Every finding on record at Bradford House Nursing and Rehab, LLC

Number of residents sampled: Number of residents cited: Based on record review and interview, the facility failed to identify and assess two (Resident #72 and Resident #78) of three residents' change in condition resulting in their death. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to, Appendix PP, CFR 483.35 at a scope and severity of J. The IJ began on [DATE] at 5:30 PM after reviewing Resident #72's Progress Notes, Neuro Assessments, Minimum Data Sheet (MDS) Assessments, Comprehensive Care Plan with interventions, Medication Administration Record (MAR), and interviews; and Resident 78's Progress Notes, MDS assessments, Comprehensive Care Plan with interventions, MAR, and interviews. The Administrator was notified of the IJ on [DATE] at 11:30 AM. A Plan of Removal was requested and accepted by the State Survey Agency on [DATE] at 4:12 PM. The IJ was removed on [DATE] at 2:58 PM after the survey team performed onsite verification that the Removal Plan had been implemented. The findings include: Resident #72 Review of an admission Record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2, Parkinson's disease, epilepsy, hypertension, occlusion and [blockage and narrowing of both carotid arteries, [plaque buildup in the aorta], repeated falls, dementia, and a cognitive communication deficit. Review of a signification change MDS, with an Assessment Reference Date (ARD) of [DATE], revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident had severe cognitive impairment. The MDS revealed Resident #72 was dependent for oral hygiene, shower/bathing/lower body dressing, putting on footwear, personal hygiene; required substantial/maximal assistance for toileting, upper dressing, and transfers. The MDS also revealed Resident #72 had active diagnoses that included atrial fibrillation (Afib), coronary artery disease (CAD), hypertension (HTN), diabetes mellitus (DM), non-Alzheimer's Dementia, depression, anxiety, Parkinson's disease and used a wheelchair for mobility. The MDS revealed Resident #72's medications included an antidepressant, an antianxiety, an opioid, and anticonvulsant, and Resident #72's health conditions indicated the resident had two or more falls since the prior assessment. Review of Resident #72's Care Plan Report with a last reviewed date of [DATE], revealed the resident had a code status of do not resuscitate (DNR) indicating that if the resident's heart stops or the resident stops breathing, cardiopulmonary resuscitation (CPR) would not be initiated. The Care Plan indicated the resident had a self-care performance deficit related to debility; had limited physical mobility related to weakness and required moderate assistance of one person to walk with a walker and a gait belt and used a manual wheelchair. Resident had CAD with interventions to monitor BP, signs and symptoms of CAD, nausea and vomiting, and excessive sweating. The Care Plan Report also indicated Resident #72 had a communication problem related to receptive aphasia and slurring. Interventions included to allow time to respond, ensure safe environment, put call light in reach, ensure the bed was in low position with wheels locked, monitor physical and non-verbal indicators of discomfort/distress, monitor and report changes in ability to communicate. The Care Plan Report indicated Resident #72 had hypertension (HTN). Interventions included monitor and document BP, monitor document and report headache, confusion, disorientation, lethargy, nausea and vomiting. Resident had delirium or acute confessional episode related to change in condition (COC). Interventions included to observe and report concerns of delirium and indicated symptoms that increase safety risk are confusion and falls. Interventions included report signs and symptoms of delirium, changes in behavior, altered mental status, communication decline, lethargy. The Care Plan Report also indicated Resident #72 had a risk for falls related to gait/balance problems. Interventions included call light in reach, paddled call light, concave mattress, bed/chair alarm, low bed, hourly toileting, bolsters to mattress, fall mat, bed alarm, bed alarm power box out of resident's reach. Resident had a terminal prognosis related to dementia. Interventions included comfort care, no transfer out to hospital or routine labs. Review of an Order Summary Report revealed that Resident #72 had the following orders:-DNR on file dated [DATE].-Admit to comfort care, DNR, do not transport [to hospital], no routine labs dated [DATE].-May send to emergency room (ER) for evaluation [DATE].-An antiemetic 4 milligram to be given as needed for nausea and vomiting, dissolve tablet on top of tongue then swallow with saliva dated [DATE]. Review of a MAR dated [DATE]-[DATE] revealed Resident #72 was administered an antiemetic 4mg on [DATE] at 10:01 PM. Review of Progress Note dated [DATE] at 11:03 PM indicated the [antiemetic] medication was effective. Review of a facility document titled, Nsg (Nursing) Neurological Assessment, dated [DATE] at 9:15 PM, indicated and initial assessment, 15-minute assessments x 4, 30-minute assessments x 4 and hourly assessments. The initial assessment indicated a temperature of 99 (no route indicated), pulse 78 (type not indicted), respirations 14, blood pressure (B/P) of 122/61 in the lying position, orientation to person and situation, level of consciousness was alert, pupils equal and reactive to light (no pupil size documented), responded to commands, had no pain, was able to move all extremities, and was signed by Licensed Practical Nurse (LPN) #24. The first 15-minute assessment dated [DATE] at 9:30 PM indicated a temperature of 99.3 (no route indicated), pulse 74 (no type indicated), B/P 120/60 lying, orientation to person only (indicated not a change to baseline), level of consciousness was alert, pupils were equal and reacted to light (no pupil size documented), responds to commands, had no pain, was able to move all extremities, and was signed by LPN #24. The fourth 15-minute assessment dated [DATE] at 10:15 PM indicated a temperature of 98.6 (no route indicated), pulse 70 (no type indicated), B/P 118/68 lying, orientation to person only (indicated not a change to baseline), level of consciousness was alert, pupils were equal and reacted to light (no pupil size documented), , responds to commands, had no pain, was able to move all extremities, the resident's ability to follow the nurse's finger with their eyes was not documented and was signed by LPN #24. The first hourly assessment on [DATE] at 1:15 AM indicated Resident #72's temperature was 97.2 (no route indicated), pulse 85 (no type indicated), respirations 16, B/P 128/62, was oriented to person, was non-rousable, and was a change from resident's baseline. The second hourly assessment on [DATE] at 2:15 AM indicated Resident #72's temperature was 97.8 (no route indicated), pulse 62 (no type indicated), respirations 16, B/P 128/62 in the lying position, was oriented to person, was alert, and was not a change from resident's baseline. The third hourly assessment on [DATE] at 3:15 AM indicated Resident #72's temperature was 97.8 (no route indicated), pulse 78 (no type indicated), respirations 16, B/P 160/80 in the lying position, oriented to person, alert, pupils equal and reacts to light (no pupil size indicated), responds to commands, no pain, and able to move all extremities. The fourth hourly assessment at 4:15 AM indicated Resident #72 was alert, temperature 97.8 F, pulse 80, respirations 16, blood pressure 150/86, pupils equal, reactive to light, pupil size 2mm, responds to commands, pain 4, had no movement of left arm, had no movement of left leg and was signed by LPN # 6. During an interview on [DATE] at 4:58 PM, Certified Nursing Assistant (CNA) #5 stated she worked on 400 Hall from 3:00 PM to 7:00 PM on [DATE]. CNA #5 stated she received report that Resident #72 had not been in a good mood and did not want to go to the dining room, did not get up for breakfast or lunch, and was being combative. CNA #5 stated Resident #72 got up for dinner and was eating normally, drinking and was happy. CNA #5 stated Resident #72 was a fall risk, had a bed alarm, barriers on the bed, and had a body pillow. CNA #5 stated she toileted Resident #72 after the dinner meal, assisted Resident #72 to bed and all precautions were put in place. CNA #5 stated Resident #72 was always confused and fell after [CNA #5] was off shift. CNA #5 stated upon arrival for the 7:00 AM shift on [DATE], Resident #72 was being assessed by CNAs and nurses, the room was crowded and Resident #72 was sent out to the hospital. During an interview on [DATE] at 5:18 PM, CNA #3 stated she worked on [DATE] from 7:00 AM to 3:00 PM and returned for the 11:00 PM to 7:00 AM shift on [DATE]. She stated that she was assigned to 300-Hall and assisted on 400-Hall. CNA #3 stated Resident #72 fell between 3:00 PM and 11:00 PM on [DATE]. CNA #3 stated she went to assist on the 400-Hall around 4:00 AM to 4:15 AM and heard Resident #72 yelling. Upon Resident #72's room the resident was crying and the left side of Resident #72's face was drooping. CNA #3 stated that she turned on the call light, CNA #10 and CNA #25 entered the room, and one went to get the nurse. Licensed Practical Nurse (LPN) #6 was assigned to the hall and was not at the nurse's station. One of the CNAs called LPN #6's cell phone. CNA #25 told CNA #3 that Resident #72 had a fall earlier in the day and had been throwing up. CNA #3 stated that LPN #6 came to Resident #72's room within 5 minutes of the call. Prior to LPN #6's arrival, CNA #3 stated that Resident #72 was swaying in bed, slurring words, and the left side of the residents' body had no movement. CNA #3 stated LPN #6 entered the room between 4:00 AM and 4:30 AM and walked to the side of Resident #72's bed and stated [resident] is on comfort care and she would let the Advance Practice Nurse (APRN) #30 know. CNA #3 stated that LPN #6 did not assess Resident #72 and walked out of the room. CNA #3 stated when she clocked out at 7:28 AM, she saw APRN #30 and Registered Nurse (RN) #23, and updated APRN #30 on Resident #72's condition. CNA #3 stated that APRN #30 stated they were not aware of Resident #72's change in condition. CNA #3 stated Registered Nurse (RN) #23 went straight to Resident #72's room. CNA #3 stated prior to leaving at 8:00 AM, RN #23 and APRN #30 were reaching out to Resident #72's power of attorney (POA). CNA #3 stated, the [APRN] should have been notified. On comfort care you are supposed to be comfortable. During an interview on [DATE] at 6:41 AM, LPN #6 stated she worked on [DATE] from 7:00 PM to 7:00 AM and was assigned the 300 and 400 Halls. At 9:15 PM, CNA #26, advised Resident #72 was on the floor, and upon entering the room, Resident #72 was lying on their left side next to the bed and had thrown up yellow colored bile. Resident #72 was given an antiemetic at 10:01 PM, and a neuro assessment was conducted. The provider was notified of the fall at 10:00 PM via secured text system, APRN #30 did not respond, and LPN #6 did not send a second secure text regarding a change in condition, because she was completing medication administration pass, and the computer had gone idle and the text was erased. LPN #6 stated Resident #72 was reassessed while asleep and CNAs were asked throughout the night if there were any changes in Resident #72's condition, and none were reported. Around 4:58 AM LPN #6 received a phone call from CNA #25 to reassess Resident #72. CNA #25 reported to LPN #6 that Resident #72 was clammy, their blood pressure (BP) was high, and the left side of Resident 72's face was drooping and resident complained of a headache. LPN #6 gave resident an analgesic at 5:00 AM. LPN #6 stated Resident #72 would not smile and that the middle of their upper lip to the left side of the upper lip was stuck to dentures, Resident #72 would not move either arm, their grip strength was fair and was able to grip both hands. LPN #6 stated the resident's pedal area was not checked because they were lying on their side. LPN #6 stated, I was in the process of sending a second text when APRN #30 was in the building, rushing to Resident #72's room. APRN #30 came to nurse station and said Resident #72's left side was droopy. LPN #6 stated she did not do a full neuro assessment when told Resident #72's face was drooping and stated it slipped my mind. I did not do the full neuro check. I wanted to tell [APRN #30] about the fall and finish my med pass. LPN #6 stated she should have done a full neuro assessment and sent a secure text message before doing anything else. When asked what the signs and symptoms of a stroke were, LPN # 6 stated, I am not sure what to look for other than drooping face and one hand will be weaker than the other and they cannot move one side. LPN #6 stated she did not see anything different with the resident and could not remember when she was notified Resident #72 was vomiting but it was after the 8 PM medication pass. During an interview on [DATE] at 10:00 AM, CNA #9 stated on [DATE] at 7: 00 AM when she arrived on shift, night shift CNA #3 gave report, stated that something was wrong with Resident #72, and that CNA #3 had reported it to the nurse. CNA #9 stated, I went to [Resident #72's] room and [ the resident's] whole left side was not moving and [resident's] face was drooping, they had no speech, and when I lifted [ the resident's] arm, it fell down, it was limp, hot, and red. CNA #9 stated Resident #72 was trying to vomit, vitals were obtained and LPN #22 (day shift nurse) was on the phone with Resident #72's family member. During an interview on [DATE] at 10:34 AM, CNA #8 stated when a resident had a fall, the nurse should be notified immediately to assess the resident and if it was determined there was no injury, the resident would be transferred to a chair or bed and neuro checks performed. CNA #8 stated neuro checks should be done by the nurse every 15 minutes four to five times, then every 30 minutes four to five times, then one an hour, then every 8 hours. CNA #8 described the neuro checks completed by the CNA, were to obtain blood pressure, pulse, temperature, and respirations, document on a sheet of paper provided by the nurse. CNA #8 stated had she not seen a nurse go into Resident #72's room and do any additional assessments on [DATE]. CNA #8 stated If vitals are looking weird they [the nurse] will go in to follow up. During an interview on [DATE] at 4:11 PM, RN #12 stated a secure message was sent out on [DATE], providers do not have to be on site to view messages and that nurses could view messages when they log into the [electronic health record] when in the facility. The message was sent out by LPN #6 on Resident #72 at 10:46 PM, regarding an unwitnessed fall that occurred at 9:15 PM and that Resident #72 was vomiting. Another message was sent at 10:47 PM with the same information and a third at 10:49 PM that had to do with a fall intervention put into place by LPN #6, the immediate intervention was to perform every 15-minute neuro checks. RN #12 stated when a resident fell, protocol was to assess the patient and assist up into a chair or bed and then contact family, management team, and providers. During an interview on [DATE] at 4:46 PM, Medication Aide Certified (MAC) #4 stated she worked the day shift of [DATE], and Resident #72 had a change in condition and was not acting right, the nurse had assessed the resident, and thought Resident #72 had a stroke. During an interview on [DATE] at 7:31 AM, LPN #22 stated she did not work with Resident #72 during the [DATE] 7:00 AM-7:00 PM shift and did not assist with the Situation Background Assessment and Recommendation (SBAR) Communication Form on [DATE]. LPN #22 was shown the SBAR form, that indicated it was signed by LPN #22, and stated, I did not assist with that form or start that form. I was not working. LPN #22 did not know how her name appeared on the document. During an interview on [DATE] at 5:10 PM, RN #23 stated, after entering the facility on [DATE] between 7:00 AM and 7:30 AM, he was told by a CNA (unknown name) that Resident #72 had fallen, was not doing good, was having stroke-like symptoms, and was unable to move their left side. Upon entering the room, RN #23 stated he observed Resident #72 as having stroke-like symptoms, could not smile on the left side, and could not squeeze hands on the left side. RN #23 stated that APRN #30 sent Resident #72 out to the local hospital. RN #23 stated he had been told by the CNA that they [the CNA] told the RN on the hall[about the change in Resident #72]. RN #23 did not know if the RN responded. RN #23 could not remember if the CNA said or insinuated that the RN did not respond and did not recall any specific times of fall being mentioned. During an interview on [DATE] at 5:37 PM, the Director of Nursing (DON) stated they were on vacation on the date of the incident regarding Resident #72 and returned on [DATE] at 6:30 AM and was updated by the ADON on Resident #72's fall. The DON stated that the nurse was alerted of the fall and placed the resident on every 15-minute checks. There were not any changes in condition until the next morning, the nurse practitioner was in the building and transferred the resident out to the hospital. The DON stated the fall occurred at approximately 9:15 PM and Resident #72 was transferred sometime the next morning. The nurse was trying to reach the resident's family to see if they wanted the resident sent to the hospital; the resident should have been sent to the hospital. The DON stated Resident #72 was listed as no transport for aggressive interventions and the DON was unsure if that meant for no heartbeat, breathing, or all emergencies. The DON stated the priority was comfort of the resident above aggressive management. During an interview on [DATE] at 8:33 AM, Minimum Data Set Coordinator (MDSC) stated Resident #72's Physician Orders for Life Sustaining Treatment (POLST) included, do not resuscitate (DNR), only comfort treatment, do not transport and no routine labs. The MDSC stated basically, we are focusing on comfort, pain, and discussing with the family about stopping medications such as statins and focusing on pain management. The MDSC stated Resident #72 had a terminal disease of advanced dementia and Resident #72's family member chose comfort care when the resident began getting to later stages. MDSC stated comfort care does not mean residents would not be treated for an acute situation such as a stroke.During an interview on [DATE] at 8:57 AM, LPN #24 stated she worked on [DATE] from 3:00 PM to 11:00 PM and Resident #72 fell during medication pass around 9:00 PM. LPN #24 stated she checked on Resident #72 several times during the night and did neuro checks, none were out of range, and the CNAs did the vital signs. LPN #24 stated an assessment was completed and entered into the electronic health record. LPN #24 stated No CNAs came to me about anything. LPN #24 did not have information on if the provider was notified. LPN #24 stated that comfort care was keeping a resident comfortable and does not mean a change is not addressed. During an interview on [DATE] at 9:23 AM, CNA #25 stated she worked the 11:00 PM shift on [DATE] and received report that Resident #72 rolled out of bed, and vitals were taken throughout the night. CNA # 25 stated, I asked if [resident] wanted to get up and [resident] said no because of a headache, [resident] was cold and clammy. Vitals were obtained, LPN #6 was called to assess the resident and was notified that Resident #72 was clammy and cold, oxygen and Blood Pressure (BP) were fine. CNA #25 stated that CNA #3 came in Resident #72's room to help with rounds and stated Residents #72's face looked droopy, CNA #3 was trying to get the resident to squeeze her hands and Resident #72 stated no and wanted to be left alone. CNA #3 notified LPN #6 that Resident #72 was having a stroke. LPN #6 stated the APRN and family were called. CNA #25 stated I was in the library with the nurse practitioner and RN #23; CNA #3 came in and the nurse practitioner got upset because they had not received a notification text. CNA #25 stated LPN #6 went into Resident #72's room several times during the night but she did not see the nurse do pupil checks or anything like that, they do those when they first fall. Review of Blood Pressure Summary revealed Resident #72's blood pressure on [DATE] at 8:30 AM was 183/109. No other blood pressures are documented on [DATE] or [DATE]. Review of a facility document titled Nsg Neurological Assessment, Fourth Hourly assessment dated [DATE] at 4:15 AM indicated the blood pressure was 150/86. During an interview on [DATE] at 9:48 AM, CNA #26 stated she worked the evening shift on [DATE] and left at 11:00 PM. CNA #26 stated that Resident #72 started vomiting, (does not remember what time), and CNA #25 notified LPN #6. CNA #26 stated Resident #72 was on fall precautions and had a fall mat, low bed, wedges on both sides of bed, and a pressure alarm on the bed. CNA #26 stated the pressure alarm box was assigned to a CNA each shift, CNA #26 did not have the box for Resident #72 and did not know who had the box. The box stayed with the person who it was assigned to. CNA #26 stated Resident #72 was found on the floor by CNA #27 and CNA #26 went to notify the nurse. When LPN #6 came into room, Resident #72 was placed in a wheelchair and taken to the bathroom. CNA #26 stated there were no additional episodes of vomiting while Resident #72 was in the bathroom. CNA #26 stated LPN #6 assigned 15-minute neuro checks to CNA #26, but the checks were done by other CNAs because they wanted to do them. CNA #26 stated comfort care is they are end of life and you are not going to attempt to prolong life, just keep them comfortable. During an interview on [DATE] at 11:05 AM, the Assistant Director of Nursing (ADON) stated Resident #72 was a do not transport, comfort care, DNR. The ADON stated she was able to reach Resident #72's family and told them the resident was having stroke-like symptoms and family member said to send resident to [local] hospital. The ADON stated APRN #30 and RN #23 were in the building and provided the ADON with observation information and stated they were trying to reach Resident #72's family. The ADON stated comfort care was like hospice without hospice. If family was not quite ready for hospice and they do not want life sustaining measures, unless it is a traumatic issue, and will agree to comfort care, the resident will be placed on comfort care. ADON stated that when a resident was on comfort care and a change in condition was brought to the attention of the nurse, by a CNA, the nurse would assess only if the change warrants assessment, such as unresponsiveness, if the resident's normal BP was 120/70 and is now 200/100, the change would warrant immediate assessment. The ADON stated that neuro checks were done by the CNA on the floor and the nurse should do a recheck of the neuros and if not in normal limits the nurse would notify the provider regardless if the resident was on comfort care. Neuro assessments included hand grips; were grips the same on both sides, were both sides moving the same, were they responsive. The nurse was to assess immediately after the first fall. The ADON stated that any change should be reported to the nurse. It was not acceptable for a nurse to go to the room when notified by a CNA regarding a change in condition, and say the resident is on comfort care, leave the room and not do an assessment. During an interview on [DATE] at 11:42 AM, CNA #27 stated she worked 7:00 PM to 11:00 PM shift on [DATE] and was assigned to the 400 Hall. CNA #27 stated Resident #72 was sick, vomiting and the resident's sheets were changed during shift. CNA stated Resident #72 was a fall risk, bed was in the low position, a fall mat was in place and CNAs checked on Resident #72 every 10 minutes. CNA #27 stated Resident #72 was found by CNA #26 lying on the floor on their side with their feet in the bed and their head was lying on the fall mat and Resident #72 was vomiting. CNA #27 stated she was notified of the fall by CNA #26 and stayed with Resident #72 while CNA #26 went to get the nurse. CNA #27 stated she told LPN #6 upon entry to resident's room that Resident #72 was vomiting. LPN #6 stated that she was aware of Resident #72 vomiting and the resident had already received medication for vomiting. CNA #27 stated that Resident #72 was no longer vomiting after LPN #6 gave the resident more medication. During an interview on [DATE] at 12:51 PM, the DON confirmed that neuro checks were completed for residents with falls involving hitting of the head and unwitnessed falls. The DON stated that vital signs were completed by CNAs; the rest of the neuro assessment is done by the nurses. Review of a Progress Note dated [DATE] at 10:01 PM, revealed Resident #72 received an [antiemetic] oral tablet 4 mg, take 2 tablets by mouth every 6 hours as needed for nausea and vomiting (dissolve tablet on top of tongue, then swallow with saliva), signed by LPN #6. Review of the Medication Administration Record (MAR) dated [DATE], revealed Resident #72 received an antiemetic on [DATE] at 10:01 PM, signed by LPN #6. Review of a Progress Note dated [DATE] at 11:03 PM, revealed the administration of [antiemetic] to Resident #72 was effective, authored by LPN #6. Review of a Progress Note dated [DATE] at 5:22 AM, revealed Resident #72 received [analgesic] oral tablet 325 mg, give 2 tablets by mouth every 6 hours as needed for fever and/or pain, authored by LPN #6. Review of the MAR dated [DATE] revealed Resident #72 received an analgesic on [DATE] at 5:22 AM for pain at level 5. Review of a Progress Note dated [DATE] at 7:30 AM, revealed Resident #72 was found on the floor, parallel to bed, and had vomited on self. Resident #72 was assisted to sitting position, had redness to left elbow/arm and left side of abdomen. Resident was moved from the floor to the wheelchair and taken to toilet. Resident #72 complained of nausea and vomited during toileting. Nausea medication given, initiated neuro checks every 15 minutes for 24 hours and was authored by LPN #6. Review of a Progress Note dated [DATE] at 8:10 AM, revealed Resident #72 was pale, skin was warm and moist to touch, dry heaving up yellow green bile with brown colored fluid. Resident #72 was lethargic with temperature of 99.0, pulse 117 and irregular, respirations 16, B/P 183/109, the provider was at bedside and was authored by LPN #22. Review of a Progress Note dated [DATE] at 8:53 AM, revealed Resident #72's spouse was contacted and the spouse requested transport to hospital emergency department for evaluation of possible CVA [stroke], authored by ADON. Review of a document titled Physician Orders for life-Sustaining Treatment (POLST) date prepared [DATE], signed by physician on [DATE], revealed Do Not Attempt Resuscitation/DNR, (Allow Natural Death), Comfort Treatment, indicated the primary goal was maximizing comfort. Transfer to hospital should be requested only if comfort needs cannot be met in current location. Additional orders indicated Do not transport. No routine labs. Review of document titled, eInteract Change in Condition Evaluation Notifications Report dated [DATE] at 5:00 PM by LPN #22 revealed, Resident #72 had a resting heart rate greater than 100 or less than 50; sudden change in level of consciousness; and diastolic pressure greater than 90 mmHg (millimeters of mercury) but less than 115 mmHg. Review of a facility document titled, SBAR Communication Form dated [DATE] revealed incident began on [DATE] with abnormal vital signs, falls, nausea/vomiting, condition has not occurred before; vitals 183/109, P 117, R 16, T 99, SPO2 90%; blood glucose 192.0; altered LOC, fall, nausea vomiting, no changes observed to neurological evaluation, dated [DATE] 8:10 AM. Signed LPN #22 Review of a document titled Emergency Medical Services (EMS) Pre-Hospital Care Report dated [DATE] at 8:53 AM revealed the EMS unit arrived on scene at 8:57 AM, departed scene at 9:08 AM and arrived at the hospital 8:15 AM. Provider primary impression was Intracranial – Stroke (CVA) Infarction. Advanced Directive listed as DNR or Medical Order Form. Assessment summary included altered mental status, abnormal cerebellar function, asymmetric strength, left facial weakness/drooping, left sided weakness, pain, asymmetric smile or droop, left leg abnormal/weakness motor function, right leg abnormal/weakness motor function, left arm motor function absent. Review of a Progress Note dated [DATE] at 9:16 AM, revealed report was called to emergency room, authored by LPN #22. Review of the Nurse Schedule for June revealed LPN #22 worked 7:00 AM to 7:00 PM on [DATE] and was not scheduled for [DATE]. Review of a Hospital Record dated [DATE] at 9:17 AM, indicated Resident #72 presented to the emergency department with facial droop, with a last known well time of 4:00 AM at the facility. Facility nursing staff did not report fevers, vomiting, or diarrhea to the emergency medical services (EMS) crew. Physical exam revealed right facial droop and flaccid (limp) left arm and leg. Computed tomography (CT) imaging included large parenchymal hemorrhage (bleeding directly into brain tissue) affecting several areas of the brain. Resident #72 was transitioned to comfort measures only. Transfer destination inpatient hospice care. Review of an untitled facility document referred to as Incident and Accident (I&A) with fall protocol, dated [DATE] at 9:15 PM, indicated Resident #72 was found in room, on floor, lying on left side, parallel to the bed. Resident had vomited on self, was assisted into sitting position, noted with redness to left elbow/arm, and left side of abdomen. Resident #72 was assisted to wheelchair and toileted per request. Resident was nauseated and vomited while toileting. Resident was assisted back to bed and given an antiemetic. Immediate action taken included Neuros (neurological) checks Q (every) 15 minutes for 24 hours. Mental status indicated Resident #72 was oriented to person. Injuries reported indicated No injuries observed post incident. Predisposing factors included fall alarm, confusion, incontinent, impaired memory, other. Other info included active vomiting before and after incident. Review of Resid

Number of residents sampled: Number of residents cited: Based on observation, interview and facility document review, the facility failed to ensure the food preparation equipment and environment were maintained to prevent contamination and potential development of foodborne pathogens. Specifically, the facility failed to properly clean and store the ice scoop for one of two ice machines reviewed. The findings include: During the tour of the kitchen on 07/06/2026 at 10:30 AM with the Dietary Manager (DM), the ice machine scoop holder which was attached to the ice machine was covered with a black residue and the ice scoop was observed to be currently resting on the black residue. This surveyor asked the DM to wipe the black residue off. The DM did so, the residue was easily wiped away. The surveyor asked the DM to describe what was observed inside the scoop holder and who used the ice from the machine. The DM stated the scoop holder was dirty, and the ice machine was used by the kitchen staff for ice in residents' drinks. The DM also stated that the ice machine and scoop holder were cleaned weekly. During an interview on 07/09/2026 at10:11AM, the Director of Nursing (DON) stated, I expect the ice scoop and scoop holder to the be cleaned as needed to prevent stomach upset and infections with the residents.During an interview on 07/09/206 at 10:31AM, the Administrator, stated the ice scoop and ice holder need to be cleaned daily to prevent infections. Review of the Ice Machine Cleaning schedule for June indicated the ice machine had been cleaned once on week for the month of June. Review of the Ice Machine Policy dated (02/12/2019),revealed the purpose of the policy was to prevent the growth of bacteria and mold. Item #5 indicated the Ice Scoop will be washed and sanitized daily and stored in a holder or bag.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to maintain a medication error rate of less than 5% for two residents (Resident #3 and Resident #27) who received medications of 31 medication administration observations. The findings include: Resident #3During a medication administration observation on 07/08/2026 7:50 AM, this survey observed LPN #14 administer one drop of an eye drop to each of Resident #3's eyes.During an interview on 07/08/2026 10:40 AM LPN # 14 confirmed that he had administered one eye drop per eye to Resident # 3, on 07/08/2026 7:50 AM. A review of June Medication Administration Record (MAR) on 7/8/2026 at 11 AM revealed Resident #3 had an order for eye drops, 2 drops both eyes 3 times daily for dry eyes and also showed that the medication administered 7:50 AM was charted as 2 drops administered both eyes by LPN #14. Resident #27During an observation of medication pass 07/07/2026 at 5:32 PM, LPN #29 assessed Resident #27's blood pressure and pulse. She reported the blood pressure was within parameters of the medication order and reported the pulse was 58. LPN #29 administered the resident's medication to treat high blood pressure. Review of an admission Record, indicated on 04/02/2026 the facility admitted Resident #27 with diagnoses that included hypertension.Review of Resident #27's Order Summary Report, revealed an active order dated 05/05/2026 for a medication to treat high blood pressure to be given two times a day for high blood pressure, HOLD if systolic BP (blood pressure) 110 or less, Diastolic BP is under 60, or HR (heart rate) is under 60 BPM (beats per minute). Report to the nurse.Review of Resident #27's July Medication Administration Record (MAR) Treatment Administration Record (TAR) revealed that on 07/07/2026 at 5:00 PM the slot for Resident #27's pulse was documented to be 58 and the slot for the medication administration to treat high blood pressure was documented to indicate the medication was administered to Resident #27 by LPN #29.During an interview on 07/08/2026 at 1:38 PM LPN #29 report she should not have administered the medication to treat high blood pressure since the pulse was 58 and the parameter set in the order was to hold the medication if the pulse was less than 60. She reported she did not call to report to the provider because she had not seen the parameter for the pulse. She indicated she only saw the parameter for the blood pressure, which was within the ordered parameter.Review of a Mayo Clinic medication sheet indicated the medication ordered for Resident #27 to treat high blood pressure worked by causing the heart to beat slower. The medication sheet also indicated the medication may cause the resident to have a side effect of a slow heartbeat.During an interview 07/09/2026 at 9:11 AM, the Director of Nursing (DON) indicated if a vital sign such as a pulse was lower than the ordered parameter included in a medication order, then the medication should be held, and the provider should be contacted. She reported the expectation of a nurse concerning orders was that the nurse should follow the orders.During an interview on 07/09/2026 at 10:24 AM the Medical Director indicated if an order specified a medication to be held for a pulse less than 60 and the resident's pulse was 58, then the medication should have been held, and the provider should be notified that the medication was held. During a second interview on 07/09/2026 at 2:15 PM, the DON stated she had no concerns about orders not being followed before she found out on Tuesday that there were medication errors. The DON stated she did not feel like orders were ambiguous, and she felt that the orders were written clearly. A review of the facility policy Medication, General Administration of revised 11/22/2016, states in section 6 Should there be any doubt concerning the administering of medications, the physician's order must be verified before the medication is administered.

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review and facility policy reviews, it was determined the facility failed to ensure infection control practices were followed during the medication administration of eye drops for one (Resident # 9) of one resident reviewed who was on contact isolation precautions. The findings include: Review of an admission Record, indicated on 12/13/2024 the facility admitted Resident #9 with diagnoses that included pressure ulcer of left buttock stage 3 and 4; osteomyelitis of vertebra (spinal bones), sacral and sacrococcygeal region; pressure ulcer of sacral region stage 3 and paraplegia (paralysis of both lower limbs). Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/2026, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Review of the Care Plan Report, initiated and revised on 02/19/2025, revealed Resident #9 had Carbapenem-Resistant Acinetobacter Baumannii (CRAB) infection (infection which is highly resistant to multiple classes of antibiotics) of wounds, with an intervention for the resident to be on contact isolation. Review of an Order Summary Report, revealed Resident #9 had an active Physician's Order dated 06/12/2026 for contact isolation precautions. During a concurrent observation and interview on 07/07/2026 at 6:25 PM, Licensed Practical Nurse (LPN) #29 and surveyor were at Resident #9's door, putting on Personal Protective Equipment (PPE) when the Minimum Data Set Coordinator (MDSC) was observed in the resident's room without PPE. The MDSC had a tissue in their hand near the resident's face. The MDSC was observed to drop the tissue into a trash can and continue outside of the resident's room without sanitizing their hands. Resident #9's door and wall beside the door display signage detailing Contact Isolation Precautions. As MDSC went out the door she indicated to LPN #29 that she just administered Resident #9's prescribed eye drops. During an interview on 07/07/2026 at 6:42 PM, the MDSC indicated Resident #9 was on Enhanced Barrier Precautions (EBP) but was not getting close to the resident's wounds or catheter, therefore would not have to put on PPE. The MDSC reported knowledge about the resident being on precautions because of the signage on the door. The MDSC looked into the resident's electronic health record to find the order for EBP and reported she was unable to find an order for EBP but was able to find an order for contact precautions. The MDSC reported it was important for staff to follow precautions for contact isolation to prevent cross contamination with herself, Resident #9 and other residents. At Resident #9's room from the hallway, without prompting, MDSC read the contact precaution sign out loud, detailing the precautions for entering the resident's room. During an interview on 07/09/2026 at 1:03 PM, the Infection Preventionist (IP) indicated staff were aware of when a resident was on contact isolation by signage on the resident's door or signage outside of the resident's door. The IP reported there would also be PPE outside of the resident's room and the resident would have an order for contact precautions in the electronic health record. The IP indicated staff should have the proper PPE put on for contact precautions anytime staff was in that room. During an interview on 07/09/2026 at 9:11 AM, the Director of Nursing (DON) reported staff knew when a resident was on contact precautions by signage on the resident's door which explained the proper PPE to wear before entering that room. The DON indicated the expectation of staff going into the room of a resident on contact precautions was for the staff to wear PPE as directed and wash their hands before coming out of that room. Review of facility policy Handwashing/Hand Hygiene revealed This facility considers hand hygiene the primary means to prevent the spread of infections. Step one of the policy indicated all personnel should follow the handwashing/hand hygiene procedures to help prevent spreading infections to staff, residents and visitors. Step 5 documented hand hygiene is the final step after removing and disposing of personal protective equipment.

Based on observations, interviews, and policy review, it was determined that the facility failed to ensure archived medical records were stored in a secure location to safeguard resident health information against loss or unauthorized use for 1 of 1 medical records storage system reviewed. The findings include: During an observation on 05/27/2025 by a Life Safety Code (LSC) Surveyor, archived medical records dated 2016 through 2020 stored in cardboard boxes were observed on a shelf in the maintenance department garage. The LSC surveyor reported the incident to this surveyor for investigation. The Maintenance Supervisor (MS) stated it was the practice of the maintenance staff to open the garage door, and leave it open during their workday, with no authorized personnel present at the storage facility. During an observation on 05/27/2025 from 1:35 PM through 3:31 PM, the garage door was seen open. This surveyor called out for staff around the garage; no staff were located in the area. At 2:06 PM, a truck was seen backed up to the opened garage. At 2:11 PM, an unknown male was observed walking away from the garage. Nine photographs were taken of the medical records and the truck backed up to the garage. During an observation on 05/28/2025 from 9:38 AM through 9:57 AM, the garage door was seen open. This surveyor attempted to locate staff; no staff were located in the garage. A truck was observed sitting behind the facility. Three photographs were taken of the garage and the medical records. During an interview on 05/29/2025 at 1:41 PM, the MS stated he had a garage which stored maintenance tools, beds, wheelchairs, and toilets. He indicated the door was locked, but when maintenance staff were at work, the garage door was left open, and that nothing had ever been stolen. The MS stated the white boxes had medical records in them. He stated, sometimes people, like the Business Office Manager (BOM), called the maintenance staff to put boxes of medical records in the garage. During an interview on 05/29/2025 at 2:49 PM, the Medical Records Director (MRD) stated paper medical records were uploaded and scanned to the electronic health record, then filed in the filing cabinets in her office. She stated that when a resident was discharged , their file was placed in the cabinets, which had files from 2020 to the current year. The MRD stated she had been in her current role for five months and was not aware of medical records that were stored anywhere else. During an interview on 05/29/2025 at 2:55 PM, the BOM stated she had worked there for two years, and medical records were stored only in the medical records office. The BOM stated it was a Health Insurance Portability and Accountability Act (HIPAA) issue if medical records were not properly stored and kept private. She stated, Resident financial documents would be stored in my office. During an interview on 05/29/2025 at 3:47 PM, the Administrator stated archived medical records were stored in a garage, which was always locked, with the MS having a key. He revealed the MRD or the MS would go out to get an archived medical record, if needed. The Administrator stated he had security cameras that faced the garage and could pull up video on his cell phone. During a concurrent observation and interview in the garage on 05/29/2025 at 3:57 PM with the Administrator, the garage door was found to be open with no maintenance staff present in or around the building. There were two unknown CNAs emptying biohazard containers in the garage. The Administrator confirmed the boxes on the shelf did contain residents' medical records, and stated, Medical records should not be out in the open like this. A review of the Admission Packet, revision dated 12/2021, indicated the facility would preserve the privacy and confidentiality of the health information created and/or maintained at their facility. The facility would maintain the privacy of a resident's health information as required by law. The facility would not disclose the Personal Health Information (PHI) for purposes not listed in the packet without the resident's authorization. An acknowledgement of receipt of notice of privacy practices indicated the resident understood their health information was private and confidential, and the facility would protect and preserve the confidentiality of the resident's PHI.

Based on observation, record review, interview and facility policy review, the facility failed to ensure residents requiring two-person assistance for transfers were transferred by the appropriate number of staff to prevent falls and/or injury for 2 (Resident #36 and #178) of 4 sampled residents reviewed for falls. Specifically, Certified Nursing Assistants (CNAs) attempted to transfer residents with 1 person assistance, resulting in falls on 11/06/24 and 03/31/25. The findings include: 1. Review of Medical Diagnosis revealed Resident #178 had diagnoses of closed left femur fracture, left heel pressure ulcer, and periorbital cellulitis. a. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated Resident #178 required assistance with indoor mobility, used a motorized wheelchair/scooter and walker, was dependent with eating, toileting, bathing, personal care, and dressing. The MDS also indicated the resident fell within one month prior to admission, resulting in a fracture. b. A review of Care Plan, (updated 11/06/2025) revealed Resident #178 had an actual fall with head injury. Staff were instructed to monitor, document, and report changes to the physician for the next 72 hours, and monitor for pain, bruising and changes in mental status. c. A review of nursing Progress Notes dated 11/07/2025 at 11:18 PM, indicated Resident #178's spouse stated the resident fell when a single CNA attempted to transfer them from the bed to the shower chair, indicating both the CNA and Resident #178 fell during the incident. Resident #178 told a nurse the resident's feet slipped; they lost their balance and fell. A quarter size abrasion was found on the top of Resident #178's head. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) assessed the resident and Resident #178 denied pain. d. A review of a Reportable with a discovery time of 11/06/2024 at 4:30 PM, revealed the Administrator was notified Resident #178 had alleged CNA #18 attempted to transfer Resident #178 without a second staff member present, moving from the bed to the wheelchair. When Resident #178's feet started to slide, CNA #18 had to lower Resident #178 to the floor, and in the process CNA #18 went to the floor with the resident. Resident #178 scraped the top of their head. e. Facility investigation findings from the Reportable stated the facility was unable to confirm Resident #178 was lowered to the floor, but CNA #18 was called by the Administrator and admitted to transferring Resident #178 from the bed to shower chair without assistance. CNA #18 revealed Resident #178's feet slipped, and the resident fell into the shower chair, but denied Resident #178 fell to the floor. CNA #18 confirmed he was aware Resident #178 was a two-person assist and should have asked for assistance transferring the resident and was sorry. CNA #18 was terminated for not following facility policy and not reporting the witnessed fall to the charge nurse. f. Review of a witness statement, dated 11/11/2024 and provided by CNA #18, revealed the CNA offered Resident #178 a shower and the resident agreed. Resident #178 was placed in the sitting position on the side of the bed, they then grabbed the bar on the side of the bed, CNA #18 assisted resident to their feet, and had resident transfer to their chair. CNA #18 stated Resident #178 did drop their weight onto the chair. At no time did CNA #18 believe this to be a fall. g. Review of the Closet Care Plan, included in the reportable file, showed Resident #178 was a two-person assist. h. Review of CNA #18's employee file (hire date 11/28/23) showed pre-employment competency training dated 10/03/23 covered abuse and neglect, and accident and incidents, and resident demonstrated one - two - person assist gait belt transfers. Termination papers dated 11/06/24 indicate CNA #18 was terminated for not following proper level of care for transfers, dropping a resident with an open investigation. i. During an interview on 05/29/25 at 09:12 AM, the DON revealed a fall was reported to her by the charge nurse (Registered Nurse #5) that CNA #18 transferred Resident #178 and the resident fell and hit their head. The DON confirmed Resident #178 was currently being monitored for a scab on top of the head. The DON stated CNA #18 said he was trying to transfer Resident #178 by himself, and the resident was supposed to be a two-person assist. Resident #178 told a family member that the resident fell. Family reported the fall to staff. The DON said Resident #178 confirmed a fall to the floor and CNA #18 helped resident get up off the floor. CNA #18 was terminated for not following the closet care plan and not reporting the fall. The DON stated staff were expected to follow the closet care plan to see if one- or two- person assistance was needed and use a gait belt. If two-person assistance was required, they needed to make sure the resident was safe to transfer and the resident could safely complete the transfer. If they had any doubts, they should not move the resident and contact the charge nurse right away. j. During an interview on 05/29/25 at 09:33 AM, Resident #178 ' s family member revealed Resident #178 was having rehab and CNAs were instructed that Resident #178 required two-person assistance with transfers, and a gait belt had to be used with transfers. CNA #18 came in by himself to transfer Resident #178. Resident #178 told the family member the resident had fallen, then CNA #18 fell to the floor and landed on top of Resident #178. k. During an interview on 05/29/25 at 03:03 PM, the Administrator stated CNA #18 chose to transfer a resident that required two-person assistance alone, and the resident fell. Protocol was not followed. The Administrator described the abrasion on top of the resident's head as it looked fresh. The Administrator said, I go over abuse and neglect monthly, and staff are expected to look at the closet care plan and follow that process. The Administrator stated CNA #18 reported seeing physical therapy transfer Resident #178 with one-person during therapy and thought that he could do it as well. 2. A review of the admission Record, indicated the facility admitted Resident #36 on 02/26/2025 with diagnoses which included fracture of right arm, muscle wasting, anemia, unsteadiness on feet, blindness, and abnormalities of gait and mobility. a. A review of the Medication Administration Record (MAR) dated March 2025 indicated Resident #36 was taking a blood thinner to prevent blood clots. The resident started taking the blood thinner on 03/19/2025 daily, with a dose taken on the morning of 03/31/2025 when CNA #12 failed to follow the care plan of maximum two-person assistance with transfers. b. A review of Resident #36's Closet Care Plan dated 05/15/2025 indicated the resident required maximum assistance of two staff for transfers. c. A review of Resident #36's Comprehensive Care Plan dated 03/05/2025 indicated the resident required maximum assistance of two staff for transfers. d. A review of the Morse Fall Scale and Care Plan with Tasks dated 04/01/2025 indicated the resident had an impaired gait. It incorrectly indicated the resident had not fallen before, but they had fell during a transfer on 03/31/2025. The resident's score was 35. Morse Fall Scoring indicated resident was a moderate risk for falls in the range of 25-44. e. A review of Incident and Accident Report (I&A), dated 04/01/2025, revealed Resident #36 was being assisted from the bed to the wheelchair on 03/31/2025 by a single staff member when the resident took a step and fell back. CNA #12 lowered the resident to the floor. The resident suffered an abrasion to the top of the scalp and had a bruise to left forearm. CNA #12 transferred the resident without the assistance of two staff members. The report indicated the Administrator interviewed CNA #12 to establish if she knew the resident was a two-person maximum assistance and if the CNA read the closet care plan. CNA #12 stated she knew the resident was a two-person assistance and the care plan was not referenced. The I&A indicated CNA #12 neglected to follow the resident transfer plan of care. f. A review of Hospital Emergency Department Visit dated 03/31/2025 at 9:24 PM, revealed Resident #36 was taken to the Emergency Department (ED) by ambulance post fall after hitting their head. Upon arrival to the ED, the resident started vomiting. Resident #36 had complaints of nausea, vomiting, headache, and pain to right arm from previous fracture. A computed tomography (CT) scan of the head was indicated for moderate to severe trauma post fall since resident was taking an anticoagulant. Scans were negative for any acute findings. Resident #36 was discharged back to the facility. g. The following Nursing Neurological Assessments were performed: i.03/31/2025 5:15 PM, Resident alert; Change from baseline; Verbal and Non-Verbal expressions of pain; Pain rated 10. ii. 03/31/2025 5:30 PM, Resident alert; no change from baseline; Verbal and Non-Verbal expressions of pain; Pain rated 10. iii. 03/31/2025 5:45 PM, Resident alert; no change from baseline; No Verbal or Non-Verbal expressions of pain; No pain rating. iv. 03/31/2025 6:00 PM, Resident alert; no change from baseline; Verbal and Non-Verbal expressions of pain; Pain rated 10. v. 03/31/2025 6:15 PM, Resident alert; no change from baseline; No Verbal or Non-Verbal expressions of pain; No pain rating. vi. 03/31/2025 6:45 PM, Resident alert; no change from baseline; Verbal and Non-Verbal expressions of pain; Pain rated 5. vii. 03/31/2025 7:15 PM, Resident alert; no change from baseline; No Verbal or Non-Verbal expressions of pain; No pain rating. viii. 03/31/2025 7:45 PM, Resident alert; no change from baseline; Verbal and Non-Verbal expressions of pain; Pain rated 4. ix. 03/31/2025 8:15 PM, Resident alert; no change from baseline; Verbal and Non-Verbal expressions of pain; No pain rating. x. 03/31/2025 9:15 PM, Not done; Resident sent to the ER per family request. h. A review of Situation, Background, Appearance, Review and Notify (SBAR) dated 03/31/2025 at 8:00 PM, indicated the primary care provider was notified of Resident #36 ' s witnessed fall with an injury to the right side of their head; contusion to back of head and indicated the resident had pain. i. A review of Skilled Nursing Facility/Nursing Facility Hospital Transfer Form (SNF/NF) dated 03/31/2025 at 8:45 PM indicated Resident #36 had fallen and hit the back of the head and exhibited a bruise to left arm. j. A review of a concurrent Office of Long-Term Care Incident and Accident Report (I&A) dated 04/04/2025 indicated the Administrator reported CNA #12 did know that Resident #36 was a two-person assist and did not follow the care plan. He reported the allegation was substantiated and the facility terminated CNA #12 for not following the resident's care plan. k. During an interview on 05/29/2025 at 8:37 AM, the DON stated if direct care staff found a resident on the floor, they were to immediately call for help. The nurse would assess, if not injured the resident would be returned to the bed or wheelchair. They would notify the physician if there were significant changes. The nurse would talk to the CNA to find out the situation. The nurse followed the basic investigation of the incident, and they would let the DON know after the provider and family were notified. If an intervention changed, the charge nurse would let the staff know and an in-person in-service was done at that time. The closet care plan was updated. All direct care staff should look at the closet care plan before they take care of the resident. The hall managers were the ones that update the closet care plans. l. During an interview on 05/30/2025 at 8:38 AM, the Medical Director (MD) stated the facility did notify him when there was a change of condition or a fall with a resident. The MD said fall assessment should be done after each fall to assess for injuries and prevent future falls. He stated if a resident fell with complaints of pain, the facility should contact him immediately. For residents which required two-person assistance for transfers, his expectation was they had two persons assist on all transfers. The MD was aware of Resident #36 and Resident #178 falling during a transfer. He expected staff to follow the orders, and the closet care plans for the residents. He stated staff making their own decisions to transfer with one-person would be an outlier. m. During an interview on 05/30/2025 at 8:58 AM, LPN #10 stated if a CNA found a resident on the floor, they should alert the nurse, and the nurse would do an assessment. If the resident was not injured, a skin assessment would be done. Then they got assistance and help the resident to bed or wheelchair. If the resident was injured, Emergency Medical Services would be called. n. During an interview on 05/30/2025 at 9:07 AM, CNA #11 stated first and foremost the staff should check the closet care plan before providing care. CNA #11 stated staff should never lift a resident that was a two-person assist without help. o. During an interview on 05/29/2025 at 7:58 AM, Resident #36's family representative stated they were notified when the resident was dropped by CNA #12 and Resident #36 hit their head on the floor. The family representative stated the resident had a knot and bruise on the head and was sent to the emergency department. The family representative stated CNA #12 was moving the resident from the wheelchair to the bed and did not follow procedure. CNA #12 did not get a second person to help with transfer resulting in the Resident #36 getting hurt. 3. A review of facility document Incident and Accident Policy (I&A) revision date 11/22/2017, indicated all incidents or accidents occurring at the facility would be reported to the Administrator and DON, and investigated. A fall should be reported immediately, and staff would assist the injured person. The resident would be assessed for injury. If unwitnessed injury or suspected head injury, the nurse would perform neurological checks and vital signs for 72 hours. Treatment would be provided as ordered by the physician. The charge nurse would complete an I&A. The administrator would report it to the state agencies if determined to be reportable.

Based on observation, interview, and facility policy review, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, expired food items were promptly removed/discarded on or before the expiration or use by date, and dietary staff washed their hands between dirty and clean tasks and before handling clean equipment for 3 of 3 meals observed. The findings include: 1. On [DATE] at 11:07 AM, the following observations were made on a shelf in the refrigerator: a. An opened box of bacon. The box was not covered or sealed. b. An opened box of sausage. The box was not covered or sealed. The Dietary Manager (DM) stated he did not know they were supposed to be sealed. 2. On [DATE] at 11:12 AM, an opened box of chicken and cheese was on a shelf in the freezer. The box was not covered or sealed. The DM confirmed the finding and stated it could get freezer burned. 3. On [DATE] at 11:40 AM, a bag of flour tortillas was on a utility cart in the kitchen with an expiration date of [DATE]. 4. On [DATE] at 11:48 AM, the area above the ice machine panel from which ice was sourced had black residue on it. During an observation and interview with the DM on [DATE] at 11:50 AM, he was asked if he could wipe off what was observed on the panel, who used the ice from the machine and how often he cleaned it. The DM used a rag to wipe the area. Black, wet residue easily transferred to the rag. He stated the area had black residue on it. The DM stated that ice machine was used by the CNAs (Certified Nursing Assistants) to obtain their ice to fill the water pitchers in the residents' rooms. 5. On [DATE] at 11:57 AM, the following observations were made on a shelf in the freezer: a. An opened box of fish. The box was not covered or sealed, exposing it to freezer burn. c. An opened box of pepperoni. The box was not covered or sealed, exposing it to freezer burn. 6. On [DATE] at 12:49 PM, Dietary Aide (DA)#1 was assisting with lunch meal service at the tray line. DA #1 opened the refrigerator, removed cartons of supplements, and placed them on the trays. Without washing his hands, he picked up glasses that contained beverages by the rims and placed them on the trays to be served to the residents with their lunch meal. DA #1 was asked what he should have done after touching dirty objects and before handling clean equipment food. He stated he should have washed his hands. 7. On [DATE] at 1:10 PM, a carton of whole milk was on a shelf in the refrigerator in the unit dining room with an expiration date of [DATE]. 8. On [DATE] at 4:13 PM, Dietary [NAME] (DC) # 2 removed a pan of fish from the oven and placed it on the counter, contaminating her hands. DC #2 then pushed a blender motor towards the edge of the counter. Without washing her hands, she attached a blade at the base of the blender to be used in pureeing food items to be served to the residents for lunch. 9. On [DATE] at 4:19 PM, DC #2 turned on the 3-compartment sink faucet, washed and sanitized the blender bowl, then turned off the faucet with her gloved hand, contaminating her hands. Without changing gloves and washing her hands, she used her contaminated gloved hand to attach the blade at the base of the blender to be used in pureeing food items to be served to the residents who received pureed diets. When she attempted to place food into the blender, she was stopped and asked what she should have done after touching dirty objects and before handling clean equipment and/or food. DC #2 removed her gloves and wash her hands. 10. On [DATE] at 4:20 PM, the DM was around food being prepared without a beard guard over his beard. During an interview on [DATE] at 3:57 PM, the DM was asked why it was important to wear a hair net and beard guards. He stated because hair may fall in the food and contaminate it. 11. On [DATE] at 4:21 PM, DA #3 turned the faucet on and washed her hands, then turned off the faucet with tissue papers. DA #3 then used the same tissue papers to dry her hands. Without rewashing her hands, she picked up plates and placed them on the rack with her fingers inside the plates. 12. On [DATE] at 4:44 PM, DA #3 turned on the food preparation sink and rinsed strawberries. DA #3 then turned off the faucet with her bare hands, contaminating her hands. Without washing her hands, she removed strawberries from the container and placed them on the cutting board and began to slice them to be served to the residents for supper meal. During an interview on [DATE] at 4:45 PM, DA #3 was asked what she should have done after touching dirty objects before handling clean equipment and or food. She stated she should have washed her hands. 13. On [DATE] at 4:56 PM, the DM emptied the ice from the ice machine. This surveyor observed an accumulation of black-orange residue inside the back of the ice machine. During an interview the DM was asked if he could describe the appearance of the inside of the ice machine and he stated it had black-orange dirt on it. 14. On [DATE] at 9:59 AM, the scoop holder on the wall by the ice machine in the main dining room had wet yellow residue all around the corner and the ice scoop was resting directly on it. The surveyor asked the DM to wipe the wet yellow residue. He did so, and wet yellow residue easily transferred to the rag. The surveyor asked the DM if he could describe what was observed inside the scoop holder, how often he cleaned the scoop holder and who used the ice from the ice machine. He stated it was a yellow residue, the CNAs use it for the water pitchers in the residents' rooms and to fill beverages served to the residents at mealtimes, and he cleaned it every week. 15. On [DATE] at12:50 PM, DC #4 who was serving lunch meal at the tray line, sorted tray cards and placed them on the trays, contaminating her hands. Without washing his hands, she picked up plates to be used in portioning food items to be served to the residents for lunch and placed them on the trays with his fingers touching inside of the plates. 16. A review of facility policy titled, Dress Code indicated, employees should wear a hair covering which covers all hair completely and beard guards should be used for employees with facial hair. 17. A review of the facility policy titled, Hand Washing indicated employees should wash their hands during food preparation and after engaging in other activities that contaminate the hands. 18. A review of the facility policy titled, Ice Machine indicated the exterior and inside of the ice machine should be sanitized daily.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the interdisciplinary team determined it was clinically appropriate for a resident to self-administer medications before allowed to do so for 1 (Resident #9) of 1 resident reviewed for self-administration of medications. The findings are: The facility policy Medications, Self-Administration of dated May 1, 2016with a revision date of November 22, 2016, indicated general guidelines permit a resident to self-administer their medications if an assessment and approval had been completed by the interdisciplinary team. Review of Resident #9 ' s Medical Diagnoses report revealed Resident #9 had diagnoses which included anxiety disorder, obstructive sleep apnea, heart disease, congestive heart failure, cognitive communication deficit, and depression. Review of the quarterly Minimum Data Set with an Assessment Reference Date of 05/06/2025 revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Review of Resident #9 ' s electronic health records revealed no medication self-administration assessment had been completed and Resident #9 was not care planned to self-administer medications. Review of Resident #9's Closet Care Plan did not identify the resident to be assessed to self-administer medications. Review of an Order Summary Report revealed an order, dated 03/14/2025, for a short acting inhalation nebulization medication that relaxes the airways of the lungs, to be inhaled orally, once every 8 hours. On 05/27/25 at 2:48 PM, this surveyor observed Resident #9 self-administering a nebulization treatment. This surveyor observed Registered Nurse (RN) #5 in the hallway passing medications to other residents. RN #5 was unable to continuously observe Resident #9 during the nebulization treatment from her location in the hallway. At 2:50 PM, RN # 5 was observed entering another resident ' s room and closing the door, while Resident #9 was self-administering the nebulization treatment. At 2:52 PM, RN #5 re-entered Resident #9 ' s room and removed the nebulization treatment mask from the resident. During an interview on 5/28/2025 at 3:50 PM, RN #5 stated Resident #9 received three nebulization treatments each day. RN #5 stated a nurse should remain with the resident while the treatment was being administered and until all the medication was gone. RN #5 stated she could not see Resident #9 when she went into the resident's room across the hall and closed the door. RN #5 stated she should not have left the resident unattended while resident was administering the treatment because the resident could pull the mask away from their face or the resident could get out of breath, and she would not have known. RN #5 stated the resident had not been assessed to self-administer the nebulization treatment and the resident was not capable of doing a self-administration program. RN #5 stated the facility protocol for a nurse to administer a resident ' s breathing treatment is to check the resident's peripheral oxygen saturation, then put the medication into the nebulizer, and apply the nebulizer mask to the resident's nose. RN #5 stated the nurse should stay with the resident until the treatment had completed and the medication was gone. On 05/28/2025 at 4:04 PM, the Administrator said no resident came to mind that had a self-administration program for administering their own nebulization treatment. He stated if a resident had been assessed to self-administer medications it should be in the resident's care plan. The Administrator stated the resident would need to be assessed to perform the task for the medication as ordered. On 05/28/25 at 4:13 PM, the Director of Nursing (DON) stated the facility did not have any residents assessed to self-administer their nebulization treatments. The DON stated a resident would have to be assessed to self-administer their own medication. The DON also stated the nurse must remain with the resident while the treatment was being administered. The DON stated her concerns for leaving a resident unattended while self-administering the nebulization treatments was if a resident started to cough or have excretions, the nurse would not see it, with a danger of the resident choking and aspirating. On 5/29/2025 at 8:20 AM, review of a facility training revealed N #5 received training on 02/10/2024 for nebulizer administration as well as cleaning and storage of nebulizers. On 05/30/2025 at 8:37 AM, the Medical Director stated he was not aware of any residents at the facility who were assessed to self-administer their own short acting inhalation nebulization medication treatments. The Medical Director stated he would have concerns of the resident administering the medication inappropriately, the resident not knowing how to use the equipment, the resident not getting the appropriate dose of the medications, or the resident giving themselves too much medication. On 05/30/2025 at 9:49 AM, LPN #8 stated the residents were not allowed to self-administer their own nebulization treatments. She stated, We do not have anyone on a self-administration program.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure a resident's antianxiety medication was not used to sedate or contain the resident's movements for staff convenience when exhibiting exit seeking/wandering behaviors for 1 (Resident #3) of 1 resident reviewed for chemical restraints. Findings include: On 01/03/2025 at 11:51 AM, the Administrator stated the facility did not have a policy for chemical restraints because they did not use them. A review of the facility in-service titled Resident Rights, Civil Rights, Dignity dated 12/20/2024 showed the staff was reeducated on Resident Rights including the right to be free from restraints. A review of the Admission Record, indicated the facility admitted Resident #3 with diagnoses that included dementia, malignant neoplasm of the frontal lobe (cancerous brain tumor which can cause personality changes and difficulty with concentration, communication, and controlling emotions), anxiety disorder, cognitive communication deficit, depression, muscle wasting, lack of coordination, and was unsteady on their feet. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2024, revealed Resident #3 had a Brief Interview of Mental Status score of 14, which indicated the resident was cognitively intact. Resident #3 Mood Interview revealed symptoms of: A. Little interest or pleasure in doing things and B. Feeling down, depressed, or hopeless were present for several days (2-6 days of the 14-day look back period). Resident #3's Behavior symptom assessment was negative for hallucination, delusions, physical behaviors directed towards others, verbal behaviors directed towards others, other behaviors not directed towards others, rejection of care, or wandering. A review of Resident #3's care plan with revisions, as of 01/03/2025 revealed the resident used psychotropic medication for anxiety and depression. Interventions included administering psychotropic medications as ordered and monitor for side effects, consulting a pharmacist for dose reduction when appropriate, review behaviors/interventions and alternative therapies attempted. The 11/16/2024 revised goal was for the resident to be free of psychotropic drug complications which included movement disorder, gait disturbances, and cognitive/behavioral impairment with a goal date of 01/30/2025. Resident #3 was care planed for cognitive deficits, interventions included personal preferences or word search books, watching the news, bird/nature watching activities, and provide for small group activities such as the Sunshine Club and Butterfly group. The Goal revised on 11/16/2024 was to provide Resident #3 with activity opportunities that meet the resident's interest and cognitive abilities with a goal date of 1/30/2025. A review of Resident #3's Closet Care Plan revealed, no instructions for redirection, distraction, personal preferences for activities, or other alternative therapies. A review of physician's orders revealed Resident #3 had an active order for scheduled (Name Brand) antianxiety medication 1 milligram (MG) to be given by mouth three times a day for convulsions and anxiety disorder. A second as needed order of (Name Brand) antianxiety medication 0.5MG could be given every four hours for dementia and anxiety. During an interview on 01/03/2025 at 10:15 AM Licensed Practical Nurse (LPN) #1 stated, Resident #3 had brain cancer and if the resident gets in their head they want to go home, the resident will push on the doors. As soon as Resident #3 wakes up we can tell what kind of a mood they are in. We attempt to talk with the resident, offer coffee, or find the resident's friend. Some days the talking doesn't work, so yes, we give the (Name Brand) antianxiety medication for exit seeking behaviors. A review of a progress note dated 10/06/2024 at 5:06 PM as needed (Name Brand) antianxiety medication 0.5MG was given to Resident #3 after yelling fire, fire and trying to leave. No alternate therapies like redirection, distraction, or consoling were noted. A review of a progress note dated 10/09/2024 at 3:25 PM revealed, alert note wandering noted as needed (Name Brand) antianxiety medication given. No other interventions noted. A review of a progress note dated 10/20/2024 at 3:37 PM revealed, as needed (Name Brand) antianxiety medication 0.5MG was given to Resident #3 when exit seeking at the front door. No other interventions noted. A review of a progress note dated 10/21/2024 at 4:00 PM revealed, as needed (Name Brand) antianxiety medication 0.5MG was given to Resident #3 for mild agitation, wandering, and entering other resident's rooms. No other interventions noted. A review of a progress note dated 10/28/2024 at 4:00 PM revealed, as needed (Name Brand) antianxiety medication 0.5MG was given to Resident #3 when hospice nurse reported Resident #3 stated they wanted to go home and began moaning, which usually means behaviors start getting worse. No other interventions noted. A review of a progress note dated 10/30/2024 at 9:31 AM revealed, as needed (Name Brand) antianxiety medication 0.5MG was given to Resident #3 when continued stating wants to go home and this usually progresses quickly to agitation and aggression. No other interventions noted. A review of a progress note dated 11/16/2024 at 3:32 PM revealed, as needed (Name Brand) antianxiety medication 0.5MG was given to Resident #3 when they were at the front door and stated, I want to go home. No other interventions noted. A review of a progress note dated 11/17/2024 at 2:33 PM revealed, as needed (Name Brand) antianxiety medication 0.5MG was given to Resident #3 when they were at the front door looking for [pronoun] husband and wanting to push the door open. No other interventions noted. A review of a progress note dated 11/29/2024 at 1:50 PM revealed, as needed (Name Brand) antianxiety medication 0.5MG was given to Resident #3 when the resident headed towards the exit door and stated they were going home. No other interventions noted. A review of a progress note dated 11/29/2024 at 2:38 PM tilted Behavior note stated, Resident #3 was assisted away from the front door by staff for closer monitoring, but when resident continued to state she wanted to go home Resident #3 was given (Name Brand) antianxiety medication 0.5MG and assisted to her recliner where they rested. A review of a progress note dated 11/30/2024 at 8:10 AM revealed, as needed (Name Brand) antianxiety medication 0.5MG was given to Resident #3 when Resident #3 began trying to stand up, walk, and asking for spouse. No other interventions noted. A review of a progress note dated 12/01/2024 at 8:04 AM revealed, as needed (Name Brand) antianxiety medication 0.5MG was given to Resident #3 when resident began trying to stand and walk saying they were going to leave. A review of a progress note dated 12/01/2024 at 9:55 AM revealed, Resident #3's chair pad alarm was not functioning. A review of a progress note dated 12/01/2024 at 1:31 PM revealed, as needed dose of (Name Brand) antianxiety medication 0.5MG was given because Resident #3 was sitting in the wheelchair quietly. A review of a progress note dated 12/13/2024 at 2:03 PM revealed, as needed dose of (Name Brand) antianxiety medication 0.5MG was given because Resident #3 was trying to standup and walk, wandering into other resident's rooms. No other interventions noted. A review of a progress note dated 12/15/2024 at 9:00 AM revealed, as needed dose of (Name Brand) antianxiety medication 0.5MG was because Resident #3 was trying to standup and walk, wandering into other resident's rooms. No other interventions noted. A review of a progress note dated 12/22/2024 at 1:49 PM revealed, as needed dose of (Name Brand) antianxiety medication 0.5MG was given because Resident #3 was wanting to go home and wheeling close to exit doors. No other interventions noted. During an interview on 01/03/2024 at 10:26 AM, the Director of Nursing (DON) stated antianxiety behaviors should not be given for exit seeking behaviors. Non-medication interventions should be used like redirection which usually works when they are exit seeking. DON stated we try not to administer antipsychotic medication, and she expected staff to use 3 non-medication intervention prior to administering medication. During an interview on 01/03/2024 at 12:05 PM, Resident #3's family member stated the facility sometimes used redirection with Resident #3, but the facility usually gives the resident's (Name Brand) antianxiety medication and pain medication, and the resident usually goes to sleep. Resident #3's family member reported a steady decline in both cognitive and motor function for the resident over the last few months.

Based on interviews, record review, facility document review, facility policy review, it was determined that the facility failed to accurately assess the use of a chair/bed alarm restraint on Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE] for 1 (Resident #3) of 5 residents reviewed for accuracy of assessments. Findings include: On 01/03/2025 at 11:51 AM, the Administrator stated the facility did not have a policy for MDS/Assessments, the facility followed the Resident Assessment Instrument (RAI) Manual. A review of the Admission Record, indicated the facility admitted Resident #3 with diagnoses that included dementia, malignant neoplasm of the frontal lobe (cancerous brain tumor which can cause personality changes and difficulty with concentration, communication, and controlling emotions), anxiety disorder, cognitive communication deficit, depression, muscle wasting, lack of coordination, and were unsteady on their feet. A review of Resident #3's care plan with revisions, as of 01/03/2025, revealed the resident had nine actual falls related to poor balance and an unsteady gait. On 09/03/2024 a chair/bed alarm restraint was added as a fall intervention. On 09/04/2024 the chair/bed alarm was added to Resident #3's care plan as a physical restraint. Interventions stated the chair/bed alarm was discussed with the resident and their family including risk and benefits, how the restraint would be used, and any concerns or issues regarding the restraint. The goal initiated 09/06/2024 and revised on 11/16/2024 stated the resident would be free of complications regarding the use of the restraint including altered mental status, isolation, and withdrawal. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2024, revealed Resident #3 had a Brief Interview of Mental Status score of 14, which indicated the resident was cognitively intact. Resident #3 Mood Interview revealed symptoms of: A. Little interest or pleasure in doing things and B. Feeling down, depressed, or hopeless were present for several days (2-6 days of the 14-day look back period). Resident #3's Behavior symptom assessment was negative for hallucination, delusions, physical behaviors directed towards others, verbal behaviors directed towards others, other behaviors not directed towards others, rejection of care, or wandering. Resident #3's falls assessment revealed the resident had 2 or more falls since their admission resulting in no injuries. No restraints were identified, specifically the facility representative answer under restraints to bed alarm was not used and to chair alarm was not used. During an observation of Resident #3 on 01/03/2024 at 8:12 AM, Resident #3 was in the dining room eating breakfast. The resident was sitting in a wheelchair was a pad alarm restraint in the seat and the alarm operation control hanging on the handle of the wheelchair, the alarm had a flashing light indicating active. During an observation of Resident #3 on 01/03/2024 at 9:27 AM, Resident #3 was in bed asleep. The pad alarm restraint was under the resident, the alarm operation control was hanging on the bed's quarter rail and flashing active. During a concurrent observation and interview on 01/03/2025 at 11:10 AM, the Administrator was shown Resident #3's Quarterly MDS dated [DATE]. The Administrator stated he thought the alarm restraint was identified, but stated it was not. The Administrator asked to see who signed the completion of the MDS. The Administrator stated the MDS was signed by the Former Assistant Director of Nursing who was terminated partially related to issues like the MDS discrepancy. During exit conference on 01/03/2025 at 12:30 PM, the Administrator stated an updated MDS identifying the alarm restraint had already been submitted.

Based on observation, record review and interview, the facility failed to ensure the resident's wheelchairs were in good condition for 1 (Resident #30) of 1 sampled resident; and the environment was safe for 1 (Resident #69) of 1 sampled resident to ensure a safe, homelike environment. The findings are: 1. A review of Resident #30's Admission Record indicated Resident #30 was admitted with a diagnosis of Metabolic encephalopathy. The Admission Minimum Data Set (MDS), dated [DATE], revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 11, (8-12 indicates moderately cognitively impaired), and required maximum assistance for transferring. On 02/21/24 at 12:13 PM, observed Resident #30 in a wheelchair. The vinyl on the right arm of the wheelchair was cracked, torn, and ripped with foam exposed. On 2/22/2024 at 2:02 PM, observed Resident #30 sitting in a wheelchair . The vinyl on the right arm of the wheelchair was cracked and torn, with foam exposed. The vinyl of the left arm of the wheelchair was torn with a hole, 1 centimeter in diameter, with foam exposed. Resident #30 was asked did you bring this wheelchair from home? Resident #30 stated, No, I think it might be therapy's, they gave it to me. Review of Resident #30's Care Plan, revised on 2/5/2024, revealed the resident had limited physical mobility related to weakness. Interventions, initiated on 1/31/2024, LOCOMOTION: The resident uses a manual wheelchair for locomotion. Review of the Maintenance Logs dated 2/1/2024 - 2/18/2024 with no documentation for R#30 wheelchair arm being torn, ripped, or needing to be replaced. Review of the Maintenance Logs dated 1/15/2024 - 1/31/2024 with no documentation for Resident #30's wheelchair arm being torn, ripped, or needing to be replaced. On 2/22/2024 at 2:13 PM, Certified Nursing Assistant (CNA) #1 was asked, what do you do if something needs to be fixed? CNA #1 stated, Do a maintenance report at the nurses station. CNA #1 was asked, when should a resident's wheelchair arms that are torn and ripped be reported? CNA #1 stated, When it started cracking and ripping. On 2/22/2024 at 2:17 PM, Physical Therapist (PT) #1 was asked, who provided Resident #30 the wheelchair? PT #1 stated, I do not know who gave it to her. On 2/22/2024 at 2:19 PM, PT #2 was interviewed via telephone. PT #2 was asked, whose wheelchair does Resident #30 have and is using? PT #2 stated, It's the facilities. PT #2 was asked, who is responsible for ensuring the arms of the resident's wheelchairs are not cracked, torn, and ripped with foam exposed? PT #2 stated, Maintenance, if we have another bariatric chair, we could switch them out. On 2/22/2024 at 2:26 PM, Maintenance #1 was asked how do staff notify you of things that need to be fixed? Maintenance #1 stated, They write it in the book. Maintenance #1 was asked, who is responsible for ensuring the wheelchair arms are not ripped and torn? Maintenance #1 stated, Normally we check the wheelchair arms, wheelchair arms should not be ripped or torn. Maintenance #1 was asked, who is responsible for reporting things like the arms of the resident's wheelchairs if they need to be fixed? Maintenance #1 stated, The nurse or CNA working on the hall should report it, sometimes I find it myself, but normally they would report it. 2. On 2/20/2024 at 11:58 am, when exiting from Resident #69's room, the Surveyor noticed the threshold between Resident #69's room and the hallway was loose. On 02/22/24 at 1:45 PM, the threshold between Resident #69's room and the hallway was still loose. On 2/22/2024, the Director of Nursing (DON) was asked if she was aware of the loose threshold at Resident #69's door. The DON said no. The DON was asked if having a loose threshold could cause any issues. The DON said that it was not good and needed to be fixed.

Based on observation and interview, the facility failed to ensure fiber-fortified therapeutic malnutrition feedings and liquid supplements had been discarded by the expiration date. The findings are: 1. On [DATE] at 2:53 PM, during a tour of the additional Storage Room with the Director of Nursing (DON) the following observations were made: a. On bottom shelf of shelving unit there was a box of nutritional supplement with four plastic bottles with a brown colored thick liquid with an expiration date of February 1, 2024. b. On the bottom shelf of the shelving unit there was a box of 47, four-ounce sealed containers labeled Honey Water with pale yellow liquid, with an expiration date of [DATE]. c. On the bottom shelf of shelving unit there were two boxes of nutritional formula 1.4 calorie/milliliter with 12 cartons in each box. There were two cartons of the nutritional formula 1.4 calorie/milliliter sitting in front of the boxes, with an expiration date of [DATE]. The Surveyor asked the DON, What would happen if the residents were given any of the expired products? The DON replied, They would be poisoned. The contents would be altered. 2. On [DATE] at 3:53 PM, the DON stated there was no policy for Storage of Nutritional Supplements.

Based on observation and interview, the facility failed to ensure food items were stored to prevent potential food borne illness as evidenced by individual milk cartons stored on top of raw meat. The findings are: On 2/20/2024 at 11:15 AM, during a kitchen tour, next to the employee entrance, the second freezer on the right, on the lower shelf was observed: a. An unopened package of 10 pounds of ground-up beef, with leaking pink, greyish thick semi-thick fluid and brown patches draining in a clear plastic tub in the bottom of the freezer. In addition, a smaller plastic tub of 8 (eight) closed cartons of milk products was stored on top of the raw meat. b. On 2/20/2024 at 11:20 AM, the Dietary Manager was asked, How and where should raw meat be stored? The Dietary Manager stated, Raw meat should be stored away from all other food and in the bottom of the freezer. The Surveyor asked, Why should milk products not be stored on top of the raw meat. The Dietary Manager responded, We should avoid cross contamination from any dripping liquids, with other items.

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program [QAPI] Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for Food Procurement, Store/Prepare/Serve and Label/Store Drugs and Biologicals. This failed practice had the potential to affect 69 residents. The findings are: 1. A Recertification survey was conducted on 11/17/2022 at the facility. During this survey, the team identified concerns with food storage and medication storage. a. A review of the facility's Plan of Correction, with a completion date of 12/9/2022 indicated the Administrator/Designee will monitor to ensure that staff are sanitizing their hands after each meal tray is delivered by observation and documentation of varying meal services on a flowsheet 5 X weekly for 4 weeks. Any negative findings will be corrected immediately, and Administrator notified. Administrator/ Designee will present all findings to the monthly/quarterly QA committee for further review and recommendations. b. A review of the facility's Plan of Correction, with a completion date of 12/9/2022 indicated the Administrator/Designee will monitor each documentation on a flow sheet 5 times per week for 4 weeks or until compliance is verified by OLTC. Any negative finding will be corrected immediately, and Administrator/Designee notified. medication cart by observation and Administrator/Designee will present all findings to the monthly/quarterly QA committee for further review and recommendations. 2. A Recertification survey was conducted on 2/9/2024 at the facility. During this survey, the team identified concerns with food and medication storage. Cross Reference F812 and F761. 3. A review of the policy titled, Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI), dated 10/18/2022, specified, It is the policy of the facility to develop a QAPI plan in accordance with federal guidelines to describe how the facility will address clinical care, resident quality of life and residents' choice, based on the scope and complexity of services defined by the Facility Assessment. The plan will include effective data collections systems to identify, collect and use data relevant to the unique characteristics and needs of the facility's residents, including feedback and input from direct care staff, other staff, residents, and resident representatives, and how such information will used to monitor and identify adverse events and problems that are high risk, high volume, or problem-prone, and opportunities for improvement. 5. On 2/23/2024 at 8:47 AM, the Administrator was asked, how does the QAA Committee know when an issue arises in any department? The Administrator stated, Collecting data and interviewing staff, indicating there's an issue we need to address. The Administrator was asked how does the QAA Committee know when a deviation from performance or a negative trend is occurring? The Administrator stated, You will see a trend. The Administrator was asked how does the QAA Committee decide which issues to work on? The Administrator stated, Priority and safety, anything that's immediate safety for the residents. The Administrator was asked how long will the QAA Committee monitor an issue that has been corrected? The Administrator stated, Usually thirty days. The Administrator was asked, is the QAA Committee aware of repeated survey deficiencies? The Administrator stated, We review them with the team and monitor and see where we are at. The Administrator was asked if the Committee implement corrective action? The Administrator stated, Yes. The Administrator was asked, is the Committee monitoring to ensure corrective action has been implemented? The Administrator stated, We do daily rounds, we have startup/standup, at the end of the day we do stand down, did the interventions get put in place. The weekend supervisor makes rounds on the weekends.

Based on observations, interviews, and facility policy review, the facility failed to ensure medications were securely stored to prevent unauthorized access. Specifically, the facility: - failed to ensure two (200 Hall and 400 Hall) of three medication carts were locked when unattended. - failed to ensure one (100 Hall) of three medication carts was maintained in good repair to allow all drawers that contained medications to be closed and locked. Findings included: Review of a facility policy titled, Medication Storage in the Facility, effective 01/01/2015, revealed, Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 1. During a concurrent observation and interview on 11/16/2022 at 8:12 AM, Licensed Practical Nurse (LPN) #1 prepared medications for a resident in room [ROOM NUMBER]. The 200 Hall medication cart was parked directly outside room [ROOM NUMBER], which was across the hall from room [ROOM NUMBER]. LPN #1 was advised by the surveyor that since the medication pass for the resident in room [ROOM NUMBER] had already started, the surveyor would observe medication administration for the next resident who had medications due. LPN #1 took medications in a medication cup into room [ROOM NUMBER]. LPN #1 left the second drawer of the medication cart open approximately one inch, and there was a medication bubble pack sticking slightly out of the drawer. LPN #1 also left the medication cart unlocked. The medication cart was not visible to LPN #1 after she entered room [ROOM NUMBER]. LPN #1 returned to the cart and stated, The medication cart should have been locked. I forgot to lock it. I am sorry. During a concurrent interview and observation on 11/16/2022 at 8:16 AM, LPN #2 was at the 400 Hall medication cart located between rooms [ROOM NUMBERS]. LPN #2 left the cart, walked across the hall diagonally, and entered room [ROOM NUMBER], leaving the medication cart unlocked and unattended. The medication cart was not visible to LPN #2 after she entered room [ROOM NUMBER]. At 8:17 AM, LPN #2 came back to the medication cart, looked at the lock, inserted the key into the lock, locked the cart, then turned the key and unlocked the cart. LPN #2 stated that she had to go into a resident's room and should have locked the cart. During a concurrent interview and observation on 11/16/2022 at 8:32 AM, the surveyor approached the medication cart assigned to LPN #1. LPN #1 was in room [ROOM NUMBER]. The surveyor observed a medication bubble pack on top of the medication cart with medication inside the bubble pack. The medication cart was also noted to be unlocked and unattended. LPN #1 returned to the medication cart and stated, Oh goodness, when she saw the surveyor, then grabbed the medication bubble pack and put it back into the cart before the surveyor could identify the type of medication. LPN #1 stated, When I leave my cart, I am supposed to lock it and shut the computer screen off. I am new to this. This is my first nursing home job. During an interview on 11/16/2022 at 12:03 PM, the Director of Nursing (DON) stated staff should ensure the medication cart was locked when unattended. She indicated there should be no medication left on top of the cart and the medication cart drawers should all be shut. During an interview on 11/16/2022 at 12:12 PM, the Administrator stated staff should ensure that the medication cart was locked when unattended and that all medication was inside the cart before it was locked. 2. During a concurrent interview and observation on 11/16/2022 at 11:35 AM, LPN #4 positioned the 100 Hall medication cart to face room [ROOM NUMBER] before she entered the resident's room to administer medication to the resident. The second drawer of the medication cart was slightly open; however, the medication cart was locked. When LPN #4 returned to the cart, she was asked to attempt to open the second drawer of the medication cart without unlocking the cart. LPN #4 stated, It's broken. The LPN indicated she had noticed the drawer the previous day and notified the Administrator, who stated the facility would have to order a part. The LPN stated, I told [Administrator] that I was just going to turn the cart around facing the wall or the nurse's station. The surveyor observed that LPN #4 was able to open the second drawer of the medication cart while the medication cart was locked. LPN #4, who was also assigned to pass medications on the secured Dementia Unit, stated that for the unit, I take the cart with me on the unit and turn it toward the door. When asked how she ensured that confused ambulatory residents did not tamper with the medication cart, she stated, Most of my people are right at the door, not at my cart. During an interview on 11/16/2022 at 12:03 PM, the DON stated maintenance had looked at the 100 Hall medication cart and ordered parts for it. The DON stated having a medication cart with a broken drawer could allow anyone to open the cart, which could lead to loss of medication or a resident taking the wrong medication. The DON stated the staff was safeguarding the medication cart by keeping it at the nurse's station to always keep watch of the cart. The DON stated no one had provided education to the staff on how to safely secure the medication if the nurse took the medication cart down the hall and stepped into a resident's room. The DON stated she supposed the nurse could turn the medication cart around and face the wall, but the facility did not put any interventions in place to safeguard the broken medication cart. During an interview on 11/16/2022 at 12:12 PM, the Administrator stated he was notified of the broken medication cart on 11/15/2022, and maintenance attempted to fix the medication cart but had to order a part. The Administrator stated he had told staff to keep the medication cart turned around and in sight when the cart was in use. The Administrator stated he was in the process of trying to find another medication cart to use. He confirmed that no education had been provided to staff regarding the medication cart, due to there only being two nurses who worked with the 100 Hall medication cart. The Administrator stated the day shift nurse was told to notify the night shift nurse about the malfunctioning cart. The Administrator stated the nurse assigned to the cart would have to bring the cart to the doorway, facing the doorway, so the medication cart would be in the nurse's direct line of sight. The Administrator stated the facility would move all medications from the second and third drawer to an unused treatment cart until the medication cart could be fixed. During an interview on 11/16/2022 at 12:32 PM, the Maintenance Consultant reported having ordered a part for the 100 Hall medication cart after becoming aware on 11/15/2022 that the medication cart was malfunctioning.

Based on observation, interview, and record review, the facility failed to ensure hands were consistently sanitized, to prevent the potential for cross contamination between food trays during the lunch meal service on 2 (200 Hall and 400 Hall) of 4 (100 Hall, 200 Hall, 300 Hall and 400 Hall) halls. This failed practice had the potential to effect 30 residents who received meal trays on 200 and 400 Halls. The findings are: a. On 11/14/22 at 12:31 PM, Certified Nursing Assistant (CNA) #1 was passing meal trays on the 200 Hall. CNA #1 delivered two trays in Resident room [ROOM NUMBER]. CNA #1 did not sanitize and/or wash her hands prior to entering the tray cart, between trays, or after coming from the resident room. b. On 11/14/22 at 12:33 PM, CNA #1 removed a tray from the meal tray cart, she entered room [ROOM NUMBER], that was noted to have enhanced precaution signage outside the door with PPE [personal protective equipment] available. Without sanitizing her hands first. She placed the tray on top of residents overbed table and moved items to make room for the tray. Once the tray was set up, she exited the room. Without sanitizing her hands, she returned to the tray cart, reached for the handle and at this time the Surveyor stopped her. The Surveyor asked if she used ABHS [alcohol based hand sanitizer] before entering room [ROOM NUMBER]. She just looked at this surveyor. The Surveyor asked again, Did you use ABHS when you exited the room? She stated, No, was I supposed to. The Surveyor asked, What type of isolation is the resident in room [ROOM NUMBER] on? She stated, I don't know. CNA #1 then turned to the room, and stated Oh, enhanced precautions. The Surveyor asked, Does that mean that you are to use ABHS when entering and exiting the room? She stated, I guess. The Surveyor asked, Are you supposed to use ABHS between the trays you serve? She stated, Yes. The Surveyor asked, Did you use ABHS between the trays you were serving? She stated, No, I didn't. c. On 11/16/22 at 3:45 PM, the Surveyor asked the Administrator a policy regarding passing meal trays and hand sanitation. After searching through available policies that did not address hand sanitation with meal tray service. The Surveyor asked if the Nurse Aides (CNAs) were trained to sanitize their hands between meal trays passed. He stated, .Yes, they are . d. On 11/16/22 at 3:56 PM, the Surveyor asked the Director of Nursing (DON), Do you expect staff to sanitize their hands between trays when passing out meal trays? She stated, .Yes, I expect them to use alcohol gel between trays . The Surveyor asked, Do you expect the facility staff to follow the policies and procedures of the facility? She stated, .Of course, I do . 46659 e. Observations on 11/14/2022 at 12:42 PM revealed Certified Nursing Assistant (CNA) #5 and Licensed Practical Nurse (LPN) #4 distributing meal trays to residents on the 400 Hall. CNA #5 did not wash her hands or use hand sanitizer between handling and passing meal trays to different residents or before reaching back into the tray cart to obtain the next tray. f. During an interview on 11/14/2022 at 1:15 PM, LPN #4 stated when passing meal trays, staff were to use hand sanitizer before and after each meal tray was handled. g. During an interview on 11/14/2022 at 2:16 PM, CNA #6 stated when staff passed meal trays, they were supposed to use hand sanitizer between each meal tray. h. During an interview on 11/14/2022 at 2:26 PM, CNA #7 stated he was taught to use hand sanitizer between each meal tray when meal trays were distributed to residents. i. During an interview on 11/14/2022 at 2:30 PM, CNA #5 stated she knew she was supposed to use hand sanitizer when passing meal trays. CNA #5 stated she had no excuse for why she did not use hand sanitizer and indicated by not using hand sanitizer, she could have spread germs between residents. j. During an interview on 11/16/2022 at 3:45 PM, the Administrator stated the facility did not have a policy regarding the use of hand sanitizer when distributing residents' meal trays. k. During an interview on 11/17/2022 at 12:48 PM, the Director of Nursing stated she expected staff to sanitize their hands between every meal tray. l. During a follow-up interview on 11/17/2022 at 1:46 PM, the Administrator stated he expected the staff to clean their hands with hand sanitizer between meal trays. m. The facility policy titled, Handwashing/Hand Hygiene, documented, .This facility considers hand hygiene the primary means to prevent the spread of infections . 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .

Based on observations, interviews, and record review, the facility failed to ensure staff consistently assisted a resident to apply hearing aids for 1 (Resident #30) of 1 sampled resident reviewed for vision/hearing devices. The failed practice had the potential to negatively impact the resident's ability to hear and communicate with staff, other residents, and visitors. Findings included: Review of an Admission Record revealed Resident #30 had diagnoses including Parkinson's disease and muscle weakness. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #30 scored 10 on a Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. The MDS did not indicate the resident had impaired hearing or used hearing aids. Review of a Nsg. [Nursing] Admit/Readmit/Quarterly Assessment, dated 04/15/2022, revealed Resident #30's hearing was highly impaired and that the resident used hearing aids in both ears. Review of a care plan, dated as initiated 04/18/2022, revealed Resident #30 had a communication problem related to a hearing deficit. A planned intervention was for staff to ensure the left and right hearing aids were in place. During an interview on 11/14/2022 at 2:12 PM, two of Resident #30's family members were visiting the resident. They reported that staff did not always put in the resident's hearing aids. The family member stated Resident #30 needed the hearing aids. Resident #30 was observed at this time, and no hearing aids were in place in the resident's ears, nor were the hearing aids properly placed on the charger. Observations in Resident #30's room on 11/14/2022 at 2:51 PM revealed Resident #30 was still not wearing the hearing aids. The resident's family members stated the hearing aids were, not even in the charger the right way. During an interview on 11/14/2022 at 2:52 PM, Certified Nursing Assistant (CNA) #6 stated he had not assisted Resident #30 with placement of the hearing aids. He stated the resident did not want them in today. He indicated he did not ask the resident about the hearing aids today, but another staff member did. CNA #6 revealed the hearing aids would ring real loud and the staff did not know what to do about that, so left them out. During an interview on 11/14/2022 at 3:02 PM, CNA #5 stated Resident #30 did not have hearing aids in that day (11/14/2022). CNA #5 stated staff should ask the resident if they wanted the hearing aids and assist the resident with putting them in. An observation on 11/15/2022 at 1:22 PM revealed Resident #30 was not wearing the hearing aids. During an interview on 11/15/2022 at 1:23 PM, CNA #7 stated he asked Resident #30 if the resident wanted to wear the hearing aids and the resident did not want them. CNA #3 acknowledged he was not sure if Resident #30 had heard the question, since the resident was hard of hearing. During an interview on 11/17/2022, the Director of Nursing (DON) stated she expected staff to assist residents with putting in their hearing aids. She indicated staff should assist the residents with whatever they needed. During an interview on 11/17/2022 at 1:46 PM, the Administrator stated he expected staff to assist residents with placement of their hearing aids as part of the residents' daily care. According to the Administrator, the facility did not have a policy regarding care residents' hearing aids.

Based on observations and interviews, the facility failed to ensure residents' personal health information (PHI) was kept secure during medication administration by one (Licensed Practical Nurse [LPN] #1) of three nurses observed during a medication pass. Findings included: During a concurrent observation and interview on 11/16/2022 at 8:12 AM, LPN #1 prepared medications for a resident in room [ROOM NUMBER]. The medication cart was parked directly outside of room [ROOM NUMBER], which was across the hall from room [ROOM NUMBER]. LPN #1 took the medication cup and entered room [ROOM NUMBER]. LPN #1 left the computer screen up with the facility's electronic health record (EHR) program's Medication Administration Record (MAR) screen visible, which included the names, photos, and room numbers of the residents assigned to the care of LPN #1. During a concurrent interview and observation on 11/16/2022 at 8:32 AM, the surveyor approached the medication cart assigned to LPN #1. The cart was in the same position as previously observed, and LPN #1 was in room [ROOM NUMBER]. The surveyor observed the computer screen was open, with the facility's electronic health record program visible, including the names, photos, and room numbers of residents assigned to the care of LPN #1. LPN #1 returned to the medication cart and stated, Oh goodness, when she saw the surveyor standing by the medication cart. According to LPN #1, When I leave my cart, I'm supposed to lock it and shut the computer screen off. I'm new to this. This is my first nursing home job. During a concurrent observation and interview on 11/16/2022 at 8:48 AM, the surveyor approached the medication cart assigned to LPN #1. The surveyor noted LPN #1 was in room [ROOM NUMBER]; however, the medication cart's computer screen was visible with the facility's electronic health record program visible, which included the names, photos, and room numbers of residents assigned to the care of LPN #1. LPN #1 returned to the medication cart and acknowledged she had left the EHR visible and stated, You may as well mark me down for everything wrong today. During an interview on 11/16/2022 at 12:03 PM, the Director of Nursing stated staff should apply a screen saver on the computer or minimize the EHR before leaving the medication cart to ensure residents' records remained confidential. During an interview on 11/16/2022 at 12:12 PM, the Administrator stated the facility did not have a policy regarding protecting resident PHI, and that staff should ensure their computer screen was locked when the medication cart was unattended.

Based on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was consistently worn while providing direct care for 1 (Resident #4) of 1 sampled resident who had physician's orders for Contact Isolation according to a list provided by the Administrator. The findings are: Resident #4 had a diagnosis of Methicillin Resistant Staphylococcus Aureus Infection. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/2022 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) a. The Care Plan documented, .I have an infection of the L [left] knee joint. Date Initiated: 03/18/2022 . b. The November 2022 Physician's Orders documented, .Contact Precautions R/T [related to] MRSA [Methicillin Resistant Staphylococcus Aureus] Wound . Order Date 11/01/2022 . Clindamycin HCl [hydrochloride] Capsule 300 MG [milligram] Give 1 capsule by mouth three times a day for R [right] knee infection related to Infection and Inflammatory Reaction due to Internal Left Knee Prosthesis, Subsequent Encounter . for 62 Administrations . Order Date 11/03/2022 Contact Precautions R/T [related to] MRSA [Methicillin Resistant Staphylococcus Aureus] Wound . 11/1/2022 . c. On 11/14/22 at 11:56 AM, Licensed Practical Nurse (LPN) #3 was Resident #4 obtaining a blood glucose and the only PPE he was wearing were gloves. When he exited the room, he removed his gloves and placed them in the trash on the side of the medication cart. The glucometer was placed in the top drawer of the medication cart. The isolation signage outside the door stated, Contact Precautions. The Surveyor asked LPN #3 if Resident #4 was in isolation. He stated, She's in enhanced precautions, as long as you don't have any contact with her, you don't need to wear any PPE. The Surveyor asked what the isolation was for. He stated, She has infection in her knee. The Surveyor asked, Is it MRSA? He stated, I'm not sure, I just know it's in her knee. The Surveyor stated, The sign states contact precautions. He stated, Oh, I thought she was in enhanced precautions. The Surveyor asked, Does that mean you should be wearing PPE when entering her room? He stated, Yes, I should. d. On 11/17/2022 at 10:50 AM, the Surveyor asked the Director of Nursing (DON), What was [Resident #4's] diagnosis for her contact isolation? She stated, .I think MRSA . The Surveyor asked, With contact isolation what type of PPE is required? She stated, .With contact, gown gloves, mask . The Surveyor asked, When should it be donned? She stated, .As you enter the resident's room . The Surveyor asked, When should it be doffed? She stated, .Before I leave the room, and dispose of PPE in the room . The Surveyor asked, Should a resident in contact isolation have their own personal non emergent equipment? She stated, .Yes, they should. If the item isn't available, then they could get it for the resident and leave in the room, or if it couldn't be left then it should be cleaned and left for however many minutes are required . The Surveyor asked, Should [Resident #4] have her own glucometer to prevent cross contamination related to using the same glucometer on more than one resident? She stated, .I would give her one, should she have her own, yes. If she didn't have one, I would get her one . The Surveyor asked, Should gloves be worn outside the resident's room after checking the residents blood glucose? She stated, .They should be removed before leaving the room . The Surveyor asked, Should a glucometer be cleaned prior to returning to the medication cart draw? She stated, .Absolutely . The Surveyor asked, Should a glucometer used in a contact isolation room, be brought out of the room and placed into the medication cart without being appropriately sanitized? She stated, .No ma'am . The Surveyor asked, What is a potential outcome if items used with contact isolation residents are not appropriately sanitized prior to returning them to the medication cart? She stated, .Cross contamination . The Surveyor asked, Do you expect the facility staff to follow the policies and procedures of the facility? She stated, .Of course, I do . e. The facility policy titled, Isolation Precautions, Categories of provided by the Administrator on 11/14/2022 at 10:30 AM documented, .Transmission-based isolation precautions have been established in order to ensure that appropriate isolation techniques are implemented in this facility when necessary ., Contact ., In addition to standard Precautions, Contact Precautions must be implemented for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environment surfaces or resident-care items in the resident's environment ., Examples of infections requiring Contact Precautions include, but are not limited to: ., Infections with multi-drug resistant organisms ., Gloves and Handwashing ., Wear gloves (clean, nonsterile) when entering the room ., Gown ., Wear a disposable gown upon entering the Contact Precautions room ., Resident Care Equipment ., When possible, Dedicate the use of non-critical Patient-care equipment ., To avoid sharing between patients .

Based on record review and interview, the facility failed to ensure a resident who had exhibited multiple exit seeking behaviors had resident specific interventions in place to prevent an actual elopement for 1 (Resident #1) of 3 (Residents #1, #2, and #3) sampled residents who were at risk of elopement. This failed practice resulted or could have resulted in serious injury, impairment, harm, or death. The facility was notified of the Past Immediate Jeopardy on 9/26/22 at 4:39 PM. This failed practice had the potential to affect 11 residents who were at risk for elopement per a list provided by the Administrator on 9/26/22 at 4:47 PM. The findings are: 1. Resident #1 had diagnoses of Unspecified Dementia, Polyneuropathy and Hypertension. An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/7/22 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), had no behaviors of wandering, used a wheelchair and required limited physical assistance of one person with locomotion on and off the unit. a. The Care Plan with a review date of 08/08/2022 documented, Focus [Resident #1] is a high risk for wandering r/t [related to] dementia, Date Initiated: 09/26/2022 . Goal [Resident #1's] safety will be maintained through the review date. Date Initiated: 07/23/2020 . [Resident #1] will not leave facility unattended through the review date. Date Initiated: 03/02/2021 . Interventions/Task Distract [Resident #1] from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 03/02/2021 . Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is [Resident #1] looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 02/10/2022 . b. The Nurses Note dated 8/10/22 documented, .22:00 [10:00 PM] Resident exit seeking claiming she was looking for her parents. Resident was redirected and calmed down . c. The Behavior Note dated 8/29/22 at 2:33 AM documented, .Behavior Identified: wandering/exit seeking Interventions .: redirection Intervention Effective: no . d. The Behavior Note dated 8/30/22 at 17:56 (5:56 PM) documented, .Behavior Identified: wandering. Describe Interventions Used .: redirection, blocking exits. Intervention effective: redirection occ. [occasionally] works and blocking exits work most of time. Continue to monitor frequently . e. The Behavior Note dated 8/31/22 at 06:11 [6:11 AM] documented, .Behavior Identified: wandering into residents' rooms, exit seeking and pressure checking doors. Resident gets upset and attempts to strike out when staff stop her from opening doors. Describe Interventions .: Therapeutic talk, monitoring resident for exit seeking, reorientation. Intervention Effective: Occasionally Effective: Resident resists intervention . f. The Behavior Note dated 8/31/22 at 10:26 AM documented, .Behavior Identified: wandering and trying to escape out doors. Describe Intervention .: redirect, distraction. Intervention Effective: Not effective at this time . g. The Behavior Note dated 9/14/22 at 6:01 AM documented, .Behavior Identified: wandering, attempting to open doors, exit seeking. Describe Interventions Used .: distraction, redirection. Intervention Effective: Effective for short times but resident will begin to exit seek again within several minutes of redirection . h. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long Term care Facilities (DMS-762) form documented, . Date and Time of Incident (if known): 09/21/2022 Time: 3:40 PM; Date and Time of Discovery: 09/21/2022 3:56 PM.Section II - Complete Description of Incident . Resident exited the building at 3:40 PM by pressing on the door until the delayed egress unlocked the door unattended by staff and was noticed by a staff member in the parking lot at 3:56 PM. Resident was escorted back into the facility and assessed by nursing staff. Residents head to toe assessment revealed no injuries of any kind, body temperature was 98.4, with no sign or symptoms of heat exhaustion or dehydration. Resident was in good spirits and reported she just wanted outside to go shopping. Administrator was notified. Family was notified of incident . Section III - Findings and Actions Taken .Administrator reviewed camera footage. Resident exited the building at 3:40 PM by pressing the door until the delayed egress unlocked the door unattended by staff. A staff member came to check the door and looked out the glass, but the resident had already ambulated around the corner out of line of sight from the doorway. Resident can be seen on camera as she ambulated in wheelchair around to the front door of the facility. Resident was noticed by nursing staff member in the parking lot at 3:56 PM. Resident was noticed by a staff member in the parking lot at 3:56 PM. Resident was escorted back into the facility and assessed by nursing staff. Residents head to toe assessment revealed no injuries of any kind, body temperature was 98.4, with no sign or symptoms of heat exhaustion or dehydration. Resident was in good spirits and reported she just wanted outside to go shopping. Administrator was notified. Family was notified of incident. Head count was performed, and all other residents accounted for. Administrator immediately moved resident to the secure unit due to exit seeking behavior. Administrator immediately began to inservice all staff on elopement and procedure to follow when a door alarm sounds . i. On 9/26/22 at 10:52 AM, the Surveyor asked the Director of Nursing (DON), What can you tell me about the elopement of [Resident #1]? She stated, I was not here when it happened. The Nurse called me and said resident had gotten outside and was in the parking lot. They brought her back in and did assessment. [Licensed Practical Nurse (LPN) #1] our Admission Nurse heard the alarm and she looked out the door and she saw no one. A CNA [Certified Nursing Assistant] was on break and saw the resident in the parking lot in her wheelchair. The Surveyor asked, Was she at risk for elopement? She stated, No, not at that time. She is now on the secure unit due to this incident. She was not an elopement risk at the time of the incident. We have inserviced all staff on elopement and what to do when the alarm goes off. If the alarm goes off they will go outside and check all around facility. We also did a complete head count of all residents. We have had no elopements since I have been here 2 years, and my Consultant said there had been no elopements from this building in her [AGE] years here. The residents we have at risk do not attempt to exit the building. They are at risk due to their number score. j. On 9/26/22 at 11:09 AM, the Surveyor asked LPN #1, What can you tell me about [Resident #1] exiting the building? She stated, I came out of my office, and I heard an alarm. I tried to figure out where it was coming from. I go into the dining room and it's not coming from there. I walk down the 300 Hall and the closer I get, I know it's 300 [Hall]. I opened the door, looked outside, and didn't see anybody. I cleared the door. I went around the hall with my CNA and checked all the residents on the 300 Hall. [Resident #1] resided on the 400 Hall and I had never seen her anywhere other than her room or the sitting area at the front. We have been inserviced since this when the alarm is sounding go outside all around facility. I've been here since 2018 and have not had an elopement in that time. We have elopement drills often. k. On 9/26/22 at 12:41 PM, the Surveyor asked LPN #2, Have you ever witnessed [Resident #1] attempting to exit the facility? She stated, On 8/31/22 when she was exit seeking and pressure checking doors, she had been at either the front door or the 300 Hall door putting her hands on the glass. She says she's waiting for her parents or looking for sister. She then went to resident doors and would jiggle the knobs. Some of them requested to have their doors shut. The Surveyor asked about her note on 9/14/22 at 6:01 AM and she stated, She was in her wheelchair and would press the bar and jiggle on the front door and I think the 400 door. After redirected, she would roll back toward the doors. I did report to [DON] and she was going to talk to [Administrator] about it and the last I heard they were making preparations [from day shift nurse] I think it was [LPN #3] that they were going to move her back on the unit and then she got out. l. On 9/26/22 at 1:19 PM, the Surveyor asked LPN #3, Prior to [Resident #1] exiting the facility on 9/21/22, had you ever witnessed exit seeking behaviors from her? She stated, Yes, on several occasions. She wanders and there's times she will go to several of the doors. She will grab the bar or glass. One time she set the alarm off, but we were already going toward her and she didn't open it that time. You can usually redirect her but it's for short periods. The last couple of months have been worse for her. It's been at least a month ago [Administrator] had told me that he had her on wait list to go on the unit. I had told them, [Hall Manager] and had told [DON] and I believe [DON] talked to [Administrator]. I know I told them at least a couple of times about her exit seeking behaviors because I was worried about her, and I can't watch her 24/7. m. On 9/26/22 at 1:35 PM, the Surveyor asked the DON, Was it ever reported to you that [Resident #1] had been exhibiting exit seeking behaviors? She stated, They have all said that they told me. I don't remember it. I can't pinpoint a time that they would have told me. I have documented that she was wandering in the hallways and brought her to high visible areas. The Surveyor asked, Had you ever seen her at the doors? She stated, No. The Surveyor asked, Were you aware she was going to be placed back on the when a bed was available? She stated, No. n. On 9/26/22 at 1:56 PM the Surveyor asked the Administrator, Were you aware prior to [Resident #1] exiting the facility on 9/21/11 that she had been exhibiting exit seeking behaviors? He stated, No. The Surveyor asked, Had you told any staff that she was on a waiting list to be placed on the unit? He stated, No, I started reading the notes Friday and found where she had been trying to exit the facility. o. On 9/26/22 at 3:27 PM, the Surveyor asked the DON, What is the difference between wandering and exit seeking? She stated, I think exit seeking is pushing on doors till it alarms and if they verbalize, they want out while pushing on the door. Wandering is going up and down the halls and into other resident's rooms. The Surveyor asked, Where are your monitoring forms for exit seeking behaviors? She stated, We don't have any monitoring forms. p. On 9/27/22 at 9:58 AM, the Surveyor asked CNA #1, Have you ever witnessed [Resident #1] attempting to exit the facility and if so, what did you do? He stated, I've seen her wander but never push on the door. q. On 9/27/22 at 10:10 AM the Surveyor asked CNA #3, Have you ever witnessed [Resident #1] attempting to exit the facility and if so, what did you do? He stated, Yes, one time I saw her, and she was pushing on the door, and I took her to her room and turned on the TV. I have had nurses and CNAs from the night shift tell me that she had been attempting to get out and to watch her close. Once or twice the nurse on day shift told me to watch her because she had been trying to get out. 2. The Inservice Education Report conducted by the Administrator on 9/21/22 documented, Any time a door alarm sounds you must step outside the door and check the area for a possible elopement . See attached signature sheet and handouts . Attached was the staff signatures, a head count of all residents immediately after Resident #1 was brought back into the facility. Resident #1 was placed on the Secure Unit after being assessed and a new elopement risk assessment was completed with a score of 13 which is indicative of high risk to wander. Due to the facility correcting this failed practice prior to the survey it resulted in a Past IJ and on 9/26/22 at 4:39 PM the Administrator, DON and Consultant were notified of this finding. 3. The facility's policy titled, Elopement and Wandering, provided by the DON on 9/26/22 at 3:52 PM documented, .Appropriate measures will be implemented to identify and respond promptly to elopement and wandering. Procedure Assessment: 1. All residents that ambulate independently, with or without the use of an assistive device or wheelchair will be assessed on admission, quarterly and with a significant change for risk of elopement and wandering. 2. Interventions will be developed according to the resident's specific needs. 3. All residents identified to be at risk for Elopement or wandering shall have a plan of care developed.Prevention and Response: .3. It is the responsibility of all employees to immediately report to the charge nurse or Director of Nursing any attempt by a resident to leave the premises, or suspicion that a resident is missing from the facility . 4. The above failed practice resulted in a past Immediate Jeopardy due to the facility correcting the failed practice prior to the survey. The Administrator, the DON and the Consultant were notified of the Past Immediate Jeopardy on 9/26/22 at 4:39 PM.