Every finding on record at Briarwood Community Living Center

Based on policy review, resident trust account review, medical record review, and interview, the facility failed to refund the residents' funds within 30 days of death or discharge for 1 of 1 (Resident #37) sampled resident reviewed for trust fund account statements. The findings include: 1. Review of the facility's undated policy titled, Resident Refund Process, revealed .Upon notification of a resident's discharge, the BOM [Business Office Manager] will review the resident's records and determine if any of the resident's funds are on deposit with the facility. Should the resident have funds on deposit, a final account and transfer of funds will be made to the resident, resident's legal representative.the resident's estate.A final accounting of the resident funds should be made within thirty (30) days of the discharge of the resident. 2. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including Heart Disease, Chronic Obstructive Pulmonary Disease, Hypertension, and Diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #37 had a Brief Interview for Mental Status (BIMS) assessment score of 5, which indicated severe cognitive impairment. Review of a Progress Note dated [DATE], revealed .Hospice pronounced resident as deceased . Review of Resident #37's Quarterly Trust Fund statement from [DATE] through [DATE], revealed an account balance of $1,087.65. Review of a facility bank check #1077 dated [DATE], revealed a money amount of $1087.65, to Resident #37 with a memo: To Close Account. The check was written 41 days after Resident #37 was deceased . During an interview on [DATE] at 7:50 AM, the Administrator was asked if she had a refund check from a deceased resident. The Administrator stated.The only one I have is on [Named Resident #37] and the check was not refunded within 30 days.I guess we will continue to get cited for this because the process is out of my hands and it takes more than 30 days to complete our corporate process.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure nail care was provided for 1 of 1 (Resident #6) sampled residents reviewed for ADLs. The findings include: 1. Review of the facility's policy titled, Nail Care Policy and Procedure, dated 1/2026, revealed .All residents will have nails cleaned and trimmed as needed.care provided by staff must be specific to the individuals needs of each resident to achieve the most desirable results for the resident. Review of the facility's undated policy titled, ADL [Activities of Daily Living] Care Of A Resident Policy and Procedure, revealed .Resident ADL care will be provided to the resident according to the individualized resident needs.care provided by the staff must be specific to the individual needs to each resident so as to achieve the most desirable results for the resident. 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Parkison Disease (erratic, involuntary writhing movements), Contracture of Muscle (a fixed, persistent shortening of muscle fibers and other soft tissue that restrict joint mobility), and Paraplegia (partial or total paralysis of the lower half of the body. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 scored a 00 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Resident #6 was assessed as being dependent on staff for all ADLs. Review of the Care Plan revised 6/22/26, revealed Resident #6 had an ADL self-care performance deficit and was totally dependent on staff to provide nail care. Observation and interview in the resident's room on 8/4/2026 at 9:50 AM, with LPN (Licensed Practical Nurse) A, revealed Resident #6's right thumb nail was very long, extremely thick with brownish tan crusty thickening matter under the nail that was pressing into Resident #6's right wrist causing a red indentation in the skin. No open area was present. LPN A stated, . I will cut her nails now . During an interview on 8/5/2026 at 7:24 AM, LPN A was asked who was responsible for keeping the residents nails trimmed. LPN A stated, .the certified nursing assistant (CNA) does nail care on all non-diabetic residents, and the nurse does the nail care on residents with diabetes, we check Resident #6's blood sugar twice daily so that would be my responsibility to do nail care on her . During an interview on 8/5/2026 at 8:43 AM, the Administrator was asked who was responsible for performing nail care on the residents. The Administrator stated, .the CNA's do care on the residents that don't have diabetes and the nurses do the nail care on the residents with diabetes.The resident's nails should be checked weekly .

Based on policy review, observation, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions, when large quantities of gray dust were found on overhead pipes, chains supporting the vent hood, and air conditioner/return vents; when plastic containers holding dry food items had dried substances and loose particles on top of the lids; when stainless steel tables, metal storage racks, and the steam table, were found with a brown substance that has the appearance of rust on the legs; and when the steam table had a black substance build up at the base of the legs; when a running streak of dried brown substance was found on the outside of the vent hood; when a discolored paper was found stuck underneath the rim of the vent hood; when white flakey and dark brown particles were found on the lower shelf of the milk cooler; and when a large round brown dried stain was found on the shelf paper in the cabinet where the plastic drinking glasses were stored. The facility had a census of 33 with 33 of those residents receiving a tray from the kitchen.The findings include:1. Review of the facility policy titled, Cleaning Schedule, with a revision date of 8/31/2018, revealed The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional .The department responsible for maintaining the cleanliness of the satellite kitchen is up to the discretion of the Community . 2. Observation in the kitchen on 5/27/2025 at 9:05 AM, revealed the following: a. gray dust on the overhead pipes, chains supporting vent hood, and air conditioner/return vents. b. large plastic containers holding dry food items had dried substances and loose particles on top of lids. c. a dark brown substance that has the appearance of rust on the legs of a stainless-steel table, the metal storage rack near the hand sink, and the steam table. d. a black substance build-up on the base of the legs of the steam table. e. a dried brown substance running down the outside of the vent hood. f. discolored paper underneath the rim of the vent hood. g. a large, round, brown dried stain on the shelf paper in the cabinet where the plastic drinking glasses were stored. Observation in the employee break room in the milk cooler on 5/27/2025 at 10:20 AM, revealed a white flakey dried substance and brown dried substance on the lower shelf inside the milk cooler. During an observation and interview in the kitchen on 5/28/25 at 3:52 PM, the Certified Dietary Manager (CDM) was asked should dust particles be on the air conditioner vent. The CDM stated, No . The CDM confirmed that the return vent over the 2-compartment sink should not have dust particles on it. The CDM confirmed that the metal racks and stainless- steel tables should not have rust on them. The CDM was shown the round dark brown stain on the shelf liner in the cabinet where the glasses were stored and confirmed the stain should not be there. The CDM was shown the white and brown dried flakey particles on the bottom shelf of the milk cooler in the employee break room and confirmed it was probably dried milk dripping from the containers on the upper shelf and it should not be there.

Based on observation and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 2 of 5 (Resident #8, #12, #20, #24, #26, and #337) resident shared bathrooms observed. The findings include: 1. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating Resident #12 was severely cognitive impaired, and was dependent on staff for Activities of Daily Living skills (ADLs). 2. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Anxiety, and Difficulty Walking. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating Resident #24 was cognitively intact, and required staff set up for ADLs. 3. Review of the medical record revealed Resident #337 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Vascular Implant, Thrombocytopenia, and Dissection of Artery. The MDS was incomplete and unavailable due to the projected completion date of 5/29/2025. Observation in the resident shared bathroom for Residents #12, #24 and #337 on 5/27/2025 at 9:50 AM, 11:48 AM, and 12:01 PM, revealed the following: a.1 bottle of Listerine mouthwash sitting on the paper towel dispenser, unlabeled and uncontained b. 1 clear plastic glass sitting on top of the vanity, unlabeled and uncontained c. 1 toilet plunger uncovered sitting on the floor beside the toilet, uncontained d. 1 packet of Wet One wipes on top of the toilet paper dispenser, unlabeled and uncontained e. 1 gray wash basin sitting on the floor underneath the sink, unlabeled and uncontained. During observation and interview on 5/27/25 at 12:01 PM, Licensed Practical Nurse (LPN) A confirmed the bathroom was a resident shared bathroom with Resident #12, #24, and #337. LPN A was shown the Listerine Mouthwash on top of the paper towel dispenser, unlabeled and uncontained, the Wet One wipes on top of the toilet paper dispenser, unlabeled and uncontained, the toilet plunger on the floor next to the toilet uncovered, one clear plastic drinking glass on top of the sink, and the gray wash basin underneath the sink, unlabeled and uncontained, and was asked how should these items be stored. LPN A confirmed that a resident's personal items should be put in the resident's drawer and should be labeled with their names on it, the plastic drinking glass should be taken to the kitchen to be cleaned and not be in the resident's bathroom, the mouthwash should be labeled with the resident's name and placed in the resident's drawer by their bed, and the gray wash basin should be wrapped in plastic and placed in the resident's drawer by their bed. 4. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus, Neuropathy, Abnormalities of Gait and Mobility, and Bipolar Disorder. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating Resident #8 had no cognitive impairment, and required substantial/maximal assistance to total staff dependence for ADLs. 5. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Bipolar Disorder and Chronic Pain Syndrome. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating Resident #20 had no cognitive impairment, and was dependent on staff for ADLs. 6. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Cerebral Infarction, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 10, indicating Resident #26 had moderate cognitive impairment, and required partial/moderate staff assistance for ADLs. Observations on the back hall in the shared bathroom for Resident # #8, #20,and #26 on 5/27/2025 at 9:30 AM and 11:25 AM, revealed 1 bedpan with a urinal inside it on the back of the toilet and 1 bedpan with a bath basin inside it on the bathroom floor next to the sink, unlabeled and uncontained. During an interview on 5/27/2025 at 3:15 PM, LPN A confirmed the bedpans, urinal, and bath basin should have been labeled.

Based on policy review, observation, and interview, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 5 of 12 (Residents #14, #17, #22, #28, and #29) residents when 3 (Housekeeper B, Certified Nursing Assistant (CNA) E, and Licensed Practical Nurse (LPN) A) staff members failed to change mop water and mop head after cleaning an isolation room and failed to clean resident reusable equipment before use. The findings included: 1. Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment revised September 2022, revealed, .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard .Reusable items are cleaned and disinfected or sterilized between residents .Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions .Durable medical equipment (DME) is cleaned and disinfected before reuse by another resident . 2. Review of the facility policy titled, Cleaning and Disinfecting Residents' Rooms, dated August 2013, revealed The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms .Change mop solution water at least every three (3) rooms, or as necessary .When possible, isolation rooms should be cleaned last and water discarded after cleaning rooms . 3. Review of the undated facility policy titled, Mops, revealed Clean mop heads must be applied when changing areas of mopping and when used in isolation rooms. 4. Review of the medical record revealed Resident #17 was admitted to the facility with diagnoses including Hypertensive Heart Disease, Heart Failure, Hypertension, Diabetes, Neuropathy, Pseudomonas, and Pressure Ulcer Left Heel Stage 4. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed Resident #17 has a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact, diagnoses of Multi-Drug-Resistant Organism (MDRO), Stage 4 Pressure Ulcer, and an infection of the foot with an application of a dressing. Review of the Care Plan dated 3/17/2025, revealed .I [Resident #17] am in Contact isolation r/t [related to] Pseudomonas [a bacteria that can cause an infection on the skin and in open wounds] to bilateral heel wounds .Contact isolation precautions r/t MRSA [Methicillin-Resistant Staphylococcus Aureus, an infection resistant to many different antibiotics] to bilateral heel wounds .contact isolation .PPE [Personal Protective Equipment] on door .wound to her bilateral heels . Review of the facility Order Summary Report for Resident #17 revealed, .Contact Isolation precautions for pseudomonas R [right] heel .4/23/2025 . During an interview on 5/27/2025 at 10:18 AM, Housekeeper B confirmed Resident #17 was in isolation. Housekeeper B was asked what the process was when mopping a contact isolation room. Housekeeper B stated, We use a string mop [a mop head that can be reused] .we have an all-purpose cleaner that we put in our mop water . Housekeeper B confirmed she only changes her mop water twice a day and doesn't change it after mopping a contact isolation room. Housekeeper B was asked do you use the same mop and mop water in a non-isolation room after mopping an isolation room. Housekeeper B stated, Yes .we should be using the ones (disposable mop heads) that we throw away, but we don't . Housekeeper B confirmed she doesn't change the water unless it was visibly soiled. Housekeeper B was asked if bleach or any other cleaning agent was added to the water to clean an isolation room that kills things like HIV, C-Difficile, COVID, or any infectious diseases Housekeeper B stated, No . During observation and interview on the back hall on 5/27/25 at 10:40 AM, Housekeeper B exited Resident #17's room and entered Resident #22 and #28's room. Housekeeper B was asked did you change your mop water and the mop head prior to entering (named Resident #22 and #28's room). Housekeeper B stated, No. Housekeeper B was asked how many rooms you cleaned using the same mop water and mop head that was used in Resident #17's room. Housekeeper B stated, Three. During an interview on 5/27/2025 at 11:00 AM, the Maintenance/Environmental Services (EVS) Supervisor confirmed staff should be using bleach to clean rooms of residents who are in isolation. The Maintenance/EVS Supervisor confirmed that the mop water and mop head should be changed immediately after cleaning an isolation room and it should never be used in a non-isolation room once it has been used. During an interview on 5/28/25 at 9:59 AM, the Director of Nursing (DON) confirmed that isolation rooms should be cleaned at the end of the day and staff should change the mop head and mop water before using in another resident's room. 5. Review of the medical record revealed Resident #14 was admitted to the facility with diagnoses including Dementia, Bipolar Disorder, and Delusional Disorder. Review of the quarterly MDS dated [DATE], revealed Resident #14 had a BIMS score of 3, which indicated severe cognitive impairment. 6. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including Traumatic Brain Injury, Mental Disorder, and Nontraumatic Subdural Hemorrhage. Review of the admission MDS dated [DATE], revealed Resident #29 had a BIMS Score of 11, which indicated moderate cognitive impairment. Observation on the back hall on 5/27/2025 at 11:32 AM, revealed CNA E was observed moving an overbed table from Resident #14's room down the hallway to Resident #29's room. LPN A was standing in Resident #29's room with his meal tray and placed it on the soiled overbed table. Neither LPN A nor CNA E cleaned the overbed table prior to placing the meal tray on it. Observation on the back hall on 5/28/2025 at 7:42 AM, CNA E was observed moving an overbed table down the hallway to Resident #14's room. During an interview on 5/28/2025 at 7:42 AM, CNA E was asked where the overbed table that was put in Resident #14's room came from. CNA E confirmed that it was removed from another resident's room. CNA E was asked when moving an overbed table from one resident's room to another what should be done. CNA E stated I probably should have wiped it down. I know I should have wiped it down. During an interview on 5/28/2025 at 10:22 AM, the Director of Nursing (DON) was asked if an overbed table was taken from one resident's room to another resident's room, should it be cleaned. The DON stated, It should be cleaned.

Based on facility policy review, facility investigation review, medical record review, and interview, the facility failed to report a staff to resident allegation of verbal abuse for 2 of 2 (Resident #1 and #13) resident abuse allegations reviewed within the required timeframe. The findings included: 1. Review of the facility policy titled, Investigating Grievances and Concerns, dated 11/23/2016, revealed, .All reports of abuse, neglect, mistreatment, or misappropriation of property must be reported to the administrator within twenty-four (24) hours of their occurrence . 2. Review of the Facility Reported Investigation dated 1/2/2025, revealed an allegation of verbal abuse when Licensed Practical Nurse (LPN) F allegedly yelled at Resident #1 and #13. The alleged incident occurred on 12/28/2024. A call to the Director of Nursing (DON) was made by Registered Nurse (RN) G on 12/31/2024. The DON returned the call on 1/2/2025. The Administrator was notified, and the report was filed with the State agency on 1/2/2025, 5 days after the alleged incident. 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Hypertension, Dementia, and Anxiety Disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #1 had severe cognitive impairment. 4. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Delusional Disorder, and Hypertension. Review of the annual MDS dated [DATE], revealed a BIMS score of 9, which indicated Resident #13 had moderate cognitive impairment. During a telephone interview on 5/29/2025 at 6:51 PM, RN G was asked to recall an event of alleged verbal abuse between LPN F and Residents #1 and #13. RN G stated these 2 patients were arguing with each other when LPN F went into the room and started to yell and curse, saying, .'Oh hell, we are not doing this today' . RN G felt this was inappropriate and concerning and stated she called the DON immediately. When asked what time she notified the DON, RN G stated she could not remember exactly what time, but it was on the 3:00 to 11: PM shift toward the end of the shift. RN G was asked if LPN F worked the rest of the shift. She stated, .I believe she did . During a telephone interview on 5/30/2025 at 11:04 AM, the DON was asked about the alleged verbal abuse with LPN F and two sisters who reside at the facility. The DON stated RN G attempted to call on 12/31/2024. The DON was unable to answer the call and RN G left a message stating she needed to speak with her about LPN F. The DON returned the call on 1/2/2025, and after hearing about the allegation, reported it to the Administrator. The DON verified any allegation of abuse must be reported to the proper agency within 2 hours and within 24 hours, if no bodily harm occurred. During an interview on 5/30/2025 at 11:13 AM, the Administrator stated she was the Abuse Coordinator, and the DON was her backup Abuse Coordinator. Staff were educated on abuse upon hire, monthly, with any abuse allegation, and annually. She stated she was responsible to report abuse allegations to the state agency within 2 hours. When asked to recall the event that involved the allegation of verbal abuse, the Administrator stated the allegation occurred on 12/28/2024. RN G tried to contact the DON on 12/31/2024 but was unsuccessful. A message was left for the DON requesting a return call. The DON returned the call on 1/2/2025. The Administrator stated RN G had never worked in a nursing home before and may not have known to report the incident immediately.

Based on policy review, observation, and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained when 3 of 3 nurses (Registered Nurse (RN A) (Licensed Practical Nurse (LPN B and LPN E) failed to clean a reusable eye medication bottle before she replaced the bottle into the medication cart, after taking the bottle in to a resident room, and when LPN B failed to ensure a reusable eye medication bottle was not cleaned, and when LPN E failed to ensure a FlexPen [a disposable, prefilled insulin pen that contains multiple doses of fast-acting insulin] was not disinfected before replacing in the medication cart. The findings include: 1. Review of the facility's policy titled, Cleaning and Disinfection of Resident- Care Items and Equipment, dated September 2022, revealed Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection .Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident-care items include .blood pressure cuffs . Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers ' instructions. Disinfection is performed with an EPA [U.S. Environmental Protection Agency]- registered disinfectant labeled for use in healthcare settings .Reusable items are cleaned and disinfected or sterilized between uses by a single resident and disposed of afterwards .Single resident-use items are cleaned/disinfected between uses by a single resident . Review of the facility's policy's titled, Administering Topical Medications, dated October 2010, revealed Trans-dermal patches .Clean and dry a selected area that is approved for application of the patch . Review of the facility's policy's titled, Instillation of Eye Drops, dated January 2014, revealed .Clean your equipment and return it to its designated storage area (i.e., beside stand .) .Clean the overbed table and return it to its proper position . 2. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Congestive Heart Failure, Hypothyroidism, and Diabetes. Observations on 7/2/2024 at 7:37 AM, revealed RN A gathered the blood pressure (BP) wrist machine and pulse oximeter (pulse ox) (an electronic device that measures the saturation of oxygen carried in your red blood cells), carried them into Resident #17 ' s room, and laid them on the over bed table (OBT), without cleaning the table. After using these devices on the resident, RN A carried them back to the medication cart and placed them back in a drawer. RN A failed to clean or disinfect the BP machine or pulse ox device before placing them back in the medication cart drawer. RN A failed to change gloves after removing the old patch and failed to clean the area where the old trans-dermal patch was removed, prior to placing the new trans-dermal patch to the same area of Resident #17. 3. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Diabetes, Chronic Kidney Disease Stage 3, Bipolar Disorder, and Anxiety. Observations on 7/2/2024 at 4:12 PM, revealed LPN E gathered supplies including a FlexPen, entered Resident #14 ' s room, administered the FlexPen insulin, then gathered the FlexPen and returned it to the drawer of the medication cart. LPN E failed to disinfect the FlexPen after using it on Resident #14 and returning it to the drawer of the medication cart. 4. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Schizoaffective Disorder, Malignant Melanoma, Dementia, and Parkinson ' s Disease. Observations on 7/3/2024 at 8:04 AM, revealed LPN B removed an eye medication bottle that was in a plastic bag, from the drawer of the medication cart. LPN B placed the plastic bag on top of the medication cart without cleaning the top of the cart. LPN B entered Resident #13 ' s room laid a tissue on the OBT for a barrier and placed the bottle of eye medication on the tissue. LPN B also placed another pair of gloves on the OBT, not on the barrier. After LPN B administered the eye drop to the right eye and removed her gloves, she picked up the gloves from the top of the OBT and donned them to administer the medication to the left eye. When LPN B went back to the medication cart and sat the eye medication bottle on top of the cart. Then LPN B replaced the bottle in the plastic bag and placed it back in the drawer of the medication cart. LPN B failed to clean or disinfect the eye drop bottle after use. During an interview on 7/3/2024 at 3:42 PM, the Director of Nursing (DON) was asked, when should a resident's reusable equipment be cleaned and disinfected. The DON stated, Before and after use on a resident. The DON was asked, what is the process for applying a trans-dermal patch to a resident. The DON stated, Remove the old patch, change gloves, clean area after removed old patch and before applying a new patch. The DON was asked, what should staff do with eye drop bottles and FlexPens after use. The DON stated, If they take them in the room they should clean them off. The DON was asked should the OBT be cleaned prior to setting items on it for medication administration. The DON stated, Yes it should.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions related to expired foods, unlabeled, undated, and uncovered food items, and carbon build-up on the eyes of the stove. The facility had a census of 40 with 38 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility's policy titled, FOOD STORAGE, dated [DATE], revealed .Food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded .All products should be inspected for safety and quality and be dated upon receipt, when open, and when prepared. Use by dates on all food stored in refrigerators and use dates .Leftovers should be dated .Remember to cover, label, and date .Frozen Meat/Poultry and Foods .Label and date all food items .Fresh vegetables .should be checked and sorted for ripeness .Most vegetables should be used within 3 to 5 days .Potentially hazardous foods including cut-leaf greens or tomatoes should be inspected for decay or damage. If present should be returned . 2. Observation in the kitchen on [DATE] at 9:24 AM, revealed in the freezer there was a package of cheese noodles with an expiration date of [DATE], an undated pork loin, and 2 undated bags of hash browns. In the refrigerator was an unlabeled and undated pan of cooked meat, unlabeled lunch meat, and unlabeled meat patties. The stove had a black shiny build up on the 6 eyes of the stove, and an unknown buildup of black substance in the ovens. 3. Observation in the kitchen on [DATE] at 5:28 PM, revealed a metal shelf that contained an uncovered bowl of pudding, an uncovered pot of gravy, an uncovered small pot of butter, and an uncovered plastic container of peanut butter. The 6 eyes of the cooking stove had a black shiny build up. The freezer contained 2 undated bags of hashbrown. 4. Observation in the kitchen on [DATE] at 1:18 PM, revealed the 6 eyes of the cooking stove had a black shiny build up, the refrigerator had brown leaves of lettuce with a date of [DATE], in the freezer was an undated pork loin, 2 undated bags of hash browns, and a clear plastic package of unlabeled and undated boneless chicken. During an interview on [DATE] at 1:34 PM, the Dietary Manager confirmed items stored in the freezer and the refrigerator should be labeled to indicate what it is and dated to indicate when it was placed in the fridge or freezer and an open date. 5. Observation in the kitchen on [DATE] at 4:53 PM and [DATE] at 8:23 AM, revealed the 6 eyes of the cooking stove had a black, shiny build up on them. During an interview on [DATE] at 10:21 AM, the Dietary Manager the confirmed the black, shiny build up on the 6 eyes of the stove was carbon and the buildup of carbon should not be there. The Dietary Manager confirmed the ovens needed to be cleaned. During an interview on [DATE] at 10:45 AM, the Dietary Manager confirmed expired food items should not be available for use and should be thrown away.

Based on policy review, medical record review, and interview, the facility failed to follow Physician's Orders related to antipsychotic medications for 1 of 5 (Resident #30) sampled residents reviewed for unnecessary medications. The findings include: 1. Review of the facility's policy titled, Physician's Orders dated 4/13/2021, revealed .Physician's orders are carried out unless the nurse or other licensed personnel believe the order to be inaccurate .Physician's orders are to be recorded in the medical record for each resident and are to be signed or initialed by the attending physician .Verbal or telephone orders are considered to be in writing when dictated by the physician or authorized health care professional and later signed .by said person . Review of the facility's policy titled, Antipsychotic Medication Use, dated 7/2022, revealed .Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time .All antipsychotic medications will be used within the clinically recommended dosage guidelines, or clinical justification will be documented for dosages that exceed guidelines for more than 48 hours .Residents will not receive PRN [as needed] doses psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the medical record . Review of the facility's policy titled, Medication Administration General Guidelines dated 8/25/2014, revealed .Medications are administered as prescribed .If a dose seems excessive considering resident's age and condition, or medication order seems to be unrelated .the nurse contacts the prescriber for clarification . 2. Review of the medical record revealed that Resident #30 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, Psychosis, and Polyneuropathy. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated resident was severely cognitively impaired. Review of the Physician's Order dated 9/27/2022, revealed Seroquel [used to treat mental and mood disorders] give 75 mg [milligram] by mouth one time a day . Review of the Provider's Progress Note dated 6/25/2024, revealed .Orders for this visit .Start Seroquel oral tablet 100 mg . Give 1 tablet by mouth one time a day .Stop Seroquel 75 mg . Review of the Physician's Order dated 6/25/2025, revealed .Seroquel (an antipsychotic) oral tablet 100 mg give 1 tablet by mouth one time a day . Review of the June 2024 Medication Administration Record (MAR) revealed Seroquel Oral 100 mg .1 tablet by mouth one time a day was administered at 8:00 PM per staff initials on the following dates of 6/25/2024 through 6/30/2024. Seroquel 75 mg 1 tab daily was also administered at 8:00 PM per staff initials on the following dates 6/1/2024 through 6/30/2024. During an interview on 7/1/2024 at 5:54 PM, Registered Nurse (RN A) confirmed the new order for Resident #30 was to increase Seroquel to 100 mg 1 tab daily and stop the Seroquel 75 mg per the Provider's visit note dated 6/25/2024. RN A confirmed that the Seroquel 100 mg was started on 6/25/2024 and the Seroquel 75 mg was not stopped. RN A was asked if Resident #30 should be on both doses of Seroquel at the same time. RN A stated, No. During an interview on 7/2/2024 8:40 AM, the Quality Assurance nurse confirmed that the nurse failed to transcribe the Seroquel 75 mg stop order on 6/25/2024.

Based on policy review, medical record review, and interview, the facility failed to have an order to monitor the dialysis shunt site every shift for 1 of 1 (Resident #29) sampled residents reviewed for dialysis. The findings include: 1. Review of the facility's policy titled End-Stage Renal Disease, Care of a Resident with dated 9/2010, revealed .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care .The general medical nurse should document in the resident's medical record every shift as follows .location of catheter .condition of dressing (interventions if needed) .If dialysis was done during shift .any part of report from dialysis nurse post-dialysis being given .Observations post-dialysis . 2. Medical record review revealed Resident #29 was admitted on [DATE], with diagnoses including End Stage Renal Disease, Heart Failure, and Diabetes. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #29's Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Special treatments included dialysis. Review of the Care Plan dated 4/10/2024, revealed .I am on Hemodialysis r/t [related to] renal failure .12/2023 started Dialysis .I will have no s/sx [signs and symptoms] of complications from dialysis through the review date .Observe/document/report PRN [as needed] any s/sx of infection to access site, R [right] chest Permacath [catheter used for dialysis]: Redness, Swelling, warmth or drainage .Observe/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Review of Physician Order dated 3/8/2024, revealed .Dialysis Monday and Friday at [named] dialysis center . The facility was unable to provide documentation of an order for monitoring the dialysis site each shift for the thrill and bruit and infection. The facility was unable to provide documentation of dialysis access site monitored each shift for thrill, bruit, and infections. During an interview on 7/3/2024 at 12:11 PM, Licensed Practical Nurse (LPN) E was asked, where do you chart the dialysis site for the thrill and bruit, and for signs and symptoms of infection in the medical record. LPN E stated, I don't chart that, I look at it but don't chart it. LPN E was asked, do you have an order to monitor for the thrill and bruit, and for signs and symptoms of infection. LPN E stated, no I don't . LPN E was asked, if it should be documented. LPN E stated Yes. During an interview on 7/3/2024 at 12:45 PM, the Director of Nursing (DON) was asked if the nurses should be monitoring the dialysis shunt sight for the thrill and bruit, and for signs and symptoms of infection. The DON stated, .Yes we should have an order and monitoring the dialysis site each shift for the thrill and bruit and infection. The DON was asked if she could be sure the nurses were monitoring the site if it was not documented. The DON stated, No.

Based on the Resident Assessment Instrument Manual (RAI) User's Manual, medical record review, and interview the facility failed to accurately assess residents for smoking, medication review, and falls for 4 of 12 (Resident #28, #31, #34, and #38) sampled residents reviewed for accuracy of assessments. The findings include: 1. Review of the Resident Assessment Instrument (RAI) User's Manual dated October 2023, revealed .The RAI helps nursing home staff look at resident's holistically-as individuals for whom quality of life and quality of care are mutually significant and necessary . 2. Review of medical record review revealed Resident #28 was admitted on [DATE], with diagnoses including Cerebral Infarction, Hemiplegia, Aphasia, Nicotine Dependence, and Psychosis. Review of the Care Plan dated 7/1/2024 revealed, .I am a smoker . Review of the Smoking and Tobacco Evaluation, dated 11/19/2021 revealed Resident #28 does smoke. Facility is unable to provide an additional Smoking and Tobacco Evaluation, assessment until 7/2/2024. During an interview on 7/3/2024 at 2:46 PM, Licensed Practical Nurse (LPN) D Minimum Data Set (MDS) Coordinator was asked about Resident #28's smoking assessments. LPN D MDS Coordinator confirmed they aren't completed but should be and the last one documented was 11/19/2021. LPN D MDS Coordinator stated, .they should be completed quarterly. 3. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE], with diagnosis including Cerebral Infarction, Hypertension, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation and Epilepsy. Review of the quarterly MDS dated [DATE], revealed Resident #31 was not taking any of the high-risk drug classes, MDS: Section N-Medications, N0415: None of the above. Review of the Medication Administration Sheet dated 6/1/2024 - 6/30/2024, revealed Resident #31 is currently taking high-risk drug class medications including an anti-depressant, diuretic, anticoagulant, and opioid. During an interview on 7/3/2024 at 1:18 PM, LPN D MDS Coordinator was asked about Resident #31 and her medications on the MDS. LPN D MDS Coordinator confirmed Resident #31 was taking high-risk medications and should have been coded properly on the MDS. She confirmed none of the medications were on the MDS. LPN D MDS Coordinator stated, .Must have been a clerical error . 4. Review of the medical record revealed Resident #34 was admitted on [DATE], with diagnoses including Nicotine Dependence, Chronic Obstructive Pulmonary Disease, Schizophrenia, Acute Kidney Failure, and Anxiety. Review of the admission MDS dated [DATE], revealed Section J; Health Conditions, J1300: Current Tobacco Use, No. Review of a Smoking and Tobacco Evaluation, dated 4/13/2024, revealed Resident #34 was not a smoker. Review of a Care Plan dated 4/15/2024, revealed I am a smoker. During an interview on 7/3/2024 at 1:18 PM, LPN D MDS Coordinator confirmed the admission Smoking and Tobacco Evaluation was not assessed properly and the MDS was incorrectly coded. LPN D MDS Coordinator confirmed Resident #34 has been a smoker since his admission. 5. Review of the medical record revealed Resident #38 was admitted on [DATE], with diagnoses of Aphasia, Cerebral Infarction, and Anxiety. Review of the quarterly MDS dated [DATE], revealed Resident #28 was not coded for falls with major injury. Review of the progress note dated 3/30/2024, revealed Resident #38 had a fall and was sent to the emergency room . Review of a Fall Investigation dated 3/30/2024 revealed Resident #38 had .Injury location right trochanter(hip) . Review of the progress note dated 4/1/2024, revealed Resident #38 had surgery on hip. Review of the progress note dated 4/2/2024 revealed Resident #38 was readmitted to the facility on [DATE] with .Surgical incision on right hip has 10 staples . During an interview on 7/3/2024 at 12:39 PM, LPN D MDS Coordinator confirmed Resident #38 had a right hip fracture on 3/30/2024, and was not coded for fall with a major injury under section J1800 on the resident's quarterly MDS dated [DATE].

Based on policy review, facility investigation review, medical record review, and interview, the facility failed to thoroughly investigate allegations of resident misappropriation for 2 of 2 (Residents #1 and #2) residents reviewed for allegations of a misappropriation. The findings included: 1. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating dated 10/2022 revealed .All reports of resident abuse .misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .Investigating Allegations .All allegations are thoroughly investigated. The administrator initiates the investigation .The individual conducting the investigation as a minimum: reviews the documentation and evidence, reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incidents, interviews the person reporting the incident; interviews any witnesses to the incident .interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; interviews the alleged resident's roommate .documents the investigation completely and thoroughly .The investigator notifies the ombudsman that an abuse investigation is being conducted .Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator .Within five (5) business days of the incident, the administrator will provide a follow-up investigation report . 2. Review of the medical record revealed Resident #1 was admitted on [DATE], with diagnoses of Cerebral Infarction, Heart Failure, Anxiety, Blindness, and Diabetes. Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Resident required minimal supervisory assistance with performing Activities of Daily Living (ADLs). Review of the Monthly Grievance/Concern Log dated February 2024, revealed Resident #1 reported money missing from her purse on 2/10/2024. The Social Worker documented on 2/11/2024, that only included the resolution of Facility replaced money. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Hypertension, Diabetes, Depression, and Myocardial Infarction. Review of the quarterly MDS dated [DATE], revealed Resident #2 had a BIMS score of 15, which indicated resident was cognitively intact. Resident required moderate assistance with ADLs. Review of the Monthly Grievance /Concern Log dated January 2024, revealed Resident #2 reported she had money missing on 1/10/2024. The Social Worker completed an investigation on 1/12/2024 with resolution documented as Facility covered money. 4. During an interview on 3/5/2024 at 10:30 AM, with the Interim Administrator confirmed that thorough investigations should have been completed regarding residents missing money on 1/10/2024, and 2/10/2024. The facility was unable to provide documentation the incidents of missing money for Resident #2 on 1/10/2024 and Resident #1 on 2/10/2024, were investigated.

Based on policy review, medical record review, and interview, the facility failed to ensure all residents were free of misappropriation of resident money for 2 of 2 (Resident #1 and #2) sampled residents reviewed for misappropriation. The findings include: 1. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 10/2022 revealed .All reports of resident abuse .misappropriation of resident property are reported to local, state and federal agencies .thoroughly investigated . documented and reported .if .misappropriation of resident property is suspected .suspicion must be reported immediately to the administrator .to the following agencies .state .agency responsible for surveying .ombudsman .resident's representative . Review of . Resident Rights, dated Nov. 28, 2016, revealed .facility shall exercise reasonable care for the protection of the resident's property from loss or theft . 2. Review of the medical record revealed, Resident #1 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Diabetes, Anxiety, Legal Blindness, and Heart Failure. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident was moderately cognitively impaired. Review of the Monthly Grievance/Concern Log, dated February 2024, revealed Resident #1 filed a grievance on 2/10/2024, related to money missing from her purse. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Hypertension, Diabetes, Depression and Myocardial Infarction. The significant change MDS dated [DATE], revealed Resident #2 had a BIMS score of 15, which indicated she was cognitively intact. Review of the facility's Monthly Grievance/Concern Log for January 2024, revealed on 1/11/2024, a grievance was filed for Resident #2 regarding missing money. During an interview on 3/4/2424 at 11:00 AM, the Social Worker (SW) was asked where the report and investigations were for the missing money on the Grievance log. The SW confirmed that he had not conducted an investigation. 4. During an interview on 3/4/2024 at 3:30 PM the SW confirmed he should have reported and investigated the missing money. During an interview on 3/5/2024 at 10:33 AM the Director of Nursing confirmed misappropriation of property should be reported. During an interview on 3/5/2024 at 10:35AM, the Interim Administrator confirmed that there was no investigation or reporting of the alleged misappropriation of the resident's property The facility failed to identify allegations of misappropriation of property and failed to protect other residents from abuse.

Based on policy review, medical record review, and interviews, the facility failed to identify and report an alleged violation of misappropriation regarding residents' property to the administrator of the facility, the State survey agency, local law enforcement, and the Long-Term Care Ombudsman for 2 of 4 sampled residents (Resident #1 and # 2) reviewed for misappropriation. The Findings Include: 1. Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 10/2022, revealed .All reports of resident abuse .misappropriation of resident property is to be reported to local, state, and federal agencies .thoroughly investigated by facility management. Findings of all investigations are documented and reported .if .misappropriation of resident property .is suspected .must be reported immediately to administrator and to other officials according to state law .The administrator .immediately reports his or her suspicion to the state agency .local ombudsman .resident's representative .law enforcement .Immediately is defined as .within twenty four hours of an allegation .Upon receiving any allegations of .misappropriation of resident property .the administrator is responsible for determining what actions .are needed .All allegations are thoroughly investigated. The administrator initiates investigations .within five (5) business days of the incident, the administrator will provide a follow up investigation report . Review of the facility's policy titled, Grievance and Complaints, dated 2/14/2023, revealed .All grievances will be reported to Social Services .follow .procedure to investigate .and resolve the grievance .Upon receipt of a grievance, Social Services will complete a written report within 5 working days of the filed grievance and determine what corrective actions, if any, should be taken. If the grievance is related to any form of abuse, the administrator must be notified immediately .Social Service must notify .who filed the grievance, within 10 working days .in the form of a report .if not satisfied with the results of the investigation .may file a report with the local ombudsman . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Diabetes, Heart Failure, Anxiety, and Legal blindness. The admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated she was moderately cognitively impaired. Review of the facility's Monthly Grievance/Concern Log, for February 2024 revealed on 2/11/2024, a grievance was filed for Resident #1 regarding money missing from her purse. During an interview on 3/4/2024 at 3:30 PM, the Social Worker (SW) was asked if suspected misappropriation of a resident's property should be investigated and reported. The SW stated, Yes. During an interview in Resident #1's room on 3/5/2024 at 9:08 AM, the resident confirmed that she had money missing in February. She stated that the SW helped her search for the money, but was unable to locate. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Hypertension, Diabetes, Depression, and Myocardial Infarction. The significant change MDS dated [DATE], revealed Resident #2 had a BIMS score of 15, which indicated she was cognitively intact. Review of the facility's Monthly Grievance/Concern Log for January 2024 revealed on 1/11/2024, a grievance was filed for Resident #2 regarding missing money. During an interview on 3/5/2024 at 9:51 AM, the SW confirmed that he and Resident #2 searched for the missing money and was unable to locate it. He was unsure of the amount that was missing. 4. During an interview on 3/5/2024 at 10:33 AM The Director of Nursing was asked if misappropriation of property should be reported. She stated, Yes. During an interview on 3/5/2024 at 10:35AM, the Interim Administrator confirmed that there was no investigation or reporting of the alleged misappropriation of the resident's property. The facility failed to identify and report a situation as an alleged violation involving misappropriation of resident property.

Based on policy review, medical record review, and interview, the facility failed to maintain accurate medical records related to bed bath and/or shower documentation on 3 of 3 sampled residents (Resident #4, #25 and #30) The findings include: 1. Review of the policy titled, ADL (Activities of Daily Living) MONITORING POLICY dated 4/29/2029, revealed .Purpose .To decrease chances of inaccurate ADL Coding on a daily basis .CNA's (Certified Nurse ' s Aide) will have charge nurse .verify ADL .sheets are filled out prior to end of shift .check for accuracy . Review of the policy titled, Charting and Documentation Guidelines dated 3/22/2021, revealed all questions or fields on documentation fields/forms .should be completed. If a question or field is not applicable [N/A], N/A entry should be made to show the question was reviewed and answered . 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Pneumonia, Diabetes, Anxiety and Bipolar Disorder. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #39's bathing activity itself did not occur. Review of the Activity of Daily Living (ADL) Verification Worksheet dated 3/31/2023 - 6/6/2023 revealed incomplete documentation of the shower/bath completion for the following days: a. On 4/1/2023, 4/2/2023, 4/4/2023, 4/13/2023, 4/15/2023, 4/16/2023, 4/18/2023, 4/20/2023, 4/22/2023, 4/23/2023, 4/25/2023, 4/27/2023, 4/29/2023, and 4/30/2023. b. On 5/2/2023, 5/4/2023, 5/6/2023, 5/7/2023, 5/9/2023, 5/11/2023, 5/13/2023, 5/14/2023, 5/16/2023, 5/18/2023, 5/20/2023, 5/23/2023, 5/25/2023, 5/27/2023, 5/28/2023, and 5/30/2023. c. On 6/1/2023, 6/3/2023, 6/4/2023, and 6/6/2023. 3. Medical record review revealed Resident #25 was admitted on [DATE] with diagnoses of Hypertension, Bipolar, Depression, and Dementia. Review of quarterly MDS dated [DATE], revealed Resident #25 required extensive assist with bathing. Review of the ADL Verification Worksheet dated 3/31/2023 - 6/6/2023 revealed incomplete documentation of the shower/bath completion for the following days: a. On 3/31/2023. b. On 4/2/2023, 4/5/2023, 4/9/2023, 4/10/2023, 4/14/2023, 4/16/2023, 4/19/2023, 4/20/2023, 4/23/2023, 4/28/2023, and 4/30/2023. c. On 5/3/2023, 5/5/2023, 5/7/2023, and 5/8/2023. 4. Review of medical record revealed Resident #30 was admitted on [DATE] with diagnoses of Hypertension, Contracture Right Hand, Cerebral Infarction, and Depression. Review of quarterly MDS dated [DATE] revealed Resident #30 required total assist with bathing. Review of the ADL Verification Worksheet dated 3/31/2023 - 6/6/2023 revealed incomplete documentation of the shower/bath completion for the following days: a. On 3/31/2023. b. On 4/9/23, 4/10/2023, 4/14/2023, and 4/30/2023. c. On 5/3/2023. During an interview on 06/07/23 at 3:20 PM, the Regional Nurse Consultant confirmed the ADL Verification Worksheets sheets had blanks and were not being documented correctly.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure medication parameters were monitored in accordance with professional standards of practice for 2 of 2 sampled residents (Resident #10 and #15) reviewed for medication parameters. The findings include: 1. Review of the facility policy titled, Accucheck /Diabetic Policy and Procedure, dated 2/9/2005 revealed, It is the policy of this facility to perform Accuchecks and administer insulin as ordered by the resident's physician .If blood glucose is greater than (>) 451, implement the Diabetic Therapeutic Protocol . Review of the facility policy titled, Diabetic Therapeutic Protocol, dated 3/3/2005 revealed, .Hyperglycemia [elevated blood glucose level] .If asymptomatic (alert and able to follow directions) .and blood glucose is greater than .451 implement the following .If no sliding scale is ordered for resident, notify physician for further orders . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Hypertension, and Diabetes. Review of the Physician Order dated 5/2/2023, revealed .Metoprolol Tartrate Oral Tablet Give 1 tablet by mouth one time a day related to ESSENTIAL HYPERTENSION . Observation during medication administration on 6/7/2023 at 8:10 AM, Licensed Practical Nurse (LPN) #1 administered Metoprolol 25 milligram (mg) to Resident #10 without obtaining a pulse. During an interview on 6/7/2023 at 8:15 AM, LPN #1 was asked if Resident #10 had parameters for Metoprolol. LPN #1 confirmed no parameters were ordered for the medication. LPN #1 administered Metoprolol 25 mg to Resident #10 without obtaining a pulse. During an interview on 6/7/2023 at 9:15 AM, the Regional Nurse Consultant (RNC) was asked if Metoprolol should have pulse parameters prior to administration. RNC stated, .there should be parameters for the medication only if the Physician orders them . During an interview on 6/7/2023 at 9:29 AM, the Nurse Practitioner confirmed Resident #10 should have pulse parameters prior to the nurse administering Metoprolol. NP stated, .a pulse should be taken prior to administering Metoprolol. I have ordered parameters for the medication Metoprolol for the resident . Review of the Physician Order dated 6/7/2023, revealed .Metoprolol Tartrate Oral Tablet .Give 1 tablet by mouth one time a day related to .HYPERTENSION give 1 25mg tablet hold for SBP [systolic blood pressure] < [less than] 120 DBP [diastolic blood pressure] < [less than] 60 or hr [heart rate] < [less than] 60 . 3. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus with Diabetic Neuropathy, Acute Kidney Failure, and Heart Failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact, and received insulin injections on 7 of 7 days. Review of the Physician's Order dated 2/23/2023 and recertified 5/2/2023 revealed, .Insulin Detemir .Inject 10 unit subcutaneously at bedtime for diabetes . There were no blood glucose parameters in the order and no sliding scale insulin ordered. Review of the Medication Administration Record (MAR) dated 6/1/2023 through 6/30/2023, revealed Resident #15 had a blood glucose level of 488 on 6/2/2023. Resident #15's regularly scheduled insulin was administered at that time. Review of the medical record revealed no documentation that Resident #15's blood glucose was rechecked, or the physician was notified, following her blood glucose level of 488 on 6/2/2023. Observation and interview in the resident's room on 6/6/2023 at 8:20 AM, revealed Resident #15 was in bed, awake and alert, and agreed to a resident interview. Resident #15 confirmed that she received Insulin injections daily. Resident #15 was asked if she had any problems with her blood sugars. Resident #15 stated, Yeah .problems with blood sugar .going high .I had some that went up to 400 the other day. Resident #15 was asked was she given insulin at that time. Resident #15 stated, I receive insulin anyway. Resident #15 was asked what staff did following the high blood sugar. Resident #15 stated, Nothing different. Review of the 24 Hour / Change of Condition Report dated 6/2/2023 and reviewed with Registered Nurse #1 on 6/6/2023 at 3:36 PM, revealed there was no documentation of Resident #15's blood glucose level of 488 on the report sheet. During an interview on 6/6/2023 at 3:36 PM, Registered Nurse (RN) #1 was asked to explain the facility's protocol for a hyperglycemic resident. RN #1 stated, Notify the doctor if it's [blood glucose] over the parameters in the computer and give their medication as ordered. RN #1 confirmed there were no blood glucose parameters documented in the computer for Resident #15. RN #1 was asked how she knew the parameters for Resident #15. RN #1 stated, If there are not any parameters on the order than you wouldn't know. RN #1 was asked how she knew when to notify the doctor. RN #1 stated, If the meter read high or it read over 500 .nursing judgment . RN #1 confirmed that she was Resident #15's nurse on 6/2/2023. RN #1 was asked what she did after she obtained a blood glucose level of 488 on Resident #15. RN #1 stated, I gave her medication [Insulin 10 units] and checked it a little bit later .she was asymptomatic . RN #1 confirmed that she did not document the recheck of Resident #15's blood glucose in the medical record, did not document the elevated blood glucose level on the 24-Hour report sheet, and did not notify the physician. During an interview on 6/6/2023 at 3:50 PM, Licensed Practical Nurse (LPN) #1 stated, I didn't want to wait until tomorrow so I called [named Family Nurse Practitioner (FNP)] and got an order for a parameter .[FNP] wants to be notified for [blood glucose] less than 60 and over 400. During an interview on 6/6/2023 at 3:56 PM, the RNC confirmed there should be parameters in the physician orders for all residents who received insulin. The RNC was asked what staff should do when a resident has a blood glucose lever of 488. The RNC stated, It would depend on if they're symptomatic, if they're symptomatic I would expect they would call the provider and notify them. The RNC was asked what staff should do if the resident was asymptomatic. The RNC stated, I think it's a reasonable expectation that they [provider] be notified. The RNC confirmed that if the blood glucose was rechecked it should be documented in the medical record. A copy of the 24-Hour / Change of Condition Report for 6/2/2023 was requested. Review of the copy requested of the 24 Hour / Change of Condition Report dated 6/2/2023 and provided on 6/6/2023 at 4:55 PM revealed the following had been added to the report, .[Named Resident #15] BG [blood glucose] 488 please Monitor for s/sx [signs or symptoms] asymptomatic at this time. During an interview on 6/6/2023 at 5:00 PM, RN #1 was asked when she documented the information about Resident #15's elevated blood glucose on the 24 Hour Report sheet. RN #1 stated, This afternoon [after the document was reviewed with the surveyor]. RN #1 confirmed that she was asked to add that information to the 24 Hour Report. RN #1 stated, I'm not going to lie to you. During an interview on 6/7/2023 at 9:35 AM, the FNP confirmed that she should have been notified on 6/2/2023 when Resident #15's blood glucose was 488.

Based on review of the Blood Glucose Monitoring Operator's Manual, policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not disinfected to prevent cross-contamination of bloodborne pathogens for 1 of 2 sampled residents (Resident #25) reviewed for sanitizing blood glucose meters and 2 of 3 nurses (Licensed Practical Nurse (LPN) #1 and LPN #2) failed to perform hand hygiene between glove use and failed to change gloves and perform hand hygiene after touching potentially contaminated objects in residents' rooms for 3 of 7 sampled residents (Resident #30, #183 and #184) observed during medication administration. The facility's failure to ensure staff properly disinfected the multi-use blood glucose meter that was used for multiple residents placed residents at risk for contamination with bloodborne pathogens and had the likelihood to cause serious injury, which resulted in Immediate Jeopardy. The facility had 10 residents receiving accu-checks with a multi-use glucometer and the facility's failure had the potential to affect the 10 residents receiving accu-checks with a multi-use blood glucose meter. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to appropriately disinfect a multi-use blood glucometer during medication administration. The Administrator, Director of Nursing, and the Regional Nurse Consultant, were notified of the Immediate Jeopardy (IJ) on 5/31/2022 at 6:35 PM, in the Physical Therapy Room. The facility was cited Immediate Jeopardy at F-880. The Immediate Jeopardy existed from 5/31/2022 through 6/1/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/1/2022 at 9:38 AM. The corrective actions were validated onsite by the surveyors on 6/1/2022 and 6/2/2022 through review of in-service documentation, observations, and staff interviews. The findings include: Review of the Blood Glucose Monitoring Operator's Manual revealed, .CLEANING AND DISINFECTING YOUR [NAMED GLUCOMETER] .Cleaning and disinfecting the meter and lancing device is very important in the prevention of infectious disease .To disinfect the meter, clean the meter with one of the validated disinfecting wipes listed below .Dispatch Hospital Cleaner Disinfectant Towels with Bleach .[MEDICATION(S)] Micro-Kill Disinfecting, Deodorizing, Cleaning Wipes .Clorox Healthcare Bleach Germicidal and Disinfectant Wipes .[MEDICATION(S)] Micro-Kill Bleach Germicidal Bleach Wipes . Review of the facility's policy titled, Glucometer Cleaning Guidelines, dated 5/16/2016, revealed .Since glucometers may be contaminated with blood and/or body fluids as well as other pathogens .this facility has chosen a disinfectant wipe that is EPA [Environmental Protection Agency] registered as tuberculocidal .therefore it is effective against [CONDITION(S)] [[CONDITION(S)]], HBV [[CONDITION(S)] Virus], and a broad spectrum of bacteria .a 1:10 bleach solution may be substituted . Review of the facility's policy titled, Hand Hygiene, dated 10/27/2017, revealed .Hand hygiene is performed to reduce the risk of transmission of infection by appropriate hand hygiene .5 MOMENTS FOR Hand Hygiene .Before touching a patient .Before clean/aseptic procedures .After body fluid exposure risk .After touching a patient .After touching patient surroundings . Review of the facility policy titled, .GLOVE USE, dated 6/6/2013, revealed .Perform hand hygiene after removing gloves . Observation in the resident's room on 5/31/2022 at 11:02 AM, revealed LPN #1 performed a blood glucose check on Resident #25, using a multi-use glucose meter. LPN #1 cleaned the glucometer with a small alcohol pad and stated, That's our standard as far as I know. LPN #1 exited the resident's room with the glucometer and placed it in the Back Hall medication cart. The failure to clean the glucometer with an EPA approved disinfectant wipe resulted in Immediate Jeopardy and the potential to spread communicable diseases to other residents. Observation and interview at the Front Hall Medication Cart on 5/31/2022 at 4:15 PM, revealed Registered Nurse (RN) #1 preparing to use a glucometer to check a resident's blood glucose level. RN #1 stated the glucometer was not working and she needed to find a new one. She went to the Back Hall Medication Cart and LPN #3 removed a glucometer, wrapped in a white paper towel, from the Back Hall Medication Cart and handed it to RN #1. When LPN #3 confirmed she had cleaned the glucometer she stated, .I used an alcohol pad . RN #1 took the glucometer to the Front Hall Medication Cart, cleaned it with a bleach wipe, and confirmed glucometers should be cleaned with bleach wipes to prevent the spread of communicable diseases. During a telephone interview on 6/1/2022 at 4:30 PM, the Medical Director confirmed blood glucometers should be cleaned with bleach wipes and not alcohol pads. During an interview on 6/2/2022 at 3:30 PM, the Director of Nursing (DON) was asked how staff should disinfect a glucometer. The DON stated, .per manufacturer recommendation .bleach wipe, then place it on a barrier until it dries . She confirmed an alcohol wipe would not kill bloodborne pathogens that would put residents at risk for communicable diseases. During an interview on 6/2/2022 at 4:05 PM, the Administrator was asked what staff should use to disinfect the glucometers. He stated, The bleach wipes. The Administrator was asked if staff should clean glucometers with alcohol pads and he stated, No, it's not appropriate, not the correct chemical to use. Observation in Resident #183's room on 5/31/2022 at 10:43 AM, revealed LPN #1 donned clean gloves, removed a medicated patch from Resident #183's upper right back, and discarded it in the sharp's box. LPN #1 removed the soiled gloves and placed them on the bedside table and then donned new gloves without performing hand hygiene. LPN #1 dropped the transparent dressing on the floor, picked it up from the floor, applied the new patch to the resident's left upper back, and covered it with the transparent dressing she had picked up from the floor. LPN #1 did not change her gloves or perform hand hygiene after picking the transparent dressing off the floor and failed to obtain a clean transparent dressing to place over the patch. During an interview on 5/31/2022 at 10:53 AM, LPN #1 confirmed she should have removed the soiled gloves, should have performed hand hygiene after picking the transparent dressing off the floor, and should have obtained a new transparent dressing. Observation outside Resident #184's isolation room on 5/31/2022 at 2:05 PM, revealed LPN #2 donned a gown, failed to perform hand hygiene, donned gloves, and entered Resident #184's room. She touched the privacy curtain, touched the overbed table, and placed the medication cups on the overbed table. She proceeded to check Resident #184's Percutaneous Endoscopic Gastrostomy (PEG) tube for placement. LPN #2 then administered medications through the PEG tube. LPN #2 did not remove her gloves and perform hand hygiene between touching potentially contaminated objects in the room, assessing Resident #184's PEG tube, and administering the medications through the PEG tube. Observation at the Front Hall Medication Cart on 5/31/2022 at 2:20 PM, revealed LPN #2 did not perform hand hygiene, donned clean gloves, knocked on Resident #30's door, and entered the room. LPN #2 administered an oral medication to Resident #30. LPN #2 then administered 1 puff of an inhaler medication to Resident #30. LPN #2 did not perform hand hygiene before donning gloves, did not change gloves, and did not perform hand hygiene after knocking on the door. During an interview on 6/2/2022 at 5:50 PM, the DON confirmed staff should perform hand hygiene before and after glove use. The surveyors verified the Removal Plan by: 1. On 5/31/2022, the Director of Nursing and Regional Nurse Consultant conducted a physical assessment and chart audit on each resident who required an accu-check to assess for any signs and symptoms of potential negative outcomes or spreading of any communicable disease. As of 5/31/2022, no resident in the facility had a communicable disease. The surveyors verified the assessments and chart audits, reviewed medical records, and interviewed nurses on all shifts. 2. On 5/31/2022, the DON and Regional Nurse Consultant began conducting in-service training with all licensed nursing staff which included that each nurse return demonstrate the correct procedures for conducting accu-checks with pre and post cleaning and disinfecting of the glucometer when using a shared meter. All nurses are to be educated on the correct procedure before working their next shift. The surveyors reviewed the in-service training, made observations of the actual training, and return demonstration, and interviewed nurses on all shifts. 3. The Regional Director of Operations and Regional Nurse Consultant reviewed and revised the policy and procedure for glucometer cleaning to include cleaning and disinfecting the glucometer following the manufacturer's guidelines recommended disinfectant agent prior to and after obtaining an accu-check. The surveyors reviewed the policy changes. 4. All residents requiring accu-checks are to be given their own glucometer. The facility ordered ten additional glucometers to provide each diabetic resident requiring accu-checks their own assigned glucometer to prevent spreading of communicable diseases during the accu-check process. Each glucometer is to be stored in the resident's private nightstand and is not to be shared between multiple residents. Each glucometer is to be cleaned and disinfected as described in the updated Glucometer Cleaning Policy. The surveyors observed that the glucometers were in each resident room and interviewed nurses on all shifts. 5. The DON or designee will audit the accu-checks with licensed nurses daily, on each shift for three days, then daily random shifts for seven days, and then weekly random shifts for four weeks for compliance. Audits are to be turned into the Quality Assurance Performance Improvement (QAPI) committee weekly for review. The surveyors reviewed the accu-check audits and interviewed the DON. 6. The Medical Director was informed of the IJ on 5/31/2022. An AD HOC (as needed) QAPI meeting was conducted 5/31/2022. The Allegation of Compliance (AoC) plan and Glucometer Cleaning Policy were reviewed and adopted. The surveyors reviewed the AD HOC QAPI meeting minutes and interviewed the Medical Director and Administrative Staff. The facility's noncompliance at F-880 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure placement checks were completed and documented for the use of an elopement wrist bracelet for 1 of 2 sampled residents (Resident #4) reviewed for wandering and elopement and failed to ensure a safe environment when unsecured disposable razors were found in 2 of 4 common shower rooms (Front Hall Men's Shower Room and Front Hall Women's Shower Room). The findings include: Review of the facility's policy titled, Elopement/Unsafe Wandering Plan, dated 2/7/2012, revealed .Residents at risk will have some type of Identifier on their person .Examples of identifiers are .colored arm band .Nurses will check for the presence of the identifier every shift and document on the Medication Administration Record [MAR] . Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with the diagnoses of Dementia, Altered Mental Status, and [CONDITION(S)]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 was assessed with a Brief Interview for Mental Status score of 6, indicating that Resident #4 had severe cognitive impairment Review of the Care Plan dated 4/12/2022, revealed .[Resident #4] is an elopement risk/wanderer .shaking exit doors trying to open them .resident to wear a wander alert on ankle . Review of the MARs dated 3/2022, 4/2022, and 5/2022, revealed no documentation of placement checks every shift for the use of a wander alert bracelet for Resident #4. Observation in Resident #4's room on 6/1/2022 at 1:00 PM, revealed Resident #4 was in her room wearing a neon green ankle bracelet on her right ankle. During an interview on 6/1/2022 at 1:05 PM, the MDS Coordinator confirmed Resident #4's ankle bracelet was used to alert staff that the resident was a wanderer. During an interview on 6/1/2022 at 3:11 PM, Licensed Practical Nurse (LPN) #1 confirmed residents who wander are identified with a bright yellow or green bracelet on their person or their wheelchair. LPN #1 confirmed that the wander alert bracelet checks for Resident #4 were not documented on the MAR. During an interview on 6/2/2022 at 3:16 PM, the Director of Nursing (DON) confirmed wander alert bracelet checks should be completed every shift and documented on the MAR by the nurse assigned to the resident. The DON was asked to review the 3/2022, 4/2022, and 5/2022 MARs for Resident #4's placement checks for the use of a wander alert bracelet. The DON stated, It is not there, it was not put on [the MAR] until today. The DON confirmed the wander alert bracelet checks should have been implemented when the bracelet was applied to Resident #4's ankle. Observation in the Front Hall Men's Shower Room on 6/1/2022 at 8:25 AM and 11:15 AM, revealed 12 razors under the sink in a basket in an unlocked cabinet. The shower room and the cabinet were easily accessible to the residents. During an interview on 6/1/2022 at 11:16 AM, the Regional Nurse Consultant confirmed the razors were not secured. She confirmed razors should be stored in a locked cabinet. Observation in the Front Hall Women's Shower Room on 6/1/2022 at 8:27 AM and 11:18 AM, revealed 3 razors in an unlocked cabinet. The shower room and the cabinet were not locked and were easily accessible to the residents. During an interview on 6/1/2022 at 11:20 AM, the Regional Nurse Consultant confirmed the razors were not secured. She confirmed razors should be stored in a locked cabinet.

Based on medical record review and interview, the facility failed to ensure the Care Plan was implemented for the Activities of Daily Living (ADL) for 1 of 14 sampled residents (Resident #19) reviewed. The findings include: Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revised on 7/13/2020, revealed . ADL [Activity of Daily Living] self-care performance deficit r/t [related to] Dementia, Limited Mobility .Interventions .TRANSFER: X [times] 2 Assist . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition and required extensive assistance of 2 persons for transfers. During an interview on 6/2/2022 at 9:26 AM, the Administrator was asked about the self-reported facility incident being investigated by the surveyor. The Administrator stated, .I did suspend that CNA [Certified Nursing Assistant] [CNA #1] while we did our investigation .didn't find anything .the resident [Resident #19] was a 2 person transfer and apparently she [CNA #1] had transferred her by herself .I let her [CNA #1] come back to work but did write her [CNA #1] up .for not following the care plan .she [Resident #19] is a 2 person assist . During an interview on 6/2/2022 at 10:52 AM, Certified Nursing Assistant #1 (CNA) confirmed she had used the stand up lift to transfer Resident #19 by herself and stated, .wasn't aware that the Care Plan had been changed to 2 person assist .I just didn't look at the Care Plan . During an interview on 6/2/2022 at 3:38 PM, the Director of Nursing confirmed CNA #1 had transferred Resident #19 by herself and that she did not follow the Care Plan.

Based on policy review, observation, and interview, the facility failed to maintain a safe, sanitary, and homelike environment for 2 of 23 resident rooms (Room #14 and Room #26) as evidenced by a blanket on the resident's bed with a yellowish tan stain and a strong odor of urine in the room, a broken privacy curtain in a resident's room, and when 2 of 4 resident's shared bathrooms (Room #14/#16, and Room #18/#20) had an unlabeled, uncontained gray wash basin, underneath the bathroom vanity, an unlabeled and uncontained graduated dispenser and a yellow wash basin underneath the commode, and an opened, unlabeled, and unwrapped bar of soap on the vanity top. The findings include: Review of the facility policy titled, Cleaning Schedule, dated 6/1/2000, revealed .facility is maintained in a safe, clean and comfortable manner . Observation in Room #26 on 5/31/2022 at 8:43 AM, 9:47 AM, 10:48 AM, 12:20 PM, 2:57 PM, and 5:25 PM, revealed an irregular ring shaped yellowish-tan stain on top of a blanket on the bed and a strong odor of urine was noted in the room. During an interview on 6/1/2022 at 8:57 AM, Certified Nursing Assistant (CNA) #2 confirmed the blanket had multiple large urine stains and the room had a strong odor of urine. During an interview on 6/2/2022 at 3:38 PM, the Director of Nursing (DON) confirmed residents' rooms should not have a strong odor of urine and blankets should not be stained. Observation in the shared bathroom for Room #14 and Room #16 on 5/31/2022 at 8:53 AM, 9:02 AM, and 4:49 PM, revealed an open, unlabeled, and unwrapped bar of soap on top of the vanity. Observation in the shared bathroom for Room #18 and Room #20 on 5/31/2022 at 9:01 AM and 11:44 AM, revealed an unlabeled and uncontained gray wash basin on the floor underneath the bathroom sink, a yellow wash basin, and an unlabeled and uncontained graduated dispenser on the floor underneath the commode. During an interview on 6/2/2022 at 3:16 PM, the DON confirmed that wash basins and graduated dispensers should be labeled with the resident's name and stored in a clear plastic bag. The DON was asked if an open, unlabeled, unwrapped bar of soap should be on top of the bathroom vanity. The DON stated, No. Observation in Room #14 on 5/31/2022 at 10:45 AM, revealed a privacy curtain with broken brackets and the curtain was detached from the broken brackets. During an interview on 6/2/2022 at 1:32 PM, the Administrator and the Housekeeping Supervisor both confirmed the privacy curtain was broken and the curtain should be in working order.

Based on review of the Regional Director of Operation's job description, review of the Medical Director's job description, review of the Director of Nursing's (DON) job description, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program when the committee did not recognize an accident hazard risk with smoking safety. The QAPI committed failed to ensure the exit door codes were secure which potentially posed a risk to wandering residents. The QAPI committee failed to ensure the facility identified the root cause of the risks associated with smoking, developed appropriate plans of action, ensured systems and processes were in place and consistently followed by staff to address quality concerns. The QAPI committee failed to ensure interventions to prevent unsupervised smoking were consistently implemented or followed, that the facility was administered in a manner that enabled it to use its resources effectively and efficiently for residents that smoke and for residents with risk of wandering concerns. The failure of the QAPI Committee to ensure the facility implemented and/or provided care and services for the residents who smoked and demonstrated exit-seeking behaviors placed 6 of 15 (Resident #1, #5, #21, #26, #37, and #242) sampled residents in Immediate Jeopardy (IJ) when Resident #1 and #5 smoked without supervision and Resident #21, #26, #37, and #242 were vulnerable and cognitively impaired residents that demonstrated exit-seeking behaviors and the exit door codes were compromised. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Regional Director of Operations/Interim Administrator, the Regional Nurse Consultant, and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/19/19 at 4:51 PM, in the Administrator office. F-657 was cited at a scope and severity of [NAME] F-689, F-835, and F-867 were cited at a scope and severity of K. F-689-K is Substandard Quality of Care. An extended survey was conducted on 11/20/19. An acceptable Removal Plan which removed the immediacy of the Jeopardy, was received on 11/21/19 at 8:40 AM, and the corrective actions were validated onsite by the surveyors on 11/21/19 and 11/22/19 through review of assessments, auditing tools, in-service training records, policies, observations, family, and staff interviews. The IJ was effective from 11/18/19 through 11/21/19. The findings include: 1. The facility's Regional Director of Operations Job Description with a revised date of 9/1/17 documented, .Responsible for communication, relationship management .direct oversight and implementation of all Company policies, procedures .for their assigned region .emphasize and model the need for collaboration and teamwork .establish and maintain communications .implement and oversee organizational policy at the facility level .act as a change agent to improve outcomes .review facility performance .standards .quality measures .maintain qualified personal in all positions .coordinating and enforcing systems, policies and procedures . 2. The facility's Director of Nursing Job Description with a revised date of 8/10/17 documented, .To manage overall operation of the Nursing Services .standards of nursing practice and governmental regulations .maintain excellent care of all the Residents .monitor department activities .conduct regular rounds to review care .follows and ensures compliance with State, Federal, and company QAPI standards .carry out, coordinate, or manage .safety program . 3. Interview with Regional Nurse Consultant on 11/21/19 at 9:21 AM, in the Administrator's Office, the Regional Nurse Consultant was asked if the Quality Assurance Committee had discussed or monitored smoking or compromised exit door codes. The Regional Nurse Consultant stated, No, not before Monday. Interview with the DON on 11/21/19 at 9:21 AM, in the Administrator's Office, the DON was asked if smoking was discussed in QAPI. The DON stated, We knew we had a problem with them being outside without supervision, but the matter was discussed in morning meetings instead. Interview with the Regional Director of Operations/Interim Administrator on 11/21/19 at 11:51 AM, in the Administrator's Office, the Regional Director of Operations confirmed that smoking policies and exit door access had not been discussed in QAPI. The facility's QAPI committee failed to identify, develop, and implement appropriate plans of action to ensure care plans were reviewed, updated, and implemented for the care of residents with diminished safety awareness. This resulted in IJ for Resident #1 and #5. Refer to F-657. The QAPI Committee failed to provide oversight of staff when they failed to ensure a safe and consistent smoking regimen for residents which resulted in IJ for Resident #1 and #5. The QAPI Committee failed to ensure staff maintained the confidential codes to the exit doors which placed residents (Resident #21, #26, #37, and #242) with wandering/exit seeking behaviors in an I[NAME] Refer to F689 The surveyors verified the Removal Plan by: 1. On 11/18/19 the Regional Nurse Consultant and DON conducted a smoking assessment and chart audits of the BIMS score on each smoking resident. The residents with a BIMS score greater than 12 were educated on the policy. Resident less than 12 had their Responsible Party educated about smoking policy. This included smoking times, the requirement of staff supervision, and potential consequences if this policy is violated. The survey team reviewed the smoking assessments, facility smoking policy, interviewed staff, and family of residents with BIMS less than 12. 2. On 11/18/19 The Regional Consultant Nurse and DON began conducting in-service training with staff members to review the smoking policy, to ensure residents were monitored while smoking, were smoking in a safe manner, and were compliant with the facility smoking policy. The survey team reviewed the in-service training sign-in sheet and the updated nursing assignment sheet. Multiple staff members, residents, and families were interviewed regarding the smoking education provided to them. Smoking sessions were also monitored to ensure adherence to the updated policy. 3. On 11/19/19 the DON conducted body audits on the two residents left unattended outside smoking to ensure [MEDICAL CONDITION] injuries were present. The survey team reviewed the body audits. Skin was intact with no issues. 4. On 11/19/19 the Regional Nurse Consultant and DON began conducting in-service training with staff members on the new door access codes and ensuring they were not shared with residents or were not being put in where residents could observe or learn the access codes to the door. The survey team interviewed multiple staff members regarding the access code in-service and validated the information provided. 5. On 11/21/19 the Regional Director of Operations/Interim Administrator initiated in-service education for the Quality Assurance Performance Improvement (QAPI) committee members which included ensuring any problems or concerns noted in each department would have a formal Performance Improvement Plan initiated. All Performance Improvement Plans (PIP) will be reviewed monthly or more often if needed. The survey team reviewed the QAPI meeting sign-in sheet dated and interviewed members of the QAPI team. 6. On 11/21/19 the Regional Director of Operations/Interim Administrator and the Regional Nurse Consultant reviewed the current QAPI plan to ensure concerns had a formal plan in place. The survey team reviewed the sign-in sheet dated for QAPI. 7. The Administrator will conduct daily audits Monday through Friday and the DON or her designee will conduct the audits on weekends to ensure the facility is in compliance with the smoking policy and amended elopement policy with the door code security process. The survey team reviewed the audit forms. 8. The Regional Director of Operations or the Regional Nurse Consultant will review the facility PIP plan monthly and it will be discussed at the monthly QAPI meeting. The Regional Nurse Consultant was interviewed by the survey team to confirm that monthly QA audits would be conducted. 9. On 11/21/19, the Medical Director and the Governing Body were informed of the Immediate Jeopardy. The QAPI meeting was attended by the Regional Director of Operations/Interim Administrator, the Regional Nurse Consultant, the DON, the Medical Director, the Social Services Director, and the MDS Nurse. The Medical Director approved the policies and procedures. Noncompliance continues at a scope and severity level of [NAME] for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on the Regional Director of Operation job description, Director of Nursing job description, medical record review, and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of the residents. Administration failed to ensure the residents who smoked had adequate supervision, and failed to provide oversight and training of staff to ensure the secure codes to the exit doors remained secure. The failure of administration placed Resident #1, #5, #21, #26, #37, and #242 in Immediate Jeopardy when staff did not report, implement, evaluate, or monitor resident safety measures for smoking and wandering residents. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Regional Director of Operations/Interim Administrator, Regional Nurse Consultant, and Director of Nursing (DON), were notified of the Immediate Jeopardy (IJ) on 11/19/19 at 4:51 PM, in the Administrator office. F-689, F-835, and F-867 were cited at a scope and severity of K. F-657 was cited at a scope and severity of [NAME] F-689-K is Substandard Quality of Care. An extended survey was conducted on 11/20/19. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/21/19 at 8:40 AM and the corrective actions were validated onsite by the survey team on 11/21/19 and 11/22/19 through review of assessments, auditing tools, in-service training records, policies, observations, and family and staff interviews. The IJ was effective 11/18/19 through 11/21/19. The findings include: The facility's Regional Director of Operations Job Description revised 9/1/17 documented, .Responsible for .management and creating/leading high-performing regional leadership teams .responsible for the direct oversight and implementation of all Company policies, procedures .Implement and oversee organizational policy at the facility level .Implement all approved strategies and act as change agent to improve outcomes .Review facility performance .coordinating and enforcing systems, policies and procedures . The facility's Director of Nursing Job Description dated 8/10/17 documented, .To manage overall operations of the Nursing Services Department in accordance with Company policies .and governmental regulations so as to maintain excellent care of all the Residents' and employee needs .communicate policies, evaluate performance and provide feedback to assist, coach or redirect team members .discipline as needed .Conduct regular rounds to review care .ensure the delivery of nursing care according to the physicians orders, care plans, and established standards and facility policies .Follow and ensures compliance with State, Federal and company QAPI (Quality Assurance Performance Improvement) standards .Directly supervises and is accountable for the Nursing department .communicating job expectations; planning, monitoring .coordinating and enforcing systems, policies, and procedures . Interview with the DON on 11/19/19 at 1:03 PM, in the Administrator's Office, the DON was asked if she had any wandering residents. The DON stated, We have several that wander throughout the building. The DON was asked who had the exit door access code. The DON stated, Only staff have the codes to the keypad . Interview with the Regional Director of Operations/Interim Administrator, Regional Nurse Consultant, and the DON on 11/19/19 at 4:28 PM, in the Administrator's Office, the Regional Director of Operations/Interim Administrator was asked if residents smoked unsupervised. The Regional Director of Operations/Interim Administrator stated, No .I have confiscated cigarettes and lighters from a resident today . The Regional Director of Operations/Interim Administrator was asked if staff should leave residents unattended during smoking. The Regional Director of Operations/Interim Administrator stated, No. The DON was asked if she had residents with wandering and exit seeking behaviors in the facility. The DON stated, Our wanderers do not exhibit exit-seeking behavior. The DON was asked if she considered residents stating they wanted to go home and shaking the door handles of exit doors as exit-seeking behaviors. The DON stated, I don't consider shaking the door exit-seeking . The DON was asked who had access to the codes and the exit doors. The DON stated, The codes are given to staff and resident's family members when they are admitted . Interview with the Business Office Manager and Maintenance Supervisor on 11/19/19 at 5:14 PM, in the Administrator's Office, the Maintenance Supervisor was asked how often the door codes were changed. The Maintenance Supervisor stated, No set pattern .when the need arises . The Maintenance Supervisor was asked what the facility policy and procedure was for the door codes. The Maintenance Supervisor stated, No policy .it is changed at our discretion . Interview with Certified Nursing Assistant (CNA) #3 on 11/20/19 at 2:28 PM, in the Dining Room, CNA #3 was asked if Resident #5 was compliant with smoking rules and regulations. CNA #3 stated, .not all the time .I'm pretty sure (Named Resident #1) would open the door and they would both (Resident #1 and #5) go out .and when our old Administrator (the previous Administrator's last day at the facility was 11/15/19, the Friday prior to the entrance of the recertification survey) was here we (staff) would tell him (previous Administrator) and he was nonchalant about enforcing the whole smoking rules. CNA #3 was asked if she personally told the previous Administrator about Resident #1 and #5 going outside unattended. CNA #3 stated, I would tell him (previous Administrator) that they (Resident #1 and #5) were out there and he would kind of just roll it off his shoulder . Interview with the Nursing Supervisor on 11/21/19 at 8:15 AM, in the Dining Room, the Nursing Supervisor stated, I personally have brought to (Named Previous Administrator's) attention that codes (secure exit door codes) were known by a lot of people and that they needed to be changed .but he wanted to make sure the residents' rights were maintained . The Nursing Supervisor confirmed the codes had not been changed. Interview with the Regional Director of Operations/Interim Administrator and Regional Nurse Consultant on 11/21/19 at 11:49 AM, in the Administrator's Office, the Regional Director of Operations was asked if the facility had been monitored for compliance of the new smoking policy which was revised in (MONTH) 2019. The Regional Director of Operations/Interim Administrator stated, Education should have been provided and followed through .I don't believe it occurred . Telephone interview with the Vice President of the parent company on 11/21/19 at 4:47 PM, in the Administrator Office, the Vice President stated, .I stepped into this role about 4 months ago .made an onsite visit to (Named this Nursing Home) within the first month and a half .the Administrator wasn't there .I did not like the fact he was not there, then reaching out through emails and phone calls that he was not available, kind of led me to think more was going on there .the more questions I asked the more they (staff) become evasive .Led to the Administrator being termed (terminated on 11/15/19) and (Named Regional Director of Operations) being placed in as interim . Administration failed to provide oversight of staff when staff failed to ensure a safe and consistent smoking regimen for residents that smoke which resulted in an IJ for Resident #1 and #5. Refer to F-657 and F-689 Administration failed to ensure staff maintained the confidential secure codes to the exit doors and ensure the safety of residents with exit seeking behaviors. This failure placed residents (Resident #21, #26, #37, and #242) with active wandering/exit seeking behaviors in an I[NAME] Refer to F-689 The surveyors verified the Removal Plan by: 1. On 11/18/19, the Director of Nursing and the Regional Nurse Consultant conducted a smoking assessment and chart audit of the BIMS score on each smoking resident to assess cognitive function prior to review of the facility smoking policy with each resident. The residents with a BIMS score greater than 12 were educated on the policy, and those with less than 12, had their Responsible party educated by the facility. This included designated smoking times, the requirement of staff supervision and the potential consequences of violation of this policy. The survey team reviewed the smoking assessments and the facility's smoking policy. The staff, residents, and family were interviewed for education on the smoking policy changes. 2. On 11/18/19, the Regional Nurse Consultant and the DON began conducting in-service training with staff members to review the facility smoking policy to ensure residents were monitored while smoking, were smoking in a safe manner, and were compliant with the facility smoking policy. The survey team reviewed the facility's smoking policy, in-service training records, and interviewed staff on each shift. All staff members must participate in training and education before they are allowed to work. Nursing assignment sheets were updated to reflect staff members that were assigned to monitor the smoking residents at the designated times. 3. On 11/19/19, the Regional Nurse Consultant and Director of Nursing began conducting in-service training with staff members on the new door access codes and ensuring they were not shared with residents or the codes were not put in where residents could observe and learn the access codes. All staff members must participate in training and education before they are allowed to work. The survey team reviewed the in-service and sign-in sheets. The survey team interviewed staff on each shift. 4. On 11/21/19, the Medical Director and the Governing Body were informed of the Immediate Jeopardy. Quality Assurance Performance Improvement (QAPI) committee education was initiated by the Regional Director of Operations/Interim Administrator. The survey team interviewed the Medical Director, the Vice President of the company, and the Senior Director of Operations regarding an Administrative plan. 5. A QAPI committee meeting was held on 11/20/19 with the Regional Director of Operations/Interim Administrator, Regional Nurse Consultant, DON, Medical Director, Social Services Director, and MDS Nurse. The policies and procedures that were discussed with and approved by the Medical Director on 11/19/19 were officially reviewed and implemented. The survey team interviewed members of the QAPI committee, reviewed the QAPI meeting sign-in sheet and the policy and procedures. 6. The Regional Director of Operations/Interim Administrator will educate the next Administrator on the Resident Smoking Policy, as well as the Elopement Policy and Addendum for changing door codes to ensure resident safety. The Regional Director and/or Regional Nurse Consultant will conduct monthly audits to review enforcement of smoking policy and the amended elopement policy with door code security process. The survey team interviewed the Vice President of the company, the Senior Director of Operations, and the Regional Nurse Consultant and reviewed the audit forms. 7. The Administrator will conduct daily audits Monday through Friday and the DON or her designee will conduct the audits on weekends to ensure the facility is in compliance with the smoking policy and amended elopement policy with the door code security process. The survey team reviewed the audit forms. Noncompliance continues at a scope and severity level of [NAME] for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to provide adequate supervision and ensure a safe environment for 6 of 15 (Resident #1, #5, #21, #26, #37, and #242) sampled residents who were reviewed for accident hazards. The failure of the facility to adequately supervise smoking residents and to ensure a safe environment for active wandering/exit-seeking residents placed Resident #1, #5, #21, #26, #37, and #242 in Immediate Jeopardy. Resident #1 and #5 exited the facility using the exit door code and were observed smoking unsupervised. Resident #21, #26, #37, and #242 were cognitively impaired residents with wandering/exit-seeking behaviors who were placed in Immediate Jeopardy when the codes for the exit doors were not kept secure. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Regional Director of Operations/Interim Administrator, Regional Nurse Consultant, and Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/19/19 at 4:51 PM, in the Administrator's Office. F-689 was cited at a scope and severity of K, which is Substandard Quality of Care. An extended survey was conducted on 11/20/19. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received 11/21/19 at 8:40 AM and the Removal Plan was validated onsite by the survey team on 11/21/19 and 11/22/19 through review of assessments, policies related to smoking and secure door codes, in-service training records, and staff, resident, and family interviews. The IJ was effective from 11/18/19 to 11/21/19. The findings include: 1. The facility's Elopement/Unsafe Wandering Plan dated 2/7/12 documented, .It is the policy of this facility to protect the resident from harm while providing care in a manner that helps promote quality of life in a safe environment . The facility's Smoking policy revised on 8/15/19 documented, .It is the policy of this facility to provide a safe environment for residents who smoke .Designated smoking periods for residents will be determined and staff scheduled to supervise during these times .Staff will remain with residents during the entire Smoking Period .Smoking materials will be distributed by staff at the designated smoking period and maintained by staff . The facility's undated Accidents and Incidents policy documented, .It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible .This is accomplished through the identification and evaluation of environmental hazards and individual risk factors, implementing interventions to reduce hazards and risks that are identified, and monitoring for the effectiveness of the interventions . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Smoking Evaluation dated 8/2/19 documented, .Does resident have visual deficit .(checked) Yes .Have all of the resident's smoking materials been secured .Ex. (Example) Lighter, cigarettes .(checked) Yes .Plan of care is used to assure resident is safe while smoking .(checked) Yes . Medical record review of a Progress Note dated 8/4/19 at 6:35 PM documented, .siting (sitting) on side of bed rolling his cigarettes . Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Medical record review of the Care Plan revised 11/18/19 revealed Resident #1 was a smoker who required the use of a smoking apron and supervision while smoking. This care plan revision was done after the facility became aware that the surveyors had observed residents smoking unsupervised. Medical record review of a Smoking Evaluation dated 11/18/19 at 1:12 PM documented, .Does resident have visual deficit .(checked) Yes .Resident need for adaptive equipment .Smoking apron (checked) .Supervision (checked) .Have all of the resident's smoking materials been secured .Ex. (Example) Lighter, cigarettes .(checked) Yes .Plan of care is used to assure resident is safe while smoking .(checked) Yes . The Smoking Evaluation dated 11/18/19 was completed at 1:12 PM, after the facility became aware that the surveyors had observed residents smoking unsupervised. 3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an annual MDS dated [DATE] revealed a BIMS score of 15, which indicated Resident #5 was cognitively intact and was coded for tobacco use. Medical record review of Resident #5's Smoking Evaluation dated 8/8/19 documented, .Does resident have dexterity problem .(checked) Yes .Resident need for adaptive equipment .Smoking apron (checked) .Have all of the resident's smoking materials been secured .Ex. (Example) Lighter, cigarettes .(checked) Yes .Plan of care is used to assure resident is safe while smoking .(checked) Yes . Medical record review of the Care Plan revised 11/18/19 revealed Resident #5 was a smoker who required the use of a smoking apron and supervision while smoking. This care plan revision was done after the facility became aware that the surveyors had observed residents smoking unsupervised. Medical record review of Resident #5's Smoking Evaluation dated 11/18/19 at 1:18 PM documented, .Does have resident have dexterity problem .(checked) Yes .Resident need for adaptive equipment .Smoking apron (checked) .Supervision (checked) .Have all of the resident's smoking materials been secured .Ex. (Example) Lighter, cigarettes .(checked) Yes .Plan of care is used to assure resident is safe while smoking .(checked) Yes . The Smoking Evaluation dated 11/18/19 was completed at 1:18 PM, after the facility became aware that the surveyors had observed residents smoking unsupervised. Observation on 11/18/19 at 11:58 AM in the Back Hall at the exit door to the Smoking Area, revealed Resident #1 propelled Resident #5 in his wheelchair to the Back Hall exit doors, entered the door code into the keypad, and wheeled Resident #5 in his wheelchair out through the doors. No staff members were present. Observation on 11/18/19 at 12:05 PM in the Smoking Area, revealed the Dietary Cook and Environmental Services Director were seated under the Smoking Pavilion and Residents #1 and #5 were each smoking a cigarette. On 11/18/19 at 12:05 PM in the Back Hall at the exit door to the Smoking Area, the surveyor attempted to open the Back Hall exit door and it would not open. Resident #6 was observed sitting on her rolling walker in front of the exit doors inside the building. Resident #6 turned around and entered the code to the secure exit door for the surveyor to exit the facility. Observation on 11/18/19 at 12:08 PM in the Smoking Area, revealed the Dietary Cook left the smoking area and entered the facility. Observation on 11/18/19 at 12:10 PM in the Smoking Area, revealed the Environmental Services Director left the smoking area and entered the facility. Residents #1 and #5 continued smoking unattended and unsupervised. Observation on 11/18/19 at 12:16 PM in the Smoking Area, revealed Certified Nursing Assistant (CNA) #1 entered the Smoking Area with a plastic container containing the residents' smoking paraphernalia for the residents' scheduled smoke break. Residents #1 and #5 were left smoking cigarettes unattended and unsupervised for 6 minutes. Interview with Resident #5 on 11/18/19 at 12:54 PM, in Resident #5's room, Resident #5 was asked who gave him the cigarettes at the noon smoking break. Resident #5 stated, That nurse give 'em (them) to me. Resident #5 was asked if the nurse gave him the cigarettes before he went out. Resident #5 stated, Yes ma'am. Resident #5 was asked if the nurse gave him a lighter. Resident #5 stated, I don't have a lighter. Resident #5 was asked how he lit his cigarette. Resident #5 stated, From that man (Resident #1) over there. Resident #5 was asked if staff were with him and Resident #1 when they went outside and started smoking at the noon smoking break. Resident #5 stated, No. Interview with Resident #1 on 11/18/19 at 1:00 PM, in Resident #1's room, Resident #1 was asked if he knew the code to the exit doors. Resident #1 stated, Yes ma'am, then told the surveyor the code. Resident #1 was asked who told him the code. Resident #1 stated, I just figured it out. Observation and interview with Licensed Practical Nurse (LPN) #1, on 11/19/19 at 10:36 AM in the Smoking Area, LPN #1 was asked if the back gate of the chain link fence (in the Smoking area) would open. LPN #1 lifted the latch and the gate swung open. LPN #1 was asked if a resident could get out the gate. LPN #1 stated, Well yeah, I guess . Random observations on 11/19/19 at 11:15 AM in the Back Hall at the exit doors, revealed an outside vendor entered the door code into the keypad and exited the facility. No staff were present. Interview with the Resident Council on 11/19/18 at 2:20 PM, in the Dining Room, the Resident Council attendees were asked if any of the residents knew the code to the secure exit doors. Resident #5 stated, I know the code. I've known it for a long time . 4. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission MDS dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment and no wandering behaviors. Medical record review of the Progress Notes dated 10/23/19 at 1:16 AM, 6:47 PM, and on 10/24/19 at 4:19 PM revealed Resident #21 wandered in the halls. Observation on 11/18/19 at 6:34 AM in the Back Hall, revealed Resident #21 exited her room, walked to the end of the hallway, and pushed on the exit door several times. 5. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment, and wandering occurred 1 to 3 days during the 7 day look back period. Medical record review of the Care Plan dated 10/2/19 documented, .elopement risk/wanderer .I wander aimlessly throughout facility . Medical record review of a Progress Note dated 11/9/19 documented, .ambulates without assistance in the hallway. Severe confusion noted . Observation on 11/19/19 at 10:15 AM in the Front Hall, revealed Resident #26 was walking in the hall and stated, I want to go home, I wish I could. Observation on 11/19/19 at 10:23 AM at the exit door by room [ROOM NUMBER], revealed Resident #26 was standing at the door with CNA #3 and was looking outside. Resident #26 constantly walked from one door to the next door. Observation on 11/21/19 at 8:33 AM in the Front Hall, revealed Resident #26 was at the front door when the surveyor entered the facility. 6. Medical record review revealed Resident #37 was admitted to facility on 11/5/12 with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed Resident #37 had a BIMS score of 2 which indicated severe cognitive impairment and no wandering behaviors. Medical record review of the Care Plan revised 11/8/19 documented, .I am a wanderer. I wander aimlessly throughout facility .Distract resident from wandering . Observation on 11/18/19 at 3:47 PM in the Front Hall, revealed Resident #37 standing at the exit doors and pushing on the doors several times. Observation on 11/19/19 at 10:03 AM in Resident #19's room, revealed Resident #37 wandered into the room and touched Resident #19's belongings. Observation on 11/19/19 at 12:45 PM in the Front Hall, revealed Resident #37 standing at the exit doors and pushing on the doors. Observation on 11/21/19 at 8:14 AM in Resident #19's room, revealed Resident #37 wandered into Resident #19's room. 7. Medical record review revealed Resident #242 was admitted to facility on 11/12/19 with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #242 had a BIMS score of 6 which indicated severe cognitive impairment and no wandering behaviors. Medical record review of the Care Plan dated 4/22/19 documented, .I am an elopement risk/wanderer .I wander throughout facility continuously .Identify pattern of wandering .provide structured activities . Observation on 11/19/19 at 5:44 PM in the Lobby, revealed Resident #242 seated on the couch with a visitor. Resident #242 got up abruptly and walked away, and began wandering aimlessly. Observation on 11/18/19 at 9:14 AM in the Back Hall by the Nurses' Station, revealed Resident #242 walked away while staff were combing her hair. Resident #242 wandered aimlessly down the hall. Interview with the Regional Director of Operations/Interim Administrator on 11/19/19 at 4:28 PM, in the Administrator's Office, the Regional Director of Operations/Interim Administrator was asked if residents should smoke unsupervised. The Regional Director of Operations/Interim Administrator stated, No .I've confiscated cigarettes and lighters from one resident today . The Regional Director of Operations/Interim Administrator was asked if residents had been smoking unattended prior to today. The Regional Director of Operations/Interim Administrator stated, Yes .got wind of it today . The Regional Director of Operations/Interim Administrator was asked if staff should leave the smoking area while residents were still smoking. The Regional Director of Operations/Interim Administrator stated, No. The Regional Director of Operations/Interim Administrator confirmed the facility's Smoking Policy documented that staff would remain with residents during the entire smoking period. The Regional Director of Operations/Interim Administrator was asked if he was aware that facility residents and outside vendors were entering the code to open the exit doors. The Regional Director of Operations/Interim Administrator shook his head from side to side, stating no. Interview with the DON on 11/19/19 at 4:28 PM, in the Administrator's Office, the DON was asked if the residents who wandered had exhibited exit-seeking behaviors. The DON stated, No, they do not . The DON was asked if she considered a resident pushing on the exit doors numerous times to be an exit-seeking behavior. The DON stated, No . The Regional Director of Operations/Interim Administrator was asked when the door code was last changed. The Regional Director of Operations/Interim Administrator stated, I have no idea . The Regional Director of Operations/Interim Administrator was asked if the gates outside the smoking area were secure when residents were alone in the area. The Regional Director of Operations/Interim Administrator stated, The residents aren't supposed to be out there unsupervised. The Regional Director of Operations/Interim Administrator was asked what the facility had in place to protect the residents if they were outside unsupervised. The Regional Director of Operations/Interim Administrator stated, That's a good question. Observation and interview with the Maintenance Supervisor on 11/19/19 at 5:14 PM, in the Smoking Area, the Maintenance Supervisor was asked if it was possible for a resident to get out the back gate in the Smoking Area. The Maintenance Supervisor stated, It is possible they could get out there. I don't know how that (scissor clasp) got unattached. Interview with CNA #3 on 11/20/19 at 2:28 PM, in the Dining Room, CNA #3 was asked if Resident #5 was compliant with smoking rules and regulations. CNA #3 stated, .not all the time .I'm pretty sure (Named Resident #1) would open the door and they would both (Resident #1 and #5) go out .and when our old Administrator (the previous Administrator's last day at the facility was 11/15/19, the Friday prior to the entrance of the recertification survey) was here we (staff) would tell him (previous Administrator) and he was nonchalant about enforcing the whole smoking rules. CNA #3 was asked if she personally told the previous Administrator about Resident #1 and #5 going outside unattended. CNA #3 stated, I would tell him (previous Administrator) that they (Resident #1 and #5) were out there and he would kind of just roll it off his shoulder . Interview with the Environmental Services Director on 11/20/19 at 5:28 PM, in the Dining Room, the Environmental Service Director was asked if Resident #1 and #5 were already smoking when he and the Dietary Cook went out for their noon smoke break on Monday, 11/18/19. The Environmental Services Director stated, Yes ma'am . The Environmental Services Director was asked who gave Resident #1 and #5 their cigarettes. The Environmental Services Director stated, I would assume maybe a family member .they were already lit when we came out there .we didn't do it . The Environmental Services Director was asked why he left the residents unattended while smoking. The Environmental Services Director stated, .past my clock in time .I messed up . Interview with the Dietary Cook on 11/21/19 at 8:02 AM, in the Dining Room, the Dietary Cook stated, When we went out (named the Environmental Services Director) grabbed the smoke aprons and put them (smoking aprons) on them (Resident #1 and #5) . The Dietary Cook was asked if Resident #1 and #5 had the smoking aprons on when she went outside. The Dietary Cook stated, No. The Dietary Cook was asked if the residents were smoking unsupervised when she and the Environmental Services Director arrived in the smoking area. She stated Yes ma'am. Interview with the Nursing Supervisor on 11/21/19 at 8:15 AM, in the Dining Room, the Nursing Supervisor stated, I personally have brought to (Named Previous Administrator's) attention that codes (secure exit door codes) were known by a lot of people and that they needed to be changed .but he wanted to make sure the residents' rights were maintained . The Nursing Supervisor confirmed the codes had not been changed. Telephone interview with the Medical Director on 11/21/19 at 10:39 AM, the Medical Director was asked if he was aware some of the residents were smoking unsupervised. The Medical Director stated, No .they're not supposed to smoke alone .should be somebody there to watch over them . The Medical Director was asked if it was safe for residents, families, and vendors to have access to the exit door codes. The Medical Director stated, I was not aware .some of them (residents) have tried to slip out with me . Telephone interview with the Vice President of the parent company on 11/21/19 at 4:47 PM, in the Administrator's Office, the Vice President stated, .I stepped into this role about 4 months ago .made an onsite visit to (Named this Nursing Home) within the first month and a half .the Administrator wasn't there .I did not like the fact he was not there, then reaching out through emails and phone calls that he was not available, kind of led me to think more was going on there .the more questions I asked the more they (staff) become evasive .Led to the Administrator being termed (terminated on 11/15/19) and (Named Regional Director of Operations) being placed in as interim . The failure of the facility to adequately supervise and monitor smoking residents and to ensure a safe environment for active wandering/exit-seeking residents placed Resident #1, #5, #21, #26, #37, and #242 in Immediate Jeopardy. The survey team verified the Removal Plan by: 1. On 11/18/19 the DON and the Regional Nurse Consultant conducted a smoking assessment and chart audit of the BIMS score on each smoking resident to determine cognitive function of the smoking residents. The residents with a BIMS score greater than 12 on the smoking policy and the responsible party of the residents with a BIMS score of less than 12 were educated on the smoking policy. This included designated smoking times and the requirement of staff supervision. The survey team reviewed the smoking assessments and interviewed residents and family members regarding the education provided by the facility. 2. On 11/18/19, the Regional Nurse Consultant and DON began in-service training with staff members to educate and review the facility smoking policy to ensure that residents are monitored while smoking, smoking safely, and compliant with the facility smoking policy. All staff members must participate in training and education before they are allowed to work. The survey team validated the education by interviewing facility staff on each shift and reviewing the in-service sign in sheets. 3. On 11/19/19, the Maintenance Supervisor changed the door codes and the green exit door release buttons were covered with a clear box that can be opened to ensure resident safety and limit ability to enter and exit the building without appropriate supervision. The smoking area gates were secured with the changing of the codes. The survey team interviewed the Maintenance Supervisor and staff on each shift and validated the codes were changed. 4. On 11/19/19, the DON conducted body audits of the 2 residents observed smoking unattended to ensure there were [MEDICAL CONDITION] injuries. The survey team reviewed the body audits. 5. On 11/19/19, the Regional Nurse Consultant and the DON began conducting in-service training with staff members on the new door access codes and ensuring that staff did not share the code with residents or enter the code where residents could observe and learn the access codes. All staff members must participate in training and education before they are allowed to work. The survey team validated the education provided to staff by interviewing staff members on each shift and reviewing the staff in-service sign in sheets. 6. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 11/20/19 at 3:30 PM. Those in attendance were the Regional Director of Operations/Acting Administrator, the Regional Nurse Consultant, the DON, the Medical Director, the Social Services Director, and the MDS Nurse. The policy and procedures discussed with the Medical Director on 11/19/19 were officially reviewed and implemented. The survey team validated this through interviews with members of the QAPI committee and review of the QAPI meeting sign-in sheet. 7. The following procedures were reviewed and adopted by the Medical Director and QAPI team regarding resident safety: The facility changed the door codes which secured the doors and smoking area access gates. The survey team interviewed the Maintenance Supervisor and staff on each shift. The Door Codes Procedure was revised to ensure the facility door codes are changed monthly or more frequently if needed to ensure resident safety. The CNA assignment sheet procedure was updated to reflect what staff members are assigned to monitor the smoking residents at the designated times to ensure assigned staff accountable to oversee resident smoke breaks. The survey team reviewed the CNA Assignment Procedure sheet and interviewed staff on each shift. Outside signage will inform visitors and vendors that staff assistance is required to enter and exit the facility. The codes will not be available for outside use. The signage was observed by the survey team. Noncompliance of F-689 continued at a scope and severity of [NAME] for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

Based on policy review, medical record review, observation, and interview, the facility failed to revise the care plan for safe smoking, wandering/exit-seeking behaviors, and falls for 6 of 26 (Resident #1, #5, #6, #19, #21, and #29) sampled residents reviewed for smoking, wandering/exit-seeking behaviors, and falls. The facility's failure to revise the care plan for safe smoking placed Resident #1 and #5 in Immediate Jeopardy when they were observed to be smoking unsupervised. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Regional Director of Operations/Interim Administrator, Regional Nurse Consultant, and Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/19/19 at 4:51 PM, in the Administrator's Office. F-657 was cited at a scope and severity of [NAME] An extended survey was conducted on 11/20/19. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/21/19 at 8:40 AM, and the corrective actions were validated onsite by the survey team on 11/21/19 and 11/22/19 through review of assessments, auditing tools, in-service training records, policies, verification of Quality Assurance Performance Improvement (QAPI) meeting, observations, family interviews, and staff interviews. The Immediate Jeopardy was effective 11/18/19 through 11/21/19. The findings include: 1. The facility's Care Plans-Comprehensive policy dated 6/1/00, documented, .It is the policy of this facility to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs .Procedure .4 .Care plans revised as changes in the resident's condition dictates . 2. The facility's Smoking policy revised 8/15/19 documented, .It is the policy of this facility to provide a safe environment for residents who smoke .Additional precautions may apply to some residents due to safety awareness concerns or medical conditions. Such additional precautions will be noted on the resident's plan of care .The interdisciplinary team will make the determination of interventions needed for the safety of the resident during smoking .These interventions will be entered in the resident's care plan .Designated smoking periods for residents will be determined and staff scheduled to supervise during these times .Staff will remain with residents during entire Smoking Period . 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Smoking Evaluation dated 8/2/19 documented, .Does resident have visual deficit .(checked) Yes .Have all of the resident's smoking materials been secured .Ex. (Example) Lighter, cigarettes .(checked) Yes .Plan of care is used to assure resident is safe while smoking .(checked) Yes . Medical record review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 used tobacco. Medical record review of the Care Plan revised 8/29/19 documented, .The resident can smoke UNSUPERVISED . The Care Plan was not revised until 11/18/19 to reflect the smoking policy change dated 8/15/19 that all residents required supervision with smoking. This care plan update was done after the facility became aware that the surveyors had observed residents smoking unsupervised. Medical record review of a Smoking Evaluation dated 11/18/19 at 1:12 PM documented, .Does resident have visual deficit .(checked) Yes .Resident need for adaptive equipment .Smoking apron (checked) .Supervision (checked) .Have all of the resident's smoking materials been secured .Ex. (Example) Lighter, cigarettes .(checked) Yes .Plan of care is used to assure resident is safe while smoking .(checked) Yes . The Smoking Evaluation dated 11/18/19 was completed at 1:12 PM, after the facility became aware that the surveyors had observed residents smoking unsupervised. 4. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS assessment dated [DATE] revealed Resident #5 used tobacco. Medical record review of Resident #5's Smoking Evaluation dated 8/8/19 documented, .Does resident have dexterity problem .(checked) Yes .Resident need for adaptive equipment .Smoking apron (checked) .Have all of the resident's smoking materials been secured .Ex. (Example) Lighter, cigarettes .(checked) Yes .Plan of care is used to assure resident is safe while smoking .(checked) Yes . Medical record review of the Care Plan revised 9/4/19 documented, .The resident can smoke UNSUPERVISED . The Care Plan was not revised until 11/18/19 to reflect the smoking policy change dated 8/15/19 that all residents required supervision with smoking. This care plan update was done after the facility became aware that the surveyors had observed residents smoking unsupervised. Medical record review of Resident #5's Smoking Evaluation dated 11/18/19 at 1:18 PM documented, .Does have resident have dexterity problem .(checked) Yes .Resident need for adaptive equipment .Smoking apron (checked) .Supervision (checked) .Have all of the resident's smoking materials been secured .Ex. (Example) Lighter, cigarettes .(checked) Yes .Plan of care is used to assure resident is safe while smoking .(checked) Yes . The Smoking Evaluation dated 11/18/19 was completed at 1:18 PM, after the facility became aware that the surveyors had observed residents smoking unsupervised. Observation on 11/18/19 at 11:58 AM in the Back Hall at the exit door to the Smoking Area, revealed Resident #1 propelled Residents #5 in his wheelchair to the Back Hall exit doors, entered the door code into the keypad, and wheeled Resident #5 in his wheelchair out through the doors. No staff members were present. Observation on 11/18/19 at 12:05 PM in the Smoking Area, revealed the Dietary Cook and Environmental Services Director were seated under the Smoking Pavilion and Resident #1 and #5 were each smoking a cigarette. Interview with the Environmental Services Director on 11/20/19 at 5:28 PM, in the Dining Room, the Environmental Service Director was asked if Resident #1 and #5 were smoking when he and the Dietary Cook went out for their smoke break on Monday, 11/18/19 at 12:05 PM. The Environmental Services Director stated, Yes ma'am . Interview with the Dietary Cook on 11/21/19 at 8:02 AM, in the Dining Room, the Dietary Cook stated, When we went out (named the Environmental Services Director) grabbed the smoke aprons and put them (smoking aprons) on them (Resident #1 and #5) . The Dietary Cook was asked if Resident #1 and #5 had the smoking aprons on when she went outside. The Dietary Cook stated, No. The Dietary Cook was asked if the residents were smoking unsupervised when she and the Environmental Services Director arrived in the smoking area. She stated Yes ma'am. 5. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS assessment dated [DATE] revealed Resident #6 used tobacco. Medical record review of the Care Plan revised 6/3/19 documented, .I am a smoker .requires a smoking apron while smoking . The Care Plan was not revised until 11/18/19 to reflect the smoking policy change dated 8/15/19 that all residents required supervision with smoking. This care plan update was done after the facility became aware that the surveyors had observed residents smoking unsupervised. Medical record review of Resident #6's Smoking Evaluation dated 8/14/19 documented, .Resident need for adaptive equipment .Smoking apron (checked) .Have all of the resident's smoking materials been secured .Ex. (Example) Lighter, cigarettes .(checked) Yes .Plan of care is used to assure resident is safe while smoking .(checked) Yes . Medical record review of Resident #6's Smoking Evaluation dated 11/18/19 at 1:18 PM documented, .Resident need for adaptive equipment .Smoking apron (checked) .Supervision (checked) .Have all of the resident's smoking materials been secured .Ex. (Example) Lighter, cigarettes .(checked) Yes .Plan of care is used to assure resident is safe while smoking .(checked) Yes . The Smoking Evaluation dated 11/18/19 was completed at 1:18 PM, after the facility became aware that the surveyors had observed residents smoking unsupervised. 6. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission/5 day MDS assessment dated [DATE] revealed Resident #19 used tobacco. Medical record review of the Care Plan revised 10/3/19 documented, .The resident can smoke UNSUPERVISED . The Care Plan was not revised until 11/18/19 to reflect the smoking policy change dated 8/15/19 that all residents required supervision with smoking. This care plan update was done after the facility became aware that the surveyors had observed residents smoking unsupervised. 7. Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the significant change MDS assessment dated [DATE] revealed Resident #29 used tobacco. Medical record review of the Care Plan revised 10/23/19 documented, .The resident does not require supervision while smoking . The Care Plan was not revised until 11/18/19 to reflect the smoking policy change dated 8/15/19 that all residents required supervision with smoking. This care plan update was done after the facility became aware that the surveyors had observed residents smoking unsupervised. Interview with the Regional Nurse Consultant on 11/19/19 at 4:45 PM, in the Administrator's Office, the Regional Nurse Consultant was asked if the residents' care plans should document the residents can smoke unsupervised. The Regional Nurse Consultant stated, .No .our smoking policy was updated .prior to that if their BIMS (Brief Interview for Mental Status) was high enough they could go outside .this update says otherwise . The Regional Nurse Consultant confirmed the smoking policy was revised on 8/15/19. The Regional Nurse Consultant was asked if the care plans should have been updated at that time. The Regional Nurse Consultant stated, Yes ma'am. Interview with the MDS Nurse on 11/21/19 at 11:15 AM, in the Business Office, the MDS Nurse was asked if the care plans for residents who smoke should have been revised when the smoking policy was changed in August. The MDS Nurse stated, Yes, they should have. 8. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS assessment dated [DATE] revealed a BIMS score of 3, which indicated severe cognitive impairment and Resident #21 did not demonstrate any wandering behavior. Medical record review of the Progress notes dated 10/23/19 at 1:16 AM, 6:47 PM, and 10/24/19 at 4:19 PM revealed Resident #21 wandered in the halls. The Incident Report dated 11/7/19 documented, .Incident Location .Therapy Gym .Incident Description .Called to therapy gym by staff to note that resident was lying in floor in front of therapy door. Resident had dropped her drink and possibly slid landing on her back . Medical record review of Resident #21's Care Plan revised 11/7/19 revealed .I am at risk for falls .Interventions .11/7/19 .Frequent (frequently) reorient to surroundings (intervention for the fall on 11/7/19) . Observation on 11/18/19 at 6:34 AM in the Back Hall, revealed Resident #21 exited her room, walked to the end of the hallway, and pushed on the exit door several times. The Care Plan was not revised to reflect Resident #21's wandering/exit-seeking behaviors and the fall intervention to reorient to surroundings was not appropriate due to Resident #21's cognitive status. Interview with the DON on 11/20/19 at 9:50 AM, in the DON's Office, the DON stated, .She (Resident#21) walks around aimlessly throughout the building . The DON was asked what intervention was put in place after her fall on 11/7/19. The DON stated, Frequent orientation to surroundings . Interview with the Nursing Supervisor on 11/20/19 at 10:20 AM, at the Back Hall Nurses' Station, the Nursing Supervisor was asked about Resident #21's cognitive status. The Nursing Supervisor confirmed the intervention of frequent orientation was not appropriate and stated, She (Resident #21) is not cognitively intact to comprehensive inservices. As far as education, she is not going to learn and retain . The failure of the facility to revise the care plans for safe smoking placed Resident #1 and #5 in Immediate Jeopardy when they were observed to be smoking unsupervised. Refer to F689. The surveyors verified the Removal Plan by: 1. On 11/18/19 the DON and the Regional Nurse Consultant conducted a review of smoking safety assessments, a chart audit of the BIMS (Brief Interview for Mental Status) score on each smoking resident, and a wandering assessment was reviewed for all wandering residents to ensure care plans accurately reflected the resident's condition. The Social Service Director revised all care plans for residents who smoked to ensure proper safety measures were in place. The survey team reviewed the smoking assessments, verified the chart for BIMS score, reviewed the wandering assessments, verified that care plans reflected the resident's current condition related to wandering, and proper safety measures were in place for the residents who smoked. 2. On 11/18/19 the Regional Nurse Consultant and the DON conducted in-service training with staff members to review the facility smoking policy to ensure residents were monitored while smoking, residents were smoking in a safe manner congruent with their care plans, residents were compliant with the facility smoking policy, and that care plans for wandering residents were current and accurate. All staff members must participate in training and education before they are allowed to work. The survey team validated the education by interviewing facility staff on each shift and reviewing the education sign in sheets. 3. On 11/18/19 the DON and the Social Services Director provided education to all smoking residents and their families regarding the smoking policy. This included designated smoking times, the requirement of staff supervision, and the potential consequences of violation of this policy. The survey team interviewed residents and families and confirmed the education provided by the facility. 4. On 11/19/19 the Regional Nurse Consultant and the DON conducted in-service training with the Interdisciplinary Team on updating resident care plans for residents with wandering behaviors and those residents that smoked to reflect their current status and safety interventions. The survey team interviewed members of the Interdisciplinary Team regarding the education provided by the facility. 5. A Quality Assurance Performance Improvement (QAPI) meeting was held on 11/20/19 at 3:30 PM. The meeting was attended by the Regional Director of Operations/Interim Administrator, the Regional Nurse Consultant, the DON, the Medical Director, the Social Services Director, and the MDS Nurse. The policies and procedures reviewed with the Medical Director on 11/19/19 were officially reviewed and implemented. The survey team reviewed the QAPI sign-in sheet dated 11/20/19 and interviewed the attendees. Noncompliance continues at a scope and severity of D for monitoring and effectiveness of corrective actions. The facility is required to submit a Plan of Correction.