacked the interviews by the police. Further review of the investigation revealed the witness statement from the Activity Director documented she was called from the main dining room by a family member, the two residents were fighting, and she went to get the nurse and supervisor. The only other written statement was by the SSD, that documented she had spoken to multiple residents that stated they were on the patio, and heard yelling, but did not see any physical contact. Review of a progress note in the clinical record of Resident #5, dated 04/15/23 and written by a direct care nurse documented, Resident had altercation - resident to resident altercation. No observation of altercation between the two residents were noted by staff and only reported. Head to toe assessment were provided to resident. Resident denied any pain or discomfort from the punches thrown from fell ow resident. One and one care and continuous supervision initiated immediately every shift. The clinical record of Resident #4 lacked any documentation of the altercation. During an interview on 06/01/23 at 5:07 PM, the SSD confirmed she was the staff member who completed this resident to resident abuse investigation. The SSD confirmed she had written that she spoke with multiple residents who did not see any physical contact. When asked if she interviewed the three involved residents and had any documented evidence of this, the SSD stated she talked with them all just after the event, as she was called into the facility. The SSD stated the documentation in the report was her interviews. When asked if there were any other residents in the gazebo at the time of the event, she mentioned the resident who was currently in the hospital and one other. When asked if she interviewed either of them she stated she had not. When asked if she interviewed Resident #12, who was identified by Resident #5 and the Activity Director as having been in the gazebo at the time of the incident, the SSD stated she had not. The SSD confirmed both residents were interviewed by the police, who told her they had smelled alcohol on the breath of Resident #5. When asked if she obtained the report from the police and or had documented what they had reported, the SSD stated she had not. 2) Review of the Nursing Home Federal Reporting Five Day Report documented an allegation of abuse by Staff A, Certified Nursing Assistance (CNA) toward Resident #7. This report documented the incident as 05/03/23 at 1:00 PM, but the narrative documented the event took place on 05/02/23 at about 10:30 PM, and the Social Services Director (SSD) was made aware of the incident by her assistant on 05/03/23 at 8:30 AM. Review of the report and the investigation lacked interviews with any other CNA's who worked with the alleged perpetrator. This investigation also documented on an Event/Interview Statement that was not signed nor dated, Writer spoke with other residents able to participate with interviews and had care provided to them by (name of Staff A). All residents denied any problem with the CNA. All residents had good things to say about CNA. During an interview on 06/01/23 at 5:35 PM, the SSD confirmed she had completed this investigation and that she had written the note about the other resident interviews. The SSD confirmed she did not document the specific residents who were interviewed. The SSD confirmed the information provided was the entire investigation.

Based on interview, observation and record review, the facility failed to use proper hand hygiene during incontinent care for 1 of 1 resident observe for incontinent care, Resident #2. The findings included: The facility policy titled Hand Washing/ Hygiene, revised 06/05/19, under the section titled Policy states: This facility considers hand hygiene the primary means to prevent the spread of infections and provides guidance to perform hand hygiene. This policy is in accordance with the national standards from the Centers of Disease Control and Prevention and the World Health Organization. Under the Procedure section there is a numbered subsection, number 3, that states The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed:. An alphabetic list follows with the letters a through p. Letter e indicates hand hygiene should be performed before and after assisting a resident with personal care;, letter j states before and after assisting a resident with toileting, and letter o states after removing gloves or aprons; The Monthly Line Listing Report for July 2022 revealed that the facility had 8 residents with facility acquired urinary Tract Infections (UTIs). Compared to the previous month, June 2022, this was increase of 7 residents. On 08/18/22 at 11:23 AM, an observation of incontinence care was made of Resident #2. The care was performed by two CNAs, Staff A and Staff B. Staff A and Staff B washed hands and donned gloves. Staff B drew the privacy curtains. Staff A raised the bed and prepared a new brief and a trash bag. Per Nursing Standards of Care, because of touching other surfaces, the gloves for both staff members were considered dirty. As Staff A did not change her gloves before touching the new brief, the new brief was contaminated by the dirty gloves. Staff A proceeded to remove the dirty brief from Resident #2. Staff A then used cleansing wipes to clean the resident without changing gloves and performing hand hygiene, which contaminated the wipes and raised the potential to transfer infectious agents to the resident. After providing the necessary perineal care Staff A removed her gloves and put on clean gloves without using proper hand hygiene, which was against the facility's policy. Staff A then rolled Resident #2 onto the resident's right side. Staff B then proceeded to clean the resident's backside without changing gloves and using proper hand hygiene. Staff B then placed the new brief under the resident who was then rolled toward Staff A. Staff A then finished applying the brief on Resident #2. Staff A and Staff B placed Resident #2 in comfortable position and returned bed to lowest position. Immediately after the observation, at 12:00 PM, a meeting was held with the DON and Infection Preventionist to review the observations regarding the hand hygiene mistakes made by Staff A and Staff B. The DON and Infection Preventionist agreed that the hand hygiene errors observed could lead to UTIs and that Staff A and Staff B did not follow facility policy.

Based on observation, interview, and record review, the facility failed to adequately identify a cognitively impaired resident as an elopement risk, and failed to supervise a resident with wandering behaviors to prevent elopement for 1 of 3 sampled residents (Resident #1), who was able to exit the facility through the front doors and walk a half mile to another skilled nursing facility, along a busy roadway. The findings included: In the facility's policy on Resident Elopement, dated 07/29/2017, definition includes: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Procedure includes: Every resident upon admission will have an initial assessment conducted. Residents identified at risk should have interventions in their comprehensive plan of care to address the potential for elopement. Resident #1 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], Dementia, Depression, [CONDITION(S)], and Cognitive Communication Deficit. An Admission Elopement Risk Screen dated 04/08/21 documented Resident #1 was not independently mobile (with or without a device) = score 0; and the resident was not alert and oriented x (times) 3 without confusion, altered thought processes or cognitive impairment, score = 1. The resident had a score of 1 out of a possible 2. A score of 0-1 = No risk of elopement; and a score of 2 = Elopement Risk. The resident is independently mobile, and this answer should of been marked as Yes (1), and then her total score would of been 2, indicating she was an Elopement Risk. Record review revealed a comprehensive assessment dated [DATE] that documented the resident had mild cognitive impairment, required limited assistance with bed mobility and transfers, and supervision only for locomotion. The assessment further documented the resident used a walker to ambulate. Resident #1 was care planned on 04/09/21 for impaired cognitive function/impaired thought process. Resident #1 was not care planned for being at risk for elopement. A review of the facility's log revealed an entry for Resident #1 for elopement on 04/20/21. On 04/20/21 Resident #1 exited the building though the front door at 3:09 PM (per photographic evidence provided by the facility). The resident walked south then east for approximately one-half mile, and was found one hour and twenty minutes later (4:30 PM), in the parking lot of another nursing facility by their personnel, who then called this facility to notify them of the missing resident. An interview was conducted with Resident #1's family member on 04/27/21 at 11:30 AM. The family member stated she was called on 04/20/21 at approximately 5:00 PM, and was told by someone at the facility that they lost Resident #1. The family member stated she was later called and told that the resident was found at another facility up the street. They stated the resident kept trying to leave the facility, so they had placed a wanderguard (alarm device) on the resident and placed the resident on 1:1 supervision. The family member stated Resident #1 was discharged from the facility on 04/21/21 to a secure facility. Resident #1's family member also stated she had been to visit the resident the Thursday(04/15/21) before the incident. The family member stated the resident attempted to follow her out of the facility when the receptionist who was on the phone, buzzed the door for her to exit the facility. The family member stated she escorted Resident #1 back to her room, and spoke to the receptionist at the door about the resident trying to follow her out of the facility. Resident #1's family member stated the receptionist told her she would inform her nurse. An interview was conducted with Staff D, the front desk receptionist, on 04/27/21 at 1:00 PM. Staff D stated she worked at the front desk lobby 7:00 AM-3:30 PM Monday-Friday. Staff D stated part of her duties entailed opening the front door for visitors/staff to enter the facility and leave the facility. Staff D stated the front door remains locked, and to unlock it, she presses a button behind her desk. Staff D was questioned by surveyor if she knew what an elopement was. Staff D stated she did not know what an elopement was, and further stated she had not had any training on elopements. Staff D was questioned by surveyor how she knows who is not supposed to go out of the facility. Staff D answered if she did not see someone come in, she stops and question them before unlocking the door for them to exit. Staff D further stated the door will alarm after 15 seconds if still opened/unlocked. Surveyor questioned Staff D if anything else would make the door alarm. Staff D stated if a resident has a wanderguard on (an alarm device), the door will alarm and she could not unlock the door without putting in a code. Staff D further stated she believed all residents had wanderguard devices on. Staff D stated she worked on 04/20/21. Staff D further stated she had unlocked the front door, and Resident #1 had exited the facility behind another person. Staff D stated she did not know Resident #1 was a resident at the facility. Staff D stated Resident #1 did not look like a resident. Staff D stated Resident #1 was dressed in regular clothes, and had been sitting in the lobby on a bench. Staff D stated she was busy that day, and the lobby was crowded. Staff D further stated Resident #1 did not have on a wanderguard, because the door would have alarmed. Staff D stated she received a phone call from another facility that said Resident #1 was at their facility between 4:00 PM and 5:00 PM. Staff D stated she handed the phone call to the business office manager. Staff D stated Resident #1 was brought back to the facility by the business office manager, the evening supervisor, and the director of nursing. An interview was conducted with the business office manager (BOM) on 04/27/21 at 2:00 PM. The BOM stated a code NASA (alert for a missing resident) was called overhead around 4:30 PM, on 4/20/21, the day the resident eloped. They were searching the premises when the Staff D informed her that another facility called and said they had Resident #1 at their facility. The BOM stated the administrator from the other facility stated they found Resident #1 wandering in front of their facility. The BOM stated she did not know how they knew the resident was from this facility. The BOM stated the evening supervisor, director of nursing, and herself went to pick up Resident #1. The BOM stated Resident #1 was outside with the administrator and the police. A telephone interview was conducted on 04/27/21 at 3:05 PM with the administrator of the facility where Resident #1 was found. The administrator stated Resident #1 was found wandering around in the parking lot of the facility on 04/20/21 at 4:30 PM. The administrator stated when she approached Resident #1, the resident was sweaty. The administrator stated the resident gave her an out of state address, and she realized the resident had dementia. The administrator stated they called the police and started calling other surrounding nursing facilities to see if anyone had a missing resident. The administrator stated Resident #1's place of residence was called on 04/20/21 at 4:40 PM. The facility staff came and picked up the resident. An interview was conducted with Staff A, a certified nursing assistant, on 04/27/21 at 3:30 PM. Staff A stated she worked the evening shift, 3:00 PM-11:00 PM on 04/20/21. Staff A stated Resident #1 had left the facility prior to her coming on shift that day. The resident came back to the facility around 5:00 PM-6:00 PM. Staff A stated Resident #1 was known to her. Resident #1 was disoriented, and independent with care. Staff A stated Resident #1 was known to walk around the facility, and also would pack up her belongings to leave the facility. Staff A could not recall if Resident #1 had a wanderguard device in place. An interview was conducted with Staff B, a Registered Nurse, on 04/27/21 at 3:35 PM. Staff B worked 04/20/21 on the day shift, 7:00 AM-3:00 PM. Staff B stated she had last seen Resident #1 on 04/20/21 at 2:45 PM talking to therapy. Staff B stated she was giving report to the on-coming shift at 3:30 PM, and Resident #1 was not seen. Staff B stated they looked for the resident and at 4:30 PM called a code NASA (missing resident alert). Staff B stated she thought Resident #1 had a wanderguard device. An interview was conducted with Staff H, the Rehabilitation Director, on 04/20/21 at 3:40 PM. Staff H stated that physical therapy, occupational therapy, and speech therapy all evaluated Resident #1 on the morning of 04/09/2021, the day after admission. It was determined that this resident did not need any assistive devices for ambulation and should only have supervision to minimum assistance which may include light touch for support. Resident #1 was also given the St. Louis University Mental Status Examination by Speech Therapy, which resulted in a score of 5 out of a possible 30 points, which indicated marked cognitive defects. The lowest possible score is 0. Staff H further stated the exam was given again after seven days to check for improvement and her score was 7 out of 30. An interview was conducted with the director of nursing (DON) on 04/27/21 at 5:00 PM. The DON stated she was on Resident #1's unit at change of shift on 04/20/21. The DON stated they started looking for Resident #1 at 3:30 PM. The DON stated a code NASA was called around 4:15 PM-4:40 PM. The DON stated they had photographic evidence of Resident #1 leaving through the front door, tailgating another employee on 04/20/21 at 3:09 PM. The DON stated the resident blended in well. The door had to be opened by the receptionist, who did not see the resident. There were benches in the lobby, but they have since been removed to prevent congregation in the lobby. Resident #1 was back to facility at 5:15 PM on 04/20/21. The DON, along with regional consultants, stated the need for re-evaluating the need for a wanderguard device, as well as the delay in time for the code NASA were identified concerns. While some persons reported Resident #1 had a wanderguard bracelet on prior to the elopement, no one could confirm this and there were no orders for the wanderguard, to check its placement, or check its function prior to the elopement, only afterwards when she returned to the facility on [DATE]. A review of Resident #1's progress notes revealed a note dated 04/20/21 at 5:50 PM that documented, obtained an order for a wanderguard, wanderguard placed, physician notified, and family notified. On 04/28/21 at 3:30 PM, the surveyor walked the route taken by Resident #1 when the resident eloped (left the facility) on 04/20/21. The facility is located on a five-lane road with a speed limit of 40 mph close to a major intersection with another five-lane road, also with a speed limit of 40 mph. At some point, the resident did cross one of the roads as the facility where she was found was on the other side. Along this road were many wooded areas, a vacant lot with debris and vegetation spilling onto the sidewalk and significant vehicle traffic, which usually travels faster than the posted speed limit. On the opposite side of the road was another residential road that led directly to a larger thoroughfare with faster traffic and increased danger. The resident may have fallen, been struck by a car, or got lost in any of the wooded areas. **The facility's Immediate Jeopardy (IJ) Removal Plan contained the following immediacy removal actions: 1. Upon return to the facility, the resident was assessed, 1:1 supervision initiated, and a wanderguard alerting bracelet was applied. The resident was discharged on [DATE] as originally planned. 2. Immediate re-education started on day of incident, 04/20/21. a. The front desk receptionist was re-education regarding monitoring of staff, residents, and visitors upon entering and exiting the center. The center will ensure staff and visitors can be identified via a name badge. Anyone without a badge will be verified prior to exiting the center. b. Staff are educated on the elopement process to initiate the missing person process immediately upon identifying a missing resident, with emphasis on announcing the missing person code (Code NASA) immediately. c. Licensed staff were re-educated on the Elopement Risk Screen, with emphasis on answering the screening evaluation and identifying the resident at risk for elopement to include the process for application of the alerting bracelet. A competency worksheet was utlized in conjunction with the Elopement Risk Assessment Process. d. Elopement drills were conducted on all shifts (3x daily) for 7 days, 4/21/21 - 4/27/21. 3. Current residents have been re-evaluated for risk of elopement, as well as care plans and wanderguards. 4. Elopement risk binders reviewed for accuracy and placed at front desk, each nursing station, and therapy department. 5. Ad Hoc QAPI meetings with all department managers was held on 04/20/21, 04/21/21, 04/23/21, 04/26/21, and 4/27/21 to discuss missing residents/incident & accidents. There are a total of 170 employees, with 109 in the nursing department, and 61 in other departments. All attended the education and drills, except for employees who were out on extended leave. Multiple staff members in all departments, on different shifts, were interviewed on April 28 and 29, and all had participated in a drill, and were able to correctly state what to do during an elopement.