Every finding on record at Claridge House Nursing and Rehabilitation Center

Based on observations, interviews and record review the facility failed to ensure 1) proper temperatures of the foods stored in the 2 South Unit Floor Pantry Refrigerator and 1 North Unit Floor Pantry Refrigerator on the resident's units and 2) ensure kitchen staff were wearing a beard restraint. This has the potential to affect 54 residents out of 55 residents who eat orally residing on 2 South unit and to affect 44 out of 58 residents who eat orally residing on the 1 North unit at the time of the survey.The findings included:1) Record review of the Refrigerator and Freezer Temperature Monitoring Policy and Procedure (no written date) documented the following: Policy: The dietary department will maintain proper temperature control for all refrigerators and freezers used for food storage to ensure food safety and regulatory compliance; Procedure: Dietary staff will maintain manual thermometer to verify accuracy of the unit temperature when needed; Temperatures will be checked and recorded daily on the refrigerator temperature log; Acceptable temperature ranges are: Refrigerators: 36 degrees Fahrenheit (F) to 41 degrees Fahrenheit (F) and if the temperature falls outside the acceptable range, staff will notify the supervisor and maintenance department for review and corrective action.Observation of the 2 South Unit Floor Pantry Refrigerator with Staff K, Licensed Practical Nurse (LPN) on 3/16/2026 at 8:08 AM revealed the refrigerator temperature was 50 degrees Fahrenheit (F). The refrigerator contained resident's food items with the resident's name, resident's room number and dates the food items were placed in the refrigerator. Photographic evidence submitted.Interview with Staff K, LPN on 3/16/2026 at 8:09 AM. She confirmed the refrigerator temperature was 50 degrees F. She revealed that she would call maintenance to let them know the refrigerator was not working properly.Record review of the 2 South Unit Pantry Refrigerator Log dated March 16, 2026 documented the temperature was 40 degrees F.Observation of the 1 North Unit Floor Pantry Refrigerator with Staff L, Registered Nurse (RN) Supervisor on 3/16/2026 at 8:16 AM revealed the refrigerator temperature was 50 degrees F. The refrigerator contained resident's food items with the resident's name, resident's room number and dates the food items were placed in the refrigerator. Photographic evidence submitted.Interview with Staff L, RN Supervisor on 3/16/2026 at 8:17 AM. She confirmed the refrigerator temperature was 50 degrees F.Record review of the 1 North Unit Pantry Refrigerator Log dated March 16, 2026 documented the temperature was 40 degrees F. 2) Record review of the Hair Restraint Policy and Procedure (no written date) documented the following: Policy: To prevent food contamination by ensuring all foodservice employees wear effective hair restraints while working in food preparation, service and ware washing areas; Policy: All foodservice employees must wear effective hair restraints to fully contain hair and prevent contamination of food, equipment, utensils and food-contact surfaces; Requirements: Employees with facial hair must wear a beard net in addition to head hair restraints; Hair restraints must be always worn in food preparation, service and dishwashing areas.Second observation of the kitchen on 3/16/2026 at 11:07 AM revealed Staff M, [NAME] with a beard and not wearing a beard guard. He was preparing items for the lunch tray line.Interview with Staff M, [NAME] on 3/16/2026 at 11:08 AM. He confirmed that he was not wearing a beard guard, and he was supposed to have one on.

Based on observations, interviews and record review the facility failed to ensure the refrigerators in the 2 South Unit Floor Pantry and 1 North Unit Floor Pantry used to store resident's food were working properly. This has the potential to affect 54 residents out of 55 residents who eat orally residing on 2 South unit and to affect 44 out of 58 residents who eat orally residing on the 1 North unit at the time of the survey.The findings included:Record review of the Refrigerator and Freezer Temperature Monitoring Policy and Procedure (no written date) documented the following: Policy: The dietary department will maintain proper temperature control for all refrigerators and freezers used for food storage to ensure food safety and regulatory compliance; Procedure: Dietary staff will maintain manual thermometer to verify accuracy of the unit temperature when needed; Temperatures will be checked and recorded daily on the refrigerator temperature log; Acceptable temperature ranges are: Refrigerators: 36 degrees Fahrenheit (F) to 41 degrees Fahrenheit (F) and if the temperature falls outside the acceptable range, staff will notify the supervisor and maintenance department for review and corrective action.Observation of the 2 South Unit Floor Pantry Refrigerator with Staff K, Licensed Practical Nurse (LPN) on 3/16/2026 at 8:08 AM revealed the refrigerator temperature was 50 degrees Fahrenheit (F). The refrigerator contained resident's food items with the resident's name, resident's room number and dates the food items were placed in the refrigerator. Photographic evidence submitted.Interview with Staff K, LPN on 3/16/2026 at 8:09 AM. She confirmed the refrigerator temperature was 50 degrees F. She revealed that she would call maintenance to let them know the refrigerator was not working properly.Record review of the 2 South Unit Pantry Refrigerator Log dated March 16, 2026, documented the temperature was 40 degrees F.Observation of the 1 North Unit Floor Pantry Refrigerator with Staff L, Registered Nurse (RN) Supervisor on 3/16/2026 at 8:16 AM revealed the refrigerator temperature was 50 degrees F. The refrigerator contained resident's food items with the resident's name, resident's room number and dates the food items were placed in the refrigerator. Photographic evidence submitted.Interview with Staff L, RN Supervisor on 3/16/2026 at 8:17 AM. She confirmed the refrigerator temperature was 50 degrees F.Record review of the 1 North Unit Pantry Refrigerator Log dated March 16, 2026, documented the temperature was 40 degrees F.

Based on observations, record review and interviews, the facility failed to ensure a safe environment free from accidents hazards in four (Room # 231, room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]) out of fifty nine rooms on the second floor and for two (Resident #10 and Resident #153) out of thirty five sampled residents; as evidenced by 1) Personal hygiene products and medication found in residents' room unsecured 2) Resident #153 observed lying in bed with bilateral siderails upright with only left side rail padded. 2) Scissors observed on the table near Resident #10's bed and 3) A can of bug spray observed on the back shelf behind Resident #10's bed. There were 225 residents residing at the facility during the time of the survey. The findings include:During initial screening observation on 03/16/2026 starting at 8:00 AM the following was observed: room [ROOM NUMBER]- a bottle of bacterial mouth wash, blue in color on the overbed table room [ROOM NUMBER]-Three (3) full vials of Medication, clear in color next to nebulizer machine on the bedside cupboard. room [ROOM NUMBER]-a bottle of bacterial mouth wash, blue in color on bedside cupboard room [ROOM NUMBER] a bottle of lotion located on the bedside table, a can of spray deodorant located on the windowsill. Interview on 03/19/2026 at 7:32 AM Staff D, Licensed Practical Nurse (LPN) revealed any medications found in the residents' room are either disposed of or stored in the correct area-medication cart or the medication room. Personal hygiene products are stored in the residents' bedside drawer for safety. Interview on 03/19/2026 at 7:45AM Staff E, Registered Nurse (RN) reported medications found in the residents' room are discarded after consulting the supervisor or placed on the medication cart or medication room in the refrigerator or cabinets. Personal hygiene products are stored in the residents' bedside drawer for safety. Interview on 03/19/2026 at 8:00 AM Staff F, Certified Nursing Assistant (CNA) stated: If I find any medications in the residents' room, I report my findings to the nurse. Personal hygiene products are stored in the resident's bedside drawer in a plastic bag for safety. On 03/19/2026 at 8:09 AM Staff G, CNA stated: Personal hygiene products are stored in the resident's bedside drawer in a plastic bag for safety and infection control. If I find any medications in the residents' room, I report my findings to the nurse. On 3/19/2026 at 8:23 AM Staff H, CNA stated: If I find any medications in the residents' room, I report my findings to the nurse. The residents' personal hygiene products are stored in the resident's bedside drawer in a plastic bag for safety and privacy. Resident #153 On 03/16/2026 at 10:15 AM Resident #153 was observed lying in bed with the bilateral side rails upright. The left side rail only had padding on it, photo evidence taken. On 03/17/2026 at 9:42 AM Resident #153 was observed lying in bed with the bilateral side rails upright. The left side rail only had padding on it, photo evidence taken. Review of Resident #153's clinical records revealed the resident was admitted to the facility on [DATE] with diagnoses that include encephalopathy. Review of resident #153's Physician orders revealed an order with a date of 03/10/2026 for bilateral 1/4 padded siderails while in bed diagnoses (dx) seizures, every shift for bed mobility/enabler. Monitor for placement/safety. Review of Resident #153's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/05/2026 Section for Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating Resident #15 is cognitively impaired. Review of Resident #153's Care Plan revealed the resident is at risk for falls related to DX: Altered mental status (AMS), Encephalopathy, Aggressive behavior/baker acted, Progressive Dementia, Hypertension (HTN), Seizures and Polyneuropathy. Interventions include: Anticipate and meet needs, assist resident with transfers/mobility and Bilateral 1/4 padded siderails as ordered. Interview on 03/18/2026 at 12:37 PM, Staff A, Licensed Practical Nurse (LPN), stated Side rails should be used as ordered. This resident has an order for bilateral padded side rails for seizure precautions, so both rails should be up and padded when he is in bed. He needs help getting out of bed and may try to get up on his own, and he is not able to lower the rails himself, so the side rails help keep him safe. Interview on 03/18/2026 with Staff B, Registered Nurse (RN) stated Side rails are evaluated to determine whether they are needed for bed mobility or seizure precautions, and they are padded when indicated. Assessments are completed quarterly or with any change in condition. Side rails are not primarily used for fall prevention. Some residents may not want or need side rails, especially for transfers. If a resident refuses, the physician is notified, and decisions are made based on the resident's BIMS score or by involving the family. All decisions and preferences are documented and included in the care plan. There are different types of beds, but all side rails are considered quarter rails. If the order includes an S, it means both (bilateral) rails. If only one side is needed, the order will specify quarter rail on one side. Resident #10 Observation in Resident #10's room on 03/16/2026 at 10:43 AM, revealed the resident was not in the room. A pair of scissors was on the overbed table in near Resident #10's bed and a can of insect spray was observed on the back shelf behind the resident's bed. (Photo evidence) On 3/17/2026 at 11:03 AM, Resident # 10 was in bed watching television, a can of insect spray was observed on the shelf behind the bed which the resident revealed was brought in by her daughter. (Photo evidence) Review of Resident #10's clinical records revealed the resident was initially admitted on [DATE] and readmitted [DATE]. Clinical diagnoses include but not limited to Seizures, Complete Traumatic Amputation of left foot level unspecified sequela, Major Depressive Disorder, Type 2 Diabetes Mellitus, End Stage Renal Disease and Dependence on Renal Dialysis. Review of the Resident #10's Quarterly Minimum Data Set, dated [DATE] Cognitive Section indicated a Brief Interview for Mental Status score of 15 out of 15 meaning Resident #10 is cognitively intact. During an interview on 3/17/2026 at 2:31 PM, the Director of Nursing revealed the protocol for maintaining a safe environment included educating family members when necessary and instructing them to route items brought into the facility through the nursing station for inventory. However, family members sometimes brought items directly to residents' rooms or handed them directly to residents. When items arrived sealed, staff did not open them but educated the residents and/or family if they identified concerns. The Director of Nursing was uncertain why the can of insect spray found in Resident #10's room had not been identified during routine checks. Interview on 03/19/2026 at 11:55 AM, Staff J, Registered Nurse, revealed when unsafe items are found in residents' rooms are and we would explain to the resident that they could not have those items in the facility, the family is also notified and both family and resident are educated. During interviews on 03/19/2026 at 12:25 PM, Staff I, Certified Nursing Assistant revealed if staff found an item that should not be in a resident's room, the nurse should be notified, the resident would be informed that the item is not allowed in the room and the item removed. Record Review of the facility's policy and procedures titled Policies and Procedures: Reporting Accidents and Incidents (03/2020) revealed 9. The facility will provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes:a. Identifying hazard(s) and risk(s);b. Evaluating and analyzing hazard(s) and risk(s);c. Implementing interventions to reduce hazard(s) and risk(s); andd. Monitoring for effectiveness and modifying interventions when necessary.10. The facility will identify each resident at risk for accidents and/or falls and adequately plan care and implement procedures to prevent accidents. 11. The facility will ensure each resident receives adequate supervision and assistance devices to prevent accidents.

Based on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate an effective plan of action was implemented to correct identified quality deficiencies in the problem area related to repeated deficient practice for F812- Food Procurement. Store/Prepare/Serve Sanitary. F867- QAPI/QAA Improvement Activities. F908- Essential Equipment, Safe Operating Condition. These repeated deficient practices have the potential to affect any of the 225 residents residing in the facility at the time of the survey. Record review of the facility's survey history revealed, during a recertification conducted on August 19, 2024, through August 22, 2024, the facility. was cited F812- Food Procurement, Store/Prepare/Serve Sanitary as the facility failed to ensure food was prepared under sanitary conditions. F908- Essential Equipment, Safe Operating Condition was cited as the facility failed to ensure a convection oven and stove used to prepare food for residents were clean and in good repair. F867- QAPI/QAA Improvement Activities was cited related to repeated deficiencies F656- Develop/Implement Comprehensive Care Plan, F761- Label/Store Drugs & Biologicals and F812- Food Procurement, Store/Prepare/Serve Sanitary, Interview on 03/20/2026 at 12:30 PM with the Director of Nursing (DON) and Administrator (NHA) revealed the QAA Committee meets every month, the last meeting was held on 02/19/26. The committee consists of the Medical Director, Administrator, Director of Nursing (DON), Infection Preventionist and all interdisciplinary team members. The purpose of QAPI is to make sure any issues presented to the facility are corrected with follow ups and interventions in place that are measured timely, to prevent/avoid continued non-compliance. Data from the previous month is reviewed, each department head reports on their assigned tasks and any new issues. Review of the facility policy and procedure titled Quality Assurance Performance Improvement Plan dated 11/27/27 states: The purpose of our QAPI plan is to ensure data-driven, proactive approach to improve quality of life, care and services in our nursing home. We strive to provide excellent quality resident care and services. Our goal is to promote excellence in quality of care, quality of life, resident choice, person-centered care, and resident transitions. [NAME] House Nursing and Rehabilitation Center has a Quality Improvement Program which systematically monitors, analyzes and improves its performance to advance resident outcomes.

Based on observation, interview and record review, the facility failed to ensure oxygen therapy was delivered as prescribed for two residents (Resident #5 and Resident #211) with tracheostomies out of 11 residents receiving oxygen therapy. As evidenced by Resident #5 and Resident # 211 oxygen concentrator flow rates were not set at the prescribed rate. The findings include. Resident #5On 03/16/2026 at 8:22 AM Resident #5 was observed in bed with eyes closed and oxygen (02) running at three liters per minute (lpm) via tracheostomy.Observations on 03/17/2026 at 10:25 AM and 03/18/2026 at 8:14 AM revealed Resident #5 in bed awake with 02 running at four lpm via tracheostomy.Review of Resident #5's medical records revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Malfunction of Tracheostomy Stoma, Pneumonia due to other specified bacteria and Acute Pulmonary Edema.Review of the Physician's Orders Sheet for March 2026 revealed Resident #5 had orders that included but not limited to: Oxygen Continuous at 4 Liters (L) via Tracheostomy every shift .Record review of Resident # 5's Quarterly Minimum Data Set (MDS) dated [DATE] Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) unable to determine. Section GG for Functional Abilities documented dependent for care. Section J for Health Conditions documented shortness of breath when lying flat, sitting at rest and with exertion. Section O for Special Treatments and Procedures documented oxygen therapy, suctioning and tracheostomy care. Record review of Resident # 5's Care Plans Reference Date 01/19/26 revealed: Resident has a tracheostomy related to: -Respiratory Failure, history of stroke. Resident will be free from respiratory infection over the next review date. Interventions include-Administer medication/ Oxygen as ordered. Change inner cannula every shift and as needed. Check tracheostomy site for redness, swelling, bleeding and skin excoriation. Extra trach at bedside every shift. Keep extra trach kit and Ambu bag at bedside. Keep trach site and dressing clean and dry. Resident#211Observation on 03/16/2026 at 7:58 AM Resident #211 was in bed with eyes closed and 02 running at 3.5 lpm via tracheostomy, no distress noted. On 03/17/2026 at 9:55 AM and 03/18/2026 at 8:06 AM Resident #211 was observed in bed with eyes closed and 02 running at 5 lpm via tracheostomy.Review of Resident # 211's medical records revealed the resident was admitted to the facility on [DATE] and readmitted [DATE]. Clinical diagnoses included but not limited to: Encounter for attention to tracheostomy, Chronic Respiratory Failure, unspecified whether with Hypoxia or Hypercapnia, Respiratory Failure, unspecified with Hypoxia. Review of the Physician's Orders Sheet for March 2026 revealed Resident #211 had orders that included but not limited to: Oxygen via tracheostomy at 5 lpm every shift.Record review of Resident #211's Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) unable to determine. Section GG for Functional Abilities documented dependent for care. Section J for Health Conditions documented no shortness of breath. Section O for Special Treatments and Procedures documented oxygen therapy, suctioning and tracheostomy care. Record review of Resident # 211's Care Plans revealed: Resident has a tracheostomy related to Respiratory Failure. Resident will be free from respiratory infection over the next review date. Interventions include- Administer medication/ Oxygen as ordered. Check trach site for redness, swelling, bleeding and skin excoriation. Monitor trach site for signs and symptoms (s/s) of infection every shift; mouth care every shift. Observe trach secretions for color, odor, consistency and amount. Respiratory therapy as needed. Suction trach every shift and as needed. Interview on 03/19/2026 at 7:32 AM Staff D, Licensed Practical Nurse (LPN) stated: For residents on oxygen therapy, I make sure the oxygen concentrator number matches the prescribed orders and nasal cannulas are in place.Interview on 03/19/26 at 7:45 AM Staff E, Registered Nurse (RN) stated: I conduct my rounds during my shift with the previous nurse at the beginning of my shift and at least every hour . For residents on oxygen therapy, I make sure the oxygen concentrator number matches the prescribed orders during my rounds.Interview on 3/19/2026 at 8:23 AM Staff H, Certified Nursing Assistant stated: during my shift I check on my residents at least every 2 hours. We are not allowed to touch or change anything on the residents' oxygen concentrators, so if I notice anything different with the resident, for example-the way they look, are they having difficulty breathing, I report it to the nurse immediately. Review of the facility's policy and procedure titled Oxygen Concentrator dated 03/2020 Indicates: To administer oxygen for the treatment of certain diseases or conditions.Policy Explanation and Compliance Guidelines: The maintenance department, or oxygen concentrator supplier, assists with the maintenance of oxygen concentrators according to manufacturer's recommendations and as needed.Oxygen should be administered only under orders of the attending physician, except in the case of an emergency. In an emergency, oxygen may be administered without physician's order, however, the order should be obtained immediately after the crisis is under control.

Based on observations, records reviewed and interviews, the facility failed to provide adequate supervision to ensure residents' safety for one out of 3 sampled residents (Resident #1). As evidenced by, on 03/30/2025 Resident #1 left the facility undetected at approximately 12:45 PM, boarded a city bus and was found 8 hours later by law enforcement. The resident was located 5.2 miles away from the facility. The areas where the facility and where the resident was located are in high traffic areas and there were cross streets which could lead to the increased risk of the resident being hit by an automobile, falling, or being assaulted and/or being robbed based on his vulnerability and cognitive impairment. According to website, Accuweather.com on 03/30/2025 the temperature ranged between 72 degrees Fahrenheit (F) to 86 degrees (F) with scattered showers. It was determined that this deficient practice posed an Immediate Jeopardy (IJ) 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. The Immediate Jeopardy (IJ) started on 03/30/2025 and was determined to be Past Noncompliance effective 04/06/2025 based on the corrective actions implemented by the facility. The findings included: Observation on 04/07/2025 at 3:34 PM, revealed Resident#1 in his room watching television and responded to his name. A wander alert system bracelet was observed on his right wrist. On 04/08/2025 at 8:40 AM, Resident #1 was standing in the hallway beside his room. Resident # 1 was asked about leaving the facility he laughed and stated, me again never and laughed. On 04/09/2025 at 10:20 AM, Resident #1 was speaking with the surveyors and staff alternating in English and Spanish; Resident #1 was asked how he left the facility that Sunday; he responded in Spanish, bus dosciendos (meaning bus 215). Clinical record review revealed, Resident #1 was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Acute respiratory failure Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], the Cognitive section documented a Brief Interview of Mental Status (BIMS) score of 4 out of 15 meaning, Resident #1 had severe cognitive impairment. The Functional status section revealed, Resident #1 requires assistance with all Activities of Daily Living (ADLs) and for Bowel and Bladder status the resident is incontinent of Bladder. Record review revealed a Health Status Note dated 03/30/2025 time stamped 13:50 (1:50 PM); The note text documented: Approximately around 12:45 PM CNA (Certified Nursing Assistant) alerted the nurse the resident's lunch tray was in the room and the resident was not there. The Nurse began searching for the resident in the unit and a facility search was done. The Nurse notified the supervisor and other floors. Review of the Health Status Note dated 3/30/2025 and timestamped 14:00 (2:00 PM) indicated the Note Text documented: The Nurse alerted the supervisor at 13:09 (1:09 PM) that she went to serve the residents lunch, and he was not seen. A complete facility search was done including facility grounds. A Code [NAME] (Code when a resident is missing) was called. Law enforcement was notified, the guardian was called, and the residents MD (Medical Doctor) notified. A voicemail message was left for the guardian. 911 was called and the call was transferred to the non-emergency number. Review of Health Status Note created by Staff CC, RN 3- 11 nurse dated 3/30/2025 and timestamped 15:30 (3:30 PM), the Note Text documented: The shift report was received and the outgoing nurse informed [3-11 nurse] that the resident was not at the facility and that they had begun a search process following established protocols. Review of Health Status Note dated 3/30/2025 at 22:25 (10:25 PM) by the Nursing Supervisor indicated: Two police officers came to facility and met with the staff. They did an internal and external facility search and provided a case number. All area hospitals were called and staff visited two area hospital emergency room s. The Guardianship Program was called, and the emergency guardianship number was called, and message was left. A Police Detective [name and badge] from [local law enforcement] located resident and called the facility to inform the facility that resident was found. Staff from the facility were dispatched to pick up the resident. Upon arriving, a complete nursing assessment was conducted .There were no neurological deficits noted as compared to the previous assessments, bruises observed to right knee [Physician Assistant] notified. A Psych consult was done, the resident was placed on 1:1 and monitoring was initiated. A message was left for Guardian Program. The resident was given shower, and a warm dinner was served. Close monitoring maintained. During an interview on 04/07/25 at 6:54 PM, the [NAME] President of Clinical Services revealed, there were a lot of visitors that Sunday who were signing in and out and the resident may have followed one of the visitors that were leaving. At lunch time when the CNAs went to place his lunch, they realized he was gone. After the incident occurred, all residents in the facility were screened, and wander management system bracelets were ordered and put in place for the residents that triggered for an elopement risk. During an interview on 04/07/2025 at 7:49 PM, Staff K, Registered Nurse (RN) and 3-11 shift Supervisor that was on duty at the time of the incident revealed: When I came, they told me about the elopement, and I went in my car and searched with the police outside and did a deep search. The police told us if they found him, they would call. [local area law enforcement] called a little after 8:00 PM and the resident was returned to the facility. The resident was okay, we did a full assessment and the resident he was okay. During an interview on 04/07/2025 at 7:55 PM, Staff CC, RN from 3-11 shift stated: When I arrived the off going nurse told me they were searching for the resident around 8:00 PM. The supervisor told me the resident was found, and the supervisor [Staff DD, an RN and 7-3 shift supervisor] took him back to the facility and I did a complete assessment. He was confused, he had no injuries, just a bruise on his right knee and he was fine. We put the [wander alert system] bracelet on his wrist and started at 1:1 staff monitoring and he is doing better. During an interview on 04/08/25 at 8:41 AM, Staff BB, Licensed Practical Nurse (LPN) revealed, He is alert and oriented to his name, but he is confused. He did not show any behaviors that he wanted to leave. That day at around 12:45 PM, I was doing Accu checks, it was lunch time, and the CNAs told me when they were passing trays at around 12:45 PM he was not in his room, so I told everybody, and we all started looking for him and we did Code Green. Everybody started looking for the resident and I printed face sheets so that everybody could identify the resident. After that the Administrator was in the building. We searched inside and out, and some staff went to look in the parking lot and, in their cars, also around the neighborhood while the Administrator and the Supervisor handled the rest. He did not miss any medications on my shift. I was in the building until he came back. He was talking in Spanish; he had a bruise on his right knee but looked fine. The nurse on duty did the assessment and I was there. He did not miss any medications on my shift. During an interview on 04/08/2025 at 9:05 AM, Staff AA, the CNA that was assigned to Resident # 1 on the date of the incident stated: That day in the morning after breakfast I gave him a shower in the morning at around 11:05 AM; I put him back in the room and I told him sit there while I went to take care of two other residents. He usually stays in his room and watch TV(Television). When I went back after I finished with the other two residents, I did not see him in the room and went to pass the lunch trays. He was not in the room for his lunch tray. At around 12:49 PM I told the nurse he was not in his room. We continued to search everywhere in the facility and outside. It was also raining at the time. The nurse called and told DON (Director of Nursing), ADON (Assistant Director of Nursing) and the Administrator to let them know what happened and they came right away. We continued to search, and they called the police and hospitals after all this time. The [ADON] told me I could go home before it got too dark. I told the oncoming CNA. I talked to the police when I was at the facility. I have no idea how he left the facility because usually after I give him a shower he walks to his room. The following day he was okay. During an interview on 04/09/2025 at 10:58 AM, the Director of Nursing (DON) stated, I was out of town and received a call at approximately 1:00 PM from the facility telling me that the resident was missing, and they were looking for the resident. The Administrator called law enforcement and reported the resident was missing. I could not go with them to find the resident. I arrived in the building between 7:00 or 8:00 PM and [law enforcement] called and reported the resident was found. The DON revealed, Resident #1 was picked up by a staff member and returned to the facility and was smiling when he returned. The doctor was called, and labs and x-rays were ordered and all came back normal. He had a psych evaluation on 03/31/2025 and medications were reviewed. The resident was placed on 1:1 monitoring, we placed a [wander alert system] bracelet on his wrist and the resident was compliant with the 1:1 monitoring and additional interventions. The DON revealed steps implemented to prevent reoccurrence that included but were not limited to trainings, all resident received an elopement assessment, the codes on all doors and elevators were checked, the main entrance, the entrance for all staff, the additional doors with codes between the lobby and unit. Started 24-hour front desk coverage. Maintenance staff checked all the exit doors that day and will continue to check. During an interview on 04/09/2025 at 11:10 AM, the Maintenance Director revealed wander alert system on doors are being checked every day and all doors and keypads are checked daily. The Maintenance Director reported, I check the doors Monday to Friday and the maintenance staff checks them on Saturday and Sunday. I installed a door between the lobby to the floor and added keypads on all the doors to go in and out of the facility and the offices. I also check the code for the elevator to make sure it is working. The Maintenance Director revealed he and all his staff received elopement and abuse training. The facility took the following actions to address the elopement incident and to prevent any additional residents from suffering an adverse outcome. (Completion Date: 4/2/2025) 1. On 3/30/2021, the nurses completed a head count using the facility's census to ensure no other residents were missing. The nursing supervisor verified the count, confirming that no other residents were missing. On 3/31/2025, the resident was reevaluated by the psychiatrist and new orders were received. On 3/31/2025, reeducation regarding the prevention of elopement was initiated for the 7-3 staff by the Director of Nurses (DON). By 4/2/2025, all nursing staff on all shifts received education from the Staff Development, Director of Nursing (DON), or their designees regarding residents who exhibit exit-seeking behavior, the risk of elopement, and the need for adequate supervision to ensure resident safety. This education aimed to prevent serious injury, harm, impairment, or death. Any staff on leave were to receive education on their next scheduled workday. By 4/2/2025, the Unit Managers, supervisors, and/or designee(s) and/or MDS Coordinator(s) re-evaluated residents at risk for elopement by completing a new elopement risk screening form. By 4/2/2025, the MDS Coordinator and/or designee reviewed and updated the care plans of the residents at risk for elopement to reflect the current elopement risk. By 4/2/2025, Nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee(s). Any staff on leave will receive education prior to returning to their shift. A Root Cause analysis was completed using the Five Whys to develop new approaches to prevent reoccurrence. The Facility conducted an AdHoc Quality Assurance Meeting on 3-31-2025 to review the Performance Improvement Plan ensuring proper interventions are put in place. The facility conducted an elopement drill every shift X 3 days, then weekly X 4 weeks, then monthly X 3 Months. 2. Facility Actions to Prevent Occurrence/Recurrence: Staff were re-educated on the Elopement and wandering, exit seeking resident policy. The staff will follow the policy to ensure safety measures are implemented. By 4/2/2025 the DON, ADON, and designee completed elopement risk screening on active residents and reviewed their plan of care to ensure appropriate interventions are in place, and the plan of care was updated to reflect the evaluation and modification of interventions that are in place. After the facility wide audit of the elopement screenings, the facility identified 4 new residents that triggered for elopement risk. Residents triggered for at risk for elopement have orders for a [wander alert system] to be put in place. Orders were obtained from the physician for psych reevaluation for residents triggered for elopement risk. The elopement book was updated with new pictures of residents triggered for elopement risk. Elevator keypads installed on the elevators by the Elevator Company. A keypad/alarm installed at the door leading to the lobby by the alarm company. Elopement drills are done monthly on every shift. The Maintenance Director or designee to conduct Safety rounds Log to check exit door, screamer alarms and outside gates daily. Residents with new behaviors of exit seeking and wandering will be added to the elopement risk book that is kept at the nursing station and is accessible to all staff. The behaviors will be added to the resident's care plan and the Kardex. Nursing staff will communicate during the shift to shift report any resident who exhibits behaviors to leave the facility, and the safety measures put into place. The nurses and nursing supervisors will use the facility census to conduct the headcount of the residents in their respective unit during shift change and they will sign the census to validate that the count is correct, and all residents are accounted for. The CNAs will conduct rounds every two hours to ensure the residents are safe and accounted for. CNAs will report to the nurse immediately if unable to locate a resident. Facility protocols for missing residents will be used immediately to locate the residents. New admissions elopement evaluations will be reviewed during clinical meetings held Monday through Friday to ensure elopement interventions are in place for residents that are at risk and the facility guidelines are followed. Nursing Supervisors will review the new admissions elopement evaluation on the weekend for compliance. The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. Residents with new behaviors of wandering, exit seeking will be reassessed by the ADON, Unit Managers, Supervisors or designee for a risk for elopement. The DON, Administrator, ADON and/or designee will enforce disciplinary action for facility staff who fail to follow the elopement policy and procedures. New hires will receive education on wandering, elopement, and resident safety by the DON, ADON or designee(s). 3. Facility Implementation: Education Target goal is 100% By 4/2/2025, the DON and ADON reeducated a total of 268 employees on the facility's policy & procedures as it is related to elopement and residents' safety. The facility achieved 100% compliance. By 4/2/2025, a total of 232 staff members had participated in the elopement drills. Facility compliance was 86.56 percent. Dates of the Elopement Drills included: Total staff participation on 3/31/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift- 40% compliance. On 4/1/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift - 71.26 % compliance. On 4/2/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift - 86.56 % compliance. As of 4/2/2025, the total staff who participated was 232 employees, which is 86.56 % On 4/9/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift-90 employees participated (only 20 employees participated for the first time). The Total staff that participated in the elopement drill: from 3/31/2025 to 4/9/2025 is a total of 252 employees which is 94%. The facility has 16 more employees who need to participate in the elopement drills. Elopement Drills will be conducted upon their return to work. On 4/2/2025, 4/4/2025, 4/7/2025 & 4/10/2025, all elopement elements put into place were verified and the facility is 100% compliance. By 4/1/2025, after the facility wide audit of the elopement screening, the facility identified 4 new residents who triggered for elopement. On 4/7/2025 a QAPI (Quality Assurance and Performance Improvement) review for follow-up was done, all the elements were verified, and facility was 100% compliance. Quality Assurance: The facility will conduct an elopement drill weekly X 4 weeks, then monthly X 3 Months. The DON, ADON, and administrator will review weekly X 4 weeks then monthly, the clinical record of any residents with behaviors of exit seeking and wandering to ensure the facility policy and procedures are implemented and followed, and residents have remained safe at the facility. Review the findings during the monthly QAPI meeting. After completing the facility wide audit the DON, ADON/designee will conduct a weekly quality review of 10 residents on each unit weekly x 4 weeks, and then every 2 weeks x 2 months. The findings of these reviews will be reported in the next Risk Management/QA Committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring by the Regional Director of Clinical Services when completing their quality systems review. The committee reviewed the plan and determined the removal plan has been implemented effectively. Facility Compliance Rate: 100% The facility's corrective actions were verified by the survey team based on staff interviews conducted on all shifts and departments indicating all-action plans had been implemented.

Based on observations, record review and interviews, the facility's administration failed to ensure effective systems were in place to provide adequate supervision for one out of three sampled residents (Resident #1). As evidenced by, on 03/30/2025 Resident #1 left the facility undetected at approximately 12:45 PM, boarded a city bus and was found 8 hours later by law enforcement. The resident was located 5.2 miles away from the facility. The facility and the area that the resident was located are both in high traffic areas with cross streets which could lead to the increased risk of the resident being hit by an automobile, falling, or being assaulted and/or being robbed based on his vulnerability and cognitive impairment. According to website, Accuweather.com on 03/30/2025 the temperature ranged between 72 degrees Fahrenheit (F) to 86 degrees (F) with scattered showers. It was determined that this deficient practice posed an Immediate Jeopardy (IJ) 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. The Immediate Jeopardy (IJ) started on 03/30/2025 and was determined to be Past Noncompliance effective 04/06/2025 based on the corrective actions implemented by the facility. The findings include: Observation on 04/07/2025 at 1:20 PM, the receptionist granted access to guests entering and leaving the facility are required to sign in and out. A new door was noted with a code between the lobby area with a staff member seated at the inner hallway to grant access. The conference room assigned for the survey team also required a code to enter. Record review of the job description titled, Administrator documented: The primary purpose of this position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern nursing facilities to ensure that the highest degree of quality care can be always provided to residents. Plan, develop, organize, implement, evaluate and direct the facility's programs and activities in accordance with guidelines issued by the governing body. Delegate a responsible staff member to act on your behalf when you are absent from the facility. Ensure that each resident receives necessary care and services to attain and maintain the highest practical physical, mental and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care .Ensure the facility and resident environment remain as free of accidents as possible and that each resident receives adequate supervision and assistive devices to prevent accidents, including identifying and analyzing hazards and risks, implementing interventions and monitoring the effectiveness of those interventions when necessary. Clinical record review revealed, Resident #1 was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Acute respiratory failure Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], the Cognitive section documented a Brief Interview of Mental Status (BIMS) score of 4 out of 15 meaning, Resident #1 had severe cognitive impairment. The Functional status section revealed, Resident #1 requires assistance with all Activities of Daily Living (ADLs) and for Bowel and Bladder status the resident is incontinent of Bladder. Record review revealed a Health Status Note dated 03/30/2025 time stamped 13:50 (1:50 PM); The note text documented: Approximately around 12:45 PM CNA (Certified Nursing Assistant) alerted the nurse the resident's lunch tray was in the room and the resident was not there. The Nurse began searching for the resident in the unit and a facility search was done. The Nurse notified the supervisor and other floors. Review of the Health Status Note dated 3/30/2025 and timestamped 14:00 (2:00 PM) indicated the Note Text documented: The Nurse alerted the supervisor at 13:09 (1:09 PM) that she went to serve the residents lunch, and he was not seen. A complete facility search was done including facility grounds. A Code [NAME] (Code when a resident is missing) was called. Law enforcement was notified, the guardian was called, and the resident's MD (Medical Doctor) was notified. A voicemail message was left for the guardian. 911 was called and the call was transferred to the non-emergency number. Review of Health Status Note dated 3/30/2025 and timestamped 15:30(3:30 PM), the Note Text documented: The shift report was received and the outgoing nurse informed me that the resident was not at the facility and that they had begun a search process following established protocols. Review of Health Status Note dated 3/30/2025 at 22:25(10:25 PM) by the Nursing Supervisor indicated: Two police officers came to facility and met with the staff. They did an internal and external facility search and provided a case number. All area hospitals were called and staff visited two area hospital emergency room s. The Guardianship Program was called, and the emergency guardianship number was called, and message was left. A Police Detective [name and badge] from [local law enforcement] located resident and called the facility to inform the facility that resident was found. Staff from the facility were dispatched to pick up the resident. Upon arriving, a complete nursing assessment was conducted, Vital Signs were obtained. There were no neurological deficits noted as compared to the previous assessments, bruises observed to right knee . [Physician Assistant] notified. The resident was placed on 1:1 and monitoring was initiated. A message was left for the Guardianship Program. The resident was given shower, and a warm dinner was served. Close monitoring maintained. During an interview on 04/07/25 at 6:54 PM, the [NAME] President of Clinical Services revealed, there were a lot of visitors that Sunday who were signing in and out and the resident may have followed one of the visitors that were leaving. At lunch time when the CNAs went to place his lunch, they realized he was gone. After the incident occurred, all residents in the facility were screened, and wander management system bracelets were ordered and put in place for the residents that triggered for an elopement risk. During an interview on 04/07/2025 at 7:49 PM, Staff K, Registered Nurse (RN) and 3-11 shift Supervisor that was on duty at the time of the incident revealed: When I came, they told me about the elopement, and I went in my car and searched with the police outside and did a deep search. The police told us if they found him, they would call. [local area law enforcement] called a little after 8:00 PM and the resident was returned to the facility. The resident was okay, we did a full assessment and the resident he was okay. During an interview on 04/07/2025 at 7:55 PM, Staff CC, RN from 3-11 shift stated: When I arrived the off going nurse told me they were searching for the resident around 8:00 PM. The supervisor told me the resident was found, and the supervisor [Staff DD, an RN and 7-3 shift supervisor] took him back to the facility and I did a complete assessment. He was confused, he had no injuries, just a bruise on his right knee and he was fine. We put the [wander alert system] bracelet on his wrist and started at 1:1 staff monitoring and he is doing better. During an interview on 04/08/25 at 8:41 AM, Staff BB, Licensed Practical Nurse (LPN) revealed, He is alert and oriented to his name, but he is confused. He did not show any behaviors that he wanted to leave. That day at around 12:45 PM, I was doing Accu checks, it was lunch time, and the CNAs told me when they were passing trays at around 12:45 PM he was not in his room, so I told everybody, and we all started looking for him and we did Code Green. Everybody started looking for the resident and I printed face sheets so that everybody could identify the resident. After that the Administrator was in the building. We searched inside and out, and some staff went to look in the parking lot and, in their cars, also around the neighborhood while the Administrator and the Supervisor handled the rest. He did not miss any medications on my shift. I was in the building until he came back. He was talking in Spanish; he had a bruise on his right knee but looked fine. The nurse on duty did the assessment and I was there. He did not miss any medications on my shift. During an interview on 04/08/2025 at 9:05 AM, Staff AA, the CNA that was assigned to Resident # 1 on the date of the incident stated: That day in the morning after breakfast I gave him a shower in the morning at around 11:05 AM; I put him back in the room and I told him sit there while I went to take care of two other residents. He usually stays in his room and watch TV(Television). When I went back after I finished with the other two residents, I did not see him in the room and went to pass the lunch trays. He was not in the room for his lunch tray. At around 12:49 PM I told the nurse he was not in his room. We continued to search everywhere in the facility and outside. It was also raining at the time. The nurse called the Director of Nursing (DON), ADON (Assistant Director of Nursing) and the Administrator to let them know what happened and they came right away. We continued to search, and they called the police and hospitals after all this time. The [ADON] told me I could go home before it got too dark. I told the oncoming CNA. I talked to the police when I was at the facility. I have no idea how he left the facility because usually after I give him a shower he walks to his room. The following day he was okay. During an interview on 04/09/2025 at 9:28 AM, the Administrator revealed the systems implemented, the identified system failure's, the completion of the root cause analysis and efforts completed to achieve compliance. During an interview on 04/09/2025 at 10:58 AM, the Director of Nursing (DON) stated, I was out of town and received a call at approximately 1:00 PM from the facility telling me that the resident was missing, and they were looking for the resident. The Administrator called law enforcement and reported the resident was missing. I could not go with them to find the resident. I arrived in the building between 7:00 or 8:00 PM and [law enforcement] called and reported the resident was found. The DON revealed, Resident #1 was picked up by a staff member and returned to the facility and was smiling when he returned. The doctor was called, and labs and x-rays were ordered and all came back normal. He had a psych evaluation on 03/31/2025 and medications were reviewed. The resident was placed on 1:1 monitoring, we placed a [wander alert system] bracelet on his wrist and the resident was compliant with the 1:1 monitoring and additional interventions. The DON revealed steps implemented to prevent reoccurrence that included but were not limited to trainings, all resident received an elopement assessment, the codes on all doors and elevators were checked, the main entrance, the entrance for all staff, the additional doors with codes between the lobby and unit. Started 24-hour front desk coverage. Maintenance staff checked all the exit doors that day and will continue to check. During an interview on 04/09/2025 at 11:10 AM, the Maintenance Director revealed the wander alert system on all doors and keypads are checked daily. The Maintenance Director reported, I check the doors Monday to Friday and the maintenance staff checks them on Saturday and Sunday. I installed a door between the lobby to the floor and added keypads on all the doors to go in and out of the facility and the offices. I also check the code for the elevator to make sure it is working. The Maintenance Director revealed he and all his staff received elopement and abuse training. The facility took the following actions to address the elopement incident and to prevent any additional residents from suffering an adverse outcome. (Completion Date: 4/2/2025) 1. On 3/30/2021, the nurses completed a head count using the facility's census to ensure no other residents were missing. The nursing supervisor verified the count, confirming that no other residents were missing. On 3/31/2025, the resident was reevaluated by the psychiatrist and new orders were received. On 3/31/2025, reeducation regarding the prevention of elopement was initiated for the 7-3 staff by the Director of Nurses (DON). By 4/2/2025, all nursing staff on all shifts received education from the Staff Development, Director of Nursing (DON), or their designees regarding residents who exhibit exit-seeking behavior, the risk of elopement, and the need for adequate supervision to ensure resident safety. This education aimed to prevent serious injury, harm, impairment, or death. Any staff on leave were to receive education on their next scheduled workday. By 4/2/2025, the Unit Managers, supervisors, and/or designee(s) and/or MDS Coordinator(s) re-evaluated residents at risk for elopement by completing a new elopement risk screening form. By 4/2/2025, the MDS Coordinator and/or designee reviewed and updated the care plans of the residents at risk for elopement to reflect the current elopement risk. By 4/2/2025, Nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee(s). Any staff on leave will receive education prior to returning to their shift. A Root Cause analysis was completed using the Five Whys to develop new approaches to prevent reoccurrence. The Facility conducted an AdHoc Quality Assurance Meeting on 3-31-2025 to review the Performance Improvement Plan ensuring proper interventions are put in place. The facility conducted an elopement drill every shift X 3 days, then weekly X 4 weeks, then monthly X 3 Months. 2. Facility Actions to Prevent Occurrence/Recurrence: Staff were re-educated on the Elopement and wandering, residents' exit seeking policy. The staff will follow the policy to ensure safety measures are implemented. By 4/2/2025 the DON, ADON, and designee completed elopement risk screening on active residents and reviewed their plan of care to ensure appropriate interventions are in place, and the plan of care was updated to reflect the evaluation and modification of interventions that are in place. After the facility wide audit of the elopement screenings, the facility identified 4 new residents that triggered for elopement risk. Residents triggered for at risk for elopement have orders for a [wander alert system] to be put in place. Orders were obtained from the physician for psych reevaluation for residents triggered for elopement risk. The elopement book was updated with new pictures of residents triggered for elopement risk. Elevator keypads installed on the elevators by the Elevator Company. A keypad/alarm installed at the door leading to the lobby by the alarm company. Elopement drills are done monthly on every shift. The Maintenance Director or designee to conduct Safety rounds Log to check exit door, screamer alarms and outside gates daily. Residents with new behaviors of exit seeking and wandering will be added to the elopement risk book that is kept at the nursing station and is accessible to all staff. The behaviors will be added to the resident's care plan and the Kardex. Nursing staff will communicate during the shift to shift report any resident who exhibits behaviors to leave the facility, and the safety measures put into place. The nurses and nursing supervisors will use the facility census to conduct the headcount of the residents in their respective unit during shift change and they will sign the census to validate that the count is correct, and all residents are accounted for. The CNAs will conduct rounds every two hours to ensure the residents are safe and accounted for. CNAs will report to the nurse immediately if unable to locate a resident. Facility protocols for missing residents will be used immediately to locate the residents. New admissions elopement evaluations will be reviewed during clinical meetings held Monday through Friday to ensure elopement interventions are in place for residents that are at risk and the facility guidelines are followed. Nursing Supervisors will review the new admissions elopement evaluation on the weekend for compliance. The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. Residents with new behaviors of wandering, exit seeking will be reassessed by the ADON, Unit Managers, Supervisors or designee for a risk for elopement. The DON, Administrator, ADON and/or designee will enforce disciplinary action for facility staff who fail to follow the elopement policy and procedures. New hires will receive education on wandering, elopement, and resident safety by the DON, ADON or designee(s). 3. Facility Implementation: Education Target goal is 100% By 4/2/2025, the DON and ADON reeducated a total of 268 employees on the facility's policy & procedures as it is related to elopement and residents' safety. The facility achieved 100% compliance. By 4/2/2025, a total of 232 staff members had participated in the elopement drills. Facility compliance was 86.56 percent. Dates of the Elopement Drills included: Total staff participation on 3/31/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift- 40% compliance. On 4/1/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift - 71.26 % compliance. On 4/2/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift - 86.56 % compliance. As of 4/2/2025, the total staff who participated was 232 employees, which is 86.56 % On 4/9/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift-90 employees participated (only 20 employees participated for the first time). The Total staff that participated in the elopement drill: from 3/31/2025 to 4/9/2025 is a total of 252 employees which is 94%. The facility has 16 more employees who need to participate in the elopement drills. Elopement Drills will be conducted upon their return to work. On 4/2/2025, 4/4/2025, 4/7/2025 & 4/10/2025, all elopement elements put into place were verified and the facility is 100% compliance. By 4/1/2025, after the facility wide audit of the elopement screening, the facility identified 4 new residents who triggered for elopement. On 4/7/2025 a QAPI (Quality Assurance and Performance Improvement) review for follow-up was done, all the elements were verified, and facility was 100% compliance. Quality Assurance: The facility will conduct an elopement drill weekly X 4 weeks, then monthly X 3 Months. The DON, ADON, and administrator will review weekly X 4 weeks then monthly, the clinical record of any residents with behaviors of exit seeking and wandering to ensure the facility policy and procedures are implemented and followed, and residents have remained safe at the facility. Review the findings during the monthly QAPI meeting. After completing the facility wide audit the DON, ADON/designee will conduct a weekly quality review of 10 residents on each unit weekly x 4 weeks, and then every 2 weeks x 2 months. The findings of these reviews will be reported in the next Risk Management/QA Committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring by the Regional Director of Clinical Services when completing their quality systems review. The committee reviewed the plan and determined the removal plan has been implemented effectively. Facility Compliance Rate: 100% The facility's corrective actions were verified by the survey team based on observations and through staff interviews that were conducted across all shifts and departments. indicating all-action plans had been implemented.

Based on observations records reviewed and interviews, the facility's staff failed to address respiratory emergencies in a timely manner for two (Resident # 5 and Resident #6) out of three residents sampled residents; as evidenced by Resident #5 and Resident # 6 were noted in respiratory distress and the nurses failed to implement interventions in a timely manner. The findings included: On 01/23/2025 at 08:03 AM, Resident #6 was observed slumped in bed in distress; loud gurgling sounds noted, coughing and drooling; the resident shaking his head from side to side with facial grimacing indicating he is not feeling well, when asked if he had pain he nodded his head indicating yes. The oxygen was at 4 Liters Per Minute (LPM), tube feeding was infusing at infusing at 75 ml/hr. The nurse was called to the room. Staff A, RN entered the room to assist the resident and left the room to get Tylenol for the resident. came to the room put on gloves, was not wearing a gown and was not wearing a mask and speaking very close to the resident in a loud tone. Staff B, RN Supervisor checked the bowel sounds and did not osculate the lung sounds and did not check the vital signs. On 01/23/2025 at 8:09 AM Staff A, RN administered the medication and still did The nurse was asked what he was going to do about the residents crackles. Staff A, RN gathered the suctioning supplies; Staff A, RN did not osculate the lung sounds and did not take the vital signs before administering the medication and before suctioning the resident. On 01/23/2025 at 09:19 AM, Resident #6 was in respiratory distress again with gurgling sounds, the drainage collection bag for secretions was missing from the resident' tracheostomy Y-Adaptor. Staff B, RN was called to the room, he took the collection bag that was on the side table and attached it. Staff B, RN proceeded with suctioning the resident without checking the oxygen level, did not auscultate the lung sounds, did not clean/prime the suction machine with normal saline before using it on the resident. Review of Resident #6's clinical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with clinical diagnoses that include Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, Chronic Obstructive Pulmonary Disease (COPD), Tracheostomy status, Dysphagia, oropharyngeal phase. Record review of Resident #6's Physician Orders for January 2025 included but not limited to: Acetaminophen (Tylenol) Tablet 325 MG.- Give 2 tablet via PEG-Tube two times a day related to pain. Oxygen titrate 2-6 LPM via trach to maintain saturation above 92%. Oxygen titrate 2-5 LPM via trachea to maintain saturation above 94% - every shift. Suction every 2 Hours and PRN every 2 hours and as needed. Pre and Post Treatment (Tx) Lung Sounds; Pre and Post Tx - Pulse, Respirations and Oxygen Saturation (O2 Sat) results. Aspiration precautions - every shift. Review of Resident # 6's Annual Minimum Data Set (MDS)MDS dated [DATE] indicated the residents cognitive status was unable to be determined. The residents functional abilities indicate the resident is dependent on staff for Activities of daily living (ADLs). Health conditions documented the resident does not have schedule pain medication; Receives PRN (as needed) pain medication and has shortness of breath or trouble breathing when lying flat. Review of Resident #6's Care Plan with start date 1/17/2025: documented Focus: [Resident #6] is at risk for aspiration r/t (related to) peg tube. Goal: [Resident] will safely tolerate a least restrictive diet without s/s of aspiration daily thru NRD (Next Review Date). Interventions included: Monitor for any coughing/choking . During an interview on 01/23/2025 Staff A, RN acknowledged he did not auscultate the Resident #6's lungs, did not turn the feeding of before repositioning the resident, did not check the vital signs before administering the medications and before and after suctioning the resident. On 01/23/25 at 03:52 PM Staff B, RN Nurse supervisor acknowledged he should have checked the residents' vitals before and after suctioning the resident. Resident #5 On 01/23/2025 at 8:40 AM Staff F, Licensed Practical Nurse (LPN) was observed leaving Resident #5's room, when asked if she had completed Trach care and medication administration for Resident #5. Staff F, LPN revealed she had just administered the medication and left the room. Upon entering the room Resident #5 was observed with facial grimacing and loud gurgling sounds were noted. The feeding was infusing via PEG at 60 ml per hour (ml/hr.). The surveyor immediately informed Staff F, LPN to return to the room based on the identified concerns. Staff F, LPN briefly entered the room and revealed she would be back to suction the resident. Staff F, LPN did not display any immediacy to address the residents respiratory distress. At 8:53 AM (twelve minutes later) Staff F, LPN returned to the resident's room with Staff E, Registered Nurse (RN). Both nurses donned PPE. Staff E, RN revealed 2 persons usually work together for suctioning residents. Staff E, RN positioned herself on the side that the suction machine was located and Staff F, LPN on the side that the feeding tube pump was located; Staff F, LPN did not stop the feeding. The nurses lowered the head of the bed. Staff F, LPN left the room to get a vital signs machine. Upon noting the feeding was still infusing, Staff E, RN immediately stopped the feeding. Staff F, RN returned to the room eleven minutes later with a vital signs machine, changed gloves and stood at the opposite side of the bed. After Staff E, RN completed suctioning the resident and checked vital signs etc. Staff E, RN revealed Resident # 5 has orders for suctioning to be done every two hours and as needed. Staff F, LPN had already left the room and was not available for an interview. On 01/24/2025 several attempts were made to conduct interviews via telephone with Staff F, LPN were unsuccessful. Review of Resident #5's clinical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include Encounter for attention to tracheostomy 11/29/2018, Chronic respiratory failure. Review of Resident #5's Physician Orders included: Suction every 2 hours and as needed. Oxygen titrate 2-5 LPM via trachea to maintain saturation above 94% - every shift for Oxygen related to chronic respiratory failure. Head of bed to be elevated 30-45 degrees. Aspiration precautions. every shift. Pre and Post treatment Lung Sounds-Pulse, Respirations, and Oxygen Saturation. Trach care every shift and as needed related to encounter for attention to tracheostomy. Review of Resident # 5's Care Plan with a review start date of 02/17/2025 and Target Completion Date 03/07/2025 indicate: Focus: [Resident] is at risk for aspiration related to: PEG tube, Tracheal intubation. Goal: [Resident] will safely tolerate a least restrictive diet without signs/symptoms of aspiration daily thru next review date. Interventions: Monitor for any coughing/choking and refer. Focus: [Resident] is at risk for complication related to use of Tracheostomy tube related to Chronic Respiratory Failure. Goal: [Resident] will have clear and equal breath sounds bilaterally through the review date. [Resident] will have no abnormal drainage around trach site through the review date. Interventions: Suction as necessary. TUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB to 45 degrees and stay with resident. Obtain medical help IMMEDIATELY. Review of the Quarterly MDS dated [DATE] revealed the residents cognitive status is unable to determine. Functional abilities indicate the resident is dependent for all Activities of Daily Living (ADLs). Interview on 1/23/2025 at 2:28 PM, Staff C, CNA revealed if she heard gurgling sounds coming from a resident with a tracheostomy, she does not touch the resident until the nurse suction the resident. Residents with tracheostomy and tube feedings should not be flat while in bed. If the oxygen humidifier container is empty the nurse must be notified immediately. During an interview on 01/23/2025 at 4:34 PM; the Director Of Nursing (DON) was informed of the concerns identified. The DON revealed the nurses should complete an assessment; even if the Resident has been here for a long time. Residents with feeding tubes are at risk for aspiration and if observed with emesis and simple vomiting staff should elevate the head of the bed assess the vital signs hold the feeding and notify the doctor. The DON revealed the LPNs are trained to suction residents with trachs. When a resident is in respiratory distress the nurse should act immediately, It only takes 1 minute to do so, and 15 minutes will be a long time pending on what is needed. The expectation is the safety of the patient and maintaining an open airway Interview on 01/24/2025 at 11:50 AM with Staff I, RN, revealed all nurses can perform suctioning and usually suctioning is completed by two nurses. For a resident in respiratory difficulty immediate assistance is required more than five minutes is too long to provide suctioning for a resident in respiratory distress. For a resident in respiratory difficulty immediate assistance is required. On 01/24/2025 several attempts were made to conduct interviews via telephone with Staff F, LPN were unsuccessful. Review of document provided by the facility indicate: Manual: Nursing Manual: Nursing Section: Respiratory Standards and Guidelines: Issued 3/2020. Documented: Respiratory Care and Oxygen Administration Standard: It is the standard of this facility to provide guidelines for respiratory care and safe oxygen administration. Review of the facility's document titled: Tracheostomy Care. Date Implemented: 3/2020 Reviewed/Revised 06/2023, 08/2024 indicates: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Compliance Guidelines: Item 2. The facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care and/or suctioning.

Based on observations, interviews and record reviewed during this survey's investigations it has been determined that the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F 761 Label/Store Drugs and Biologicals, F693 Tube Feeding Management and F867 QAPI-QAA Improvement Activities. These repeated deficiencies have the potential to affect all residents residing in the facility. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated 08/22/2024 the facility was cited: F 761 Label/Store Drugs and Biologicals, F693 Tube Feeding Management and F867 QAPI-QAA Improvement Activities and during this complaint survey with exit dated 01/24/2024 the facility was cited again for F761 Label/Store Drugs and Biologicals, F693 Tube Feeding Management and F867 QAPI-QAA Improvement Activities. Review of the Policy and procedures revealed; It is the policy of the facility to develop, Implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility will take action aimed at performance improvement as documented in QAA committee meeting minutes and action plan. Performance/success of action will be monitored in subsequent QAA Committee or sub-committee meeting. Corrective action plans should include, but not limited to, the following: A definition of the problem Measurable goals and targets Step by step interventions to correct the problem and achieve established goals. A description of how the QAA committee will monitor to ensure changes yield the expected results. The facility will utilize Root Cause Analysis and the Plan, Do, Study, Act (PDSA) cycle of improvement to improve existing processes. Chosen actions for change will be linked to the root causes and will be designed to effect change at the systems level. To ensure improvements are sustained, the effectiveness of performance improvement activities will be monitored in QAA Committee meetings in accordance with QAPI plan, but no less than annually.

Based on observations records reviewed and interviews the facility's staff failed to implement infection prevention control precautions as evidenced by staff failed to follow Enhanced Barrier Precautions during Tracheostomy care for one out of two residents with tracheostomy in the facility. The findings included: Observation on 01/22/2025 at 02:09 PM Resident #3 was in bed with eyes closed, gurgling sounds and vomit draining from her the mouth. The tube feeding was infusing at 65 ml/hr. On 01/22/2025 at 02:30 PM Staff B, RN Supervisor entered the room performed hand hygiene put gloves on, did not put a gown, he checked the resident's mouth removed gloves and exited the room. On 01/23/24 at 8:03 AM before entering Resident 6's room an Enhanced Barrier Precautions sign was noted posted, and Personal Protective Equipment (PPE) was observed in a plastic container with drawers at the doorway. Resident #6 was observed in bed in distress with loud gurgling sounds noted coughing and drooling; the resident shaking his head from side to side with facial grimacing indicating he is not feeling well, when asked if he is in pain he nodded his head indicating yes. The oxygen was at 4 Liters Per Minute (LPM) via Tracheostomy, tube feeding was infusing at infusing at 75 ml/hr. The nurse was called to the room. Staff A and RN entered the room to assist the resident, and repositioned the resident. the supervisor was not wearing a mask was noted speaking very close to the resident in a loud tone; The supervisor checked the bowel sounds with his stethoscope exited the room and did not clean his stethoscope both. Both Staff A, and Staff B were not a gown while checking the resident Peg tube. On 01/23/2025 Staff A, RN acknowledged he did not follow infection prevention and control policy and procedures for Enhanced Barrier Precautions (EBP) while providing care to Resident #6. On 01/23/25 at 03:52 PM Staff B, RN acknowledged he did not follow and implement infection prevention and control precautions while caring for Resident #3 and Resident #3 at all times. Review of the facility's Policy and Procedures: for Infection Prevention and Control Program Issued: 6/2020 and Revised:9/29/2021, 6/2023 indicates: It is the policy of the facility to ensure that the Infection Control Program is designed to prevent, identify, report, investigate, and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement; provide a safe, sanitary and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with State and Federal Regulations, and national guidelines. Item 16: All shared medical equipment will be cleaned using an EPA-approved disinfectant wipe effective against TB and Hepatitis B. The Policy and Procedures: Titled Enhanced Barrier Precautions; Issued: 8/16/2022 and Revised: 4/1/2024 indicate: It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO.

Based on observations, reviews and interviews, the facility's staff failed to notify Resident #3's family /representative and physician of a change in condition for one out of three residents sampled as evidenced by Resident #3 who is at high risk for aspiration was observed vomiting and displaying signs of respiratory distress and on that specific date the facility staff did not notify the physician and the family of the changes in her condition. There were two hundred and ten residents residing in the facility at the time of the survey. The findings include. On 01/22/2025 at 8:44 AM Resident #3 was observed in bed the bed head was slightly elevated, her eyes were closed; audible gurgling breathing sounds also known as Rhonchi were noted, oxygen via nasal cannula was flowing at 2 Liters Per Minute (LPM), dark beige thick vomit was draining from Resident # 3's mouth, a large white towel was observed tucked under her chin and draped across her chest absorbing the vomit; Percutaneous endoscopic gastrostomy (PEG) feeding formula was infusing at 65 milliliters per hour (ml/hr.). Upon identifying these concerns the surveyor pressed the call light for the nurse. Staff A, Registered Nurse (RN) entered the room, looked at the resident and did not do an assessment. Staff A, RN was about to exit the room when the surveyor asked what interventions were in place related to the concerns observed. Staff A, RN stated: She is always like that. Staff A, RN further revealed there is no additional orders in place including suctioning because she does not need suctioning and exited the room. On 01/22/2025 at 8:46 AM Staff C, Certified Nursing Assistant (CNA) walked into Resident # 3's room and cleaned the vomit drainage from the resident's mouth and placed a clean towel under the resident's chin and across the chest. Observation on 01/22/2025 at 02:09 PM, Resident #3 was in bed with eyes closed and still had the gurgling sounds and vomit draining from her mouth. The PEG feeding infusing formula at 65 ml/hr. Closer observation revealed a Scopolamine patch (usually used for motion sickness and for drying secretions) was noted behind the resident's right ear. On 01/22/2025 at 2:13 PM Staff C, CNA entered Resident #3's room, cleaned the vomit draining from Resident #3's mouth; Staff C,CNA and revealed the nurse knew and she was going to inform him again. On 01/22/2025 at 02:24 PM, Staff A, RN entered the room, looked at the resident and did not check the residents vitals, did not check bowel sounds, did not auscultate the lung sounds and did not hold the feedings. Staff A, RN was asked what interventions would be implemented; Staff A, RN revealed in this case, Ondansetron (Zofran) injection would be administered. On 01/22/2025 at 02:30 PM, Staff B, RN Supervisor entered the room performed hand hygiene put on gloves, checked the resident's mouth and exited the room without checking the residents vital signs and did not assess the bowel sounds and auscultate the lung sounds. Record review of Resident #3's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include Cerebral Infarction, Chronic Obstructive Pulmonary Disease (COPD), Dysphagia following Cerebral Infarction and seizures. Review of Resident # 3's Care Plans with start date of 1/14/2025 and target completion date of 1/28/2025 include: Focus- [Resident] is at risk for ASPIRATION related to PEG tube, Goal: The resident will safely tolerate a least restrictive diet without signs and symptoms (s/s) of aspiration daily thru next review date (NRD). Interventions/Task: Monitor for any coughing/choking and refer, monitor labs as available. Position/sit resident upright at all meals. Focus: [Resident] is at risk for complications related to tube feeding such as aspiration, infection, intolerance to feeding, fluid overload/deficits, etc. Goal: [Resident] will tolerate tube feeding without signs/symptoms of complications . Monitor for signs of intolerance such as nausea, vomiting, diarrhea. If vomiting, hold feeding and notify MD (Medical Doctor). Monitor for signs/symptoms of aspiration every shift such as congestion, coughing, changes in respiratory rate and rhythm and notify MD as needed. Interview on 01/23/2025 at 3:03 PM, Staff C, CNA revealed she has been working in the facility for [AGE] years and the conditions displayed the day prior with Resident #3 was unusual, also today Resident #3 did not have any other episodes of vomiting. Interview on 01/23/2025 at 3:25 PM, Staff A, RN was asked if he was concerned about Resident # 3's condition on 01/23/2025. He stated, I always see her like that, I opened her mouth to check if anything was in her mouth. Staff A, RN, was asked what basic interventions should have been implemented to address the respiratory concerns for a resident who has PEG feeding and at high risk for aspiration, he stated: Yesterday I did not check the lungs and held the feeding. Staff A, RN, reported he notified the family and the doctor, and no new orders were received, and he had also documented all this information in the residents records and told the supervisor. On 01/23/2025 At 3:41 PM the surveyor reviewed the electronic health records (EHR) with Staff A, RN to confirm documentation regarding notification of change in condition to the doctor and family. Side by side review of Resident #3's Electronic Health Records (EHR) with Staff A, RN revealed no documentation indicating the resident's family and doctor were notified. On 01/23/2025 at 4:05 PM Staff B, RN Supervisor revealed he was not informed of a change in condition related to Resident #3 on 01/22/2025; and the policy for changes in condition; the doctor must be called, notify the family, document in the computer and the 24-hour log. On 01/23/2025 at 4:10 PM, review of the 24-hour log for 01/22/2024 revealed no documentation related to Resident # 3's change in condition. Review of the facility's policy and procedure titled: Change in Condition; issued: 3/2020 and revised 3/22/2024 indicates: The purpose of this policy is to ensure the facility promptly informs the resident, consult the resident's physician; and notify, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician, and /or notify the resident's family member or legal representative when there is a change requiring such notification.

Based on observation, interviews, and record review, the facility failed to implement measures to prevent aspiration for one (Resident #3) out of three residents with percutaneous endoscopic gastrostomy (PEG) tube at risk for aspiration as evidenced by Resident # 3 was observed with vomit draining from her mouth and the Registered Nurses failed to implement interventions in a timely manner; and failed to implement interventions to prevent PEG tube dislodgement for two (Resident #6 and Resident # 7) out of three residents sampled as evidenced by Resident #6 was noted with his unsecured PEG tube line resting above his hand and Resident #7's tube feeding line was observed wrapped around the privacy curtain that was wrapped around the metal pole that had the feeding infusing and hanging loosely on the inner section of the wheelchair's wheel (Photo evidence). Both residents clinical diagnoses include Seizures. These risk factors increases the risk for dislodgement of the PEG tubes and affect the residents' nutritional status. The findings included: On 01/22/2025 at 8:44 AM Resident #3 was observed in bed with her eyes closed; loud gurgling sounds were noted, the head of the bed was slightly elevated and dark beige thick liquid resembling vomit was drooling from Resident # 3's mouth, a large white towel was tucked under the chin and draped across the resident's chest absorbing the thick liquid. Oxygen via nasal cannula was flowing at 2 Liters Per Minute (LPM), tube feeding was infusing at 65 milliliters per hour (ml/hr.). Respiratory supplies for breathing treatments were dated 01/10/2025 and the oxygen humidifier was dated 01/08/2025. The nurse was called to the room and asked what interventions were in place related to the concerns observed. Staff A, Registered Nurse (RN) entered the room and looked at the resident, Staff A revealed the resident is always like that resident does not need suctioning or anything and exited the room. On 01/22/2025 at 8:46 AM Staff C, Certified Nursing Assistant (CNA) walked into Resident # 3's room and cleaned the vomit draining from the resident's mouth and placed a clean towel under the resident's chin and across the chest. Observation on 01/22/2025 at 02:09 PM, Resident #3 was in bed with eyes closed and still had the gurgling sounds and vomit draining from her mouth. The PEG feeding infusing formula at 65 ml/hr. Closer observation revealed a Scopolamine patch (usually used for motion sickness and for drying secretions) was noted behind the resident's right ear. On 01/22/2025 at 2:13 PM Staff C, CNA entered Resident #3's room, cleaned the vomit draining from Resident #3's mouth and revealed the nurse knew and she was going to inform him again. Observation on 01/22/2025 at 02:09 PM; Resident #3 was in bed with eyes closed and still had the gurgling sounds and drainage from the mouth. The tube feeding was infusing at 65 ml/hr. Closer observation of the resident revealed a Scopolamine patch (usually used for motion sickness and for drying secretions) was observed behind the residents right ear On 01/22/2025 at 2:13 PM Staff C walked into the room wiped the cleaned the resident's mouth and reported she was going to inform the nurse. She also revealed the nurse knew and she was going to inform him again. On 01/22/2025 at 02:24 PM, Staff A, RN entered the room, looked at the resident and mentioned this happens sometimes and Ondansetron (Zofran) injection would be administered in this case. The nurse did not check the residents vitals, did not check bowel sounds, did not auscultate lung sounds and did not hold the PEG feeding. On 01/22/2025 at 02:30 PM Staff B, RN Supervisor entered the room performed hand hygiene put on gloves, checked the resident's mouth and exited the room. Record review revealed Resident # 3 was admitted to the facility on [DATE]. Clinical diagnoses include Chronic Obstructive Pulmonary Disease (COPD), Dysphagia following Cerebral Infarction and seizures. Review of the Physician Orders for January 2025 included but not limited to: Scopolamine Transdermal Patch 72 Hour 1 MG (milligram) every 3 days at 9:00AM- Start Date: 12/17/2024. Check Scopolamine Transdermal Patch every shift Enteral Feeding two times a day 65 ml/hr. for 20 hrs, start at 2:00 PM, end at 10:00 AM, (or until 1300 ml total formula volume)-revision date 9/21/2024. Water flush two times a day Auto flush water 50 ml/hr. for 20 hrs via Peg (percutaneous endoscopic gastrostomy), off:10:00AM, on :1400-Revision date 9/19/2024. Oxygen at 2 LPM via nasal cannula every shift for COPD, ipratropium-Albuterol inhalation Solution 3 ml inhale orally via nebulizer every 6 hours related to COPD; Ondansetron HCI Injection Solution 4 MG/2 ML -Inject 2 ml intramuscularly every 6 hours as needed for Nausea and vomiting. Enhanced Barrier Precautions related to presence of Peg tube. On 01/23/2025 at 08:03 AM, during a PEG tube medication administration for Resident #6, it was noted that the PEG tube was above the resident's right hand; the resident guarded the site and Staff B, RN had to hold the resident's hands while Staff A, RN administered the medications. The PEG tube site was not secured. Review of Resident #6's clinical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with clinical diagnoses that include Gastronomy status, Seizures, Tracheostomy status and Dysphagia, Review of a Health Status Notes dated 1/15/2025 time stamped 02:15:00 and note dated 1/16/2025 time stamped 07:13:08 created By: Staff L, Licensed Practical Nurse (LPN) indicate: Resident fights and guards abdomen area when trying to provide PEG care, PEG site noted leaking fluids with odor and brown drainage, Review of Health Status Note dated 1/16/2025 time stamped 11:30 revealed Resident # 6's PEG tube was noted out of place and the Nurse Practitioner was notified. Review of dietary note created by the Dietitian on 1/17/2025 time stamped 12:45:00 noted: WEIGHT WARNING, Weekly weight completed: resident's weight continues to decline. Weight 121 lbs, down 4 lbs this week . Currently, Feeding is on hold D/T (due to) PEG-Tube is out of place. Review of Health Status note dated 1/17/2025 timestamped 23:29:00 revealed Resident #3's PEG tube was reinserted, On 01/23/2025 at 9:30 AM and at 09:43 AM, Resident #7 was observed in her room seated in a wheelchair asleep. The tube feeding line was wrapped around the metal pole that had the feeding pump, the privacy curtain and the wheelchair. The feeding was running at 60 ml/hr. (milliliters per hour). (Photo evidence) increasing the risk for dislodgement. On 01/23/2025 at 9:45 AM Staff I, RN was asked why Resident #7 was in the room seated in wheelchair; staff I, RN explained Resident #7 had been waiting to be transported to therapy. Staff I was told to check the resident tubing. Review of Resident #7's clinical records revealed an initial admitted [DATE] and a readmitted d 11/19/2024. Clinical Diagnoses include Gastronomy Status, Dysphagia, and other Seizures. Interview on 01/23/2025 at 03:16 PM. Staff A revealed they do not secure the Residents' PEG tubes and there is no need to. 01/23/2025 at 03:16 PM Staff B, RN supervisor revealed peg tubes does not need to be secured. On 01/23/2025 at 4:47 PM, the Director of Nursing (DON) was asked what interventions the facility has in place to secure and prevent a percutaneous endoscopic gastrostomy (PEG) tube from dislodging. The DON revealed, no special anchoring or adhesive is used to secure the PEG tubes. On 01/24/ 2025 Staff J, CNA revealed the tube feeding line should not be wrapped around anything because it increases the risk of dislodgment

Based on observations, records reviewed and interviews, the facility failed to secure medications and ensure the resident (Resident #6) received all of the crushed medications mixed with water during medication administration observation for one out of one resident (Resident #6) as evidenced by, Staff A, Registered Nurse (RN) left Resident #6's medications unattended and failed to ensure the resident received the full amount of each medication via PEG (Percutaneous Endoscopic Gastrostomy/also known as G-tube). There were 27 Residents residing in the facility with PEG tubes. Medication observation on 01/23/2025 at 08:09 AM, Staff A, RN was observed administering medications to Resident # 6 via PEG. Staff A, RN entered the resident's room with crushed medications Tylenol 325 milligrams (mg.) 2 tablets and Eliquis Oral Tablet 2.5 mg 1 tablet separately mixed with water in cups and. room to get the medications for the resident. Staff A, RN returned to the room with the medications (Tylenol 325 milligrams(mg) 1 tablet, Levetiracetam solution 100 5mL (milliliters) and Eliquis oral tablet 2.5 mg), placed the medications on the resident's overbed table and walked out of the room leaving the medications on the table (photographic evidence). Staff A, RN returned to the room, administered the medication via PEG and was about to discard the medication cups and extra water, the surveyor intervened and showed Staff A, RN, that approximately 75 percent (%) of the Tylenol and Eliquis were still in the cups (Photographic evidence). Staff A, RN left the room to get more water, left the cups with the left-over medications on the overbed table then returned and mixed and administered the mixtures via PEG. Review of Resident #6's clinical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with clinical diagnoses that include Tracheostomy status. Record review of Resident #6's Physician Orders for January 2025 included Levetiracetam 100 mg/ml-Give 5 ml via G-Tube two times a day related to unspecified convulsions. Eliquis oral tablet 2.5 MG (Apixaban)-Give 1 tablet via PEG-Tube two times a day for DVT (Deep Vein Thrombosis) Prophylactic, Acetaminophen (Tylenol) Tablet 325 MG.- Give 2 tablet via PEG-Tube two times a day related to pain. During an interview on 01/23/2025 at 3:16 PM, Staff A was asked about the unattended medications noted during medication administration for Resident #6. Staff A, RN. Staff A acknowledged he had left the medications unattended, but the resident is not going anywhere and is not able to get the medications. Staff A, LPN revealed he is aware medications should not be left unattended.

Based on observation, interview and record review, the facility failed to ensure a convection oven and stove used to prepare food for residents were in good repair and clean. This has the potential to affect one hundred and eighty-nine out of two hundred and seventeen residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the facility's policy titled Food Safety Requirements (implemented date 2/2020) documented: Policy-It is the policy of the facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety Policy Explanation and Compliance Guidelines: 6) All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination, a) Staff shall follow facility procedures for cleaning fixed cooking equipment. Review of the facility's policy titled Cleaning Instructions: Ovens (written date 2/2020) documented: Policy-Ovens will be cleaned as needed and according to the cleaning schedule Spills and food particles will be removed after each use; Procedure: 7) Wipe off any loosened grease and particles from inside the oven and the oven door and 10) Remove spills and food particles after each oven use as needed (before re-heating the oven). Review of the facility's policy titled Cleaning Instructions: Ranges/Griddles (written date 2/2020) documented: Policy-The cook/chef on each shift is responsible for keeping the range as clean as possible during the preparation of the meal. The range will be cleaned after each use. Spills and food particles will be wiped as they occur; Procedure: 4) Wipe the outside surfaces of the appliance using a sanitizing solution and 5) Spills should be cleaned up as they occur. Observation of the initial kitchen tour on 8/19/24 at 8:13 AM with the Dietary Supervisor revealed brown like stains on the outside of the convection oven, inside and outside of the convection oven doors, inside the convection oven, on the stove cook top and on the sides of the oven. Photographic evidence submitted. On 8/19/24 at 8:15 AM, interview with the Dietary Supervisor. She stated, We do a deep clean once a week of the oven and it is cleaned daily. She confirmed the brown like stains on the outside of the convection oven, inside and outside of the convection oven doors, inside the convection oven, on the stove cook top and on the sides of the oven. Review of the Cleaning Log for AM and PM August 2024 documented the ovens and convention ovens were cleaned daily.

Based on observations, record review and interview the facility failed to ensure food was prepared under sanitary conditions as evidenced by failure to maintain equipment in the kitchen in a clean sanitary manner. This has the potential to affect one hundred and eighty-nine out of two hundred and seventeen residents who eat orally residing in the facility at the time of the survey. The findings include: Record review of the facility's policy titled Food Safety Requirements (implemented date 2/2020) documented: Policy-It is the policy of the facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety Policy Explanation and Compliance Guidelines: 6) All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination, a) Staff shall follow facility procedures for cleaning fixed cooking equipment. Review of the facility's policy titled Cleaning Instructions: Ovens (written date 2/2020) documented: Policy-Ovens will be cleaned as needed and according to the cleaning schedule Spills and food particles will be removed after each use; Procedure: 7) Wipe off any loosened grease and particles from inside the oven and the oven door and 10) Remove spills and food particles after each oven use as needed (before re-heating the oven). Review of the facility's policy titled Cleaning Instructions: Ranges/Griddles (written date 2/2020) documented: Policy-The cook/chef on each shift is responsible for keeping the range as clean as possible during the preparation of the meal. The range will be cleaned after each use. Spills and food particles will be wiped as they occur; Procedure: 4) Wipe the outside surfaces of the appliance using a sanitizing solution and 5) Spills should be cleaned up as they occur. Observation of the initial kitchen tour on 8/19/24 at 8:13 AM with the Dietary Supervisor revealed brown like stains on the outside of the convection oven, inside and outside of the convection oven doors, inside the convection oven, on the stove cook top and on the sides of the oven. Photographic evidence submitted. On 8/19/24 at 8:15 AM, interview with the Dietary Supervisor. She stated, We do a deep clean once a week of the oven and it is cleaned daily. She confirmed the brown like stains on the outside of the convection oven, inside and outside of the convection oven doors, inside the convection oven, on the stove cook top and on the sides of the oven. Review of the Cleaning Log for AM and PM August 2024 documented the ovens and convention ovens were cleaned daily.

Based on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F 656 Develop/Implement Comprehensive Care Plan, F 761 Label/Store Drugs and Biologicals, and F 812 Food Procurement, Store/Prepare/Serve-Sanitary,. These repeated deficiencies have the potential to affect the 217 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated 04/20/2023, F 656 Develop/Implement Comprehensive Care Plan, F 761 Label/Store Drugs and Biologicals, and F 812 Food Procurement, Store/Prepare/Serve-Sanitary were cited. Review of the Policy and procedures revealed; It is the policy of the facility to develop, Implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility will take action aimed at performance improvement as documented in QAA committee meeting minutes and action plan. Performance/success of action will be monitored in subsequent QAA Committee or sub-committee meeting. Corrective action plans should include, but not limited to, the following: A definition of the problem Measurable goals and targets Step by step interventions to correct the problem and achieve established goals. A description of how the QAA committee will monitor to ensure changes yield the expected results. The facility will utilize Root Cause Analysis and the Plan, Do, Study, Act (PDSA) cycle of improvement to improve existing processes. Chosen actions for change will be linked to the root causes and will be designed to effect change at the systems level. To ensure improvements are sustained, the effectiveness of performance improvement activities will be monitored in QAA Committee meetings in accordance with QAPI plan, but no less than annually. On 08/22/2024 at 02:00 PM during an interview with Risk Manager/Administrator, Assistant of Director of Nursing (ADON), and [NAME] President stated that they meet monthly with all department Administrator, DON, infection control, Housekeeping, some people from, MDS, Rehab, Restorative and Medical Director. They review the binder with all the Performance Improvement Project (PIP's) to make sure that they are on track and getting the goals set.

Based on observations, interviews, and record review facility failed to store and label medications properly in three medication carts out four sampled as evidenced by one expired eye drop on First floor south front medication cart, one unrefrigerated medication on second floor south back medication cart and one controlled substance count sheet not matching bingo card on the first floor north back medication cart. There were 232 residents residing in the facility at the time of survey. The findings included: 1) On [DATE] at 10:47 AM During a medication storage check with Staff D, Licensed Practical Nurse (LPN) on the first-floor South nursing station front medication cart. An eye drop labeled Cosopt for R#28 with an opened date written on bottle of [DATE] and no expiration date written. (see photo). Record review of Medications and eye drops listing located in book in cart stated once opened The Cosopt eye drop expires in 15 days. (see photo). Staff D, LPN stated, I check all the medications for the expiration date and if it is expired, I reorder and discard it. I discard the expired medication because administering it to the resident can cause harm. The expiration date for this eye drop is [DATE]. This is expired. 2) On [DATE] at 12:06 PM During a medication storage check with Staff B, Registered Nurse (RN) on the second-floor South nursing station back medication cart, an observation was made of a box labeled sublingual Lorazepam for Resident#470 and refrigerate. (see photo). Staff B, RN stated, This medication was delivered this morning and not placed in the refrigerator. Also stated I check the cart when I come shift and check the narcotics with the previous nurse. Lastly stated I saw that medication this morning and did not place in refrigerator. 3) On [DATE] at 1:16 PM During a medication storage check with Staff E, LPN on the first floor North front medication cart a narcotic sheet with a different prescription number was being used to reconcile the Oxycodone 10 milligram tablet bingo card for Resident#160. (see photo). Staff E, LPN stated, I counted with the off going nurse this morning. I don't know how this happened or what happened to the sheet. On [DATE] at 1:55 PM Staff E, LPN and Pharmacy consultant came to conference room and stated, The wrong narcotic sheet was being used for the bingo card, but the count is correct. Pharmacy consultant showed surveyor the correct narcotic sheet for bingo card. On [DATE] at 2:41 PM The Director of Nursing stated, Nurses are to read instructions on labeling of medications pertaining to storage of medication. There is no reason why it should not be stored according to pharmacy instructions. Nurses are to check the expiration date of medications and if the medication and biologicals is expired it should be discarded appropriately. For controlled substances the nurses are required to count with the off going nurse using the narcotic sheet to verify the count is correct. The narcotic sheet and bingo care should match according to resident name, medication, dosage and prescription number. Record review of The Policy and Procedure entitled, Labeling of Medications Storage of Drugs and Biologicals issued: ,d+[DATE] Policy: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations. Purpose: The purpose of this procedure is to ensure the accurate labeling of all medications and biologicals to facilitate consideration of precautions and safe administration of medications. Definitions: Storage of Drugs Safe and secure storage (including proper temperature controls, limited access, and mechanisms to minimize loss or diversion) of all medication.

Based on observation, record review and interview the facility failed to ensure the facility's protocols and policies and procedures were followed for Enteral Feeding for four residents (Residents #37, #89, #157 and #194) out of four residents observed for tube feedings. As evidenced by incorrect dates and missing start times observed on enteral supplements, water bag flushes and incorrect date on an Enteral Feeding syringe. The findings Included: Resident #37 During observation on 08/19/24 at 09:01 AM Resident #37's enteral feeding Glucerna noted running at 70 milliliter per hour (ml/hr.), automatic water flush 50 ml/hr., enteral feeding supplement dated 08/18/2024 with no start time (photo available). Review of the medical records for Resident #37 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Gastro-Esophageal Reflux Disease without Esophagitis. Review of the Physician's Orders Sheet for August 2024 revealed Resident #37 had orders that included but not limited to: Enteral Feed-two times a day Glucerna 1.5 at 70 ml/hr. x 20 hours via Percutaneous Endoscopic Gastrostomy (PEG), on at 2:00 PM, off at 10:00 AM or until completed (1400 ml total formula volume). Enteral Feed-two times a day auto water flush 50 ml/hr. x 20 hours via PEG, on at 2:00 PM, off at 10:00 AM (1000 ml total auto flush volume). Record review of Resident #37 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score 5, on a 0-15 scale indicating the resident is cognitively impaired. Section GG for Functional Abilities documented dependent for care, substantial assistance required. Section K for Nutritional Status documented no unknown weight loss/gain. Record review of Resident # 37's Care Plans Reference Date 05/05/2024 revealed: Resident is at risk for complications related to tube feeding such as aspiration, infection, intolerance to feeding, fluid overload/deficits . Resident #89 During observation on 08/19/24 at 08:25 AM Resident #89 was noted in bed, enteral feeding Jevity 1.5 running at 65 ml/hr., automatic water flush 750ml/hr., enteral feeding syringe dated 8/18/24, (photo available). Record review of the Resident #89's monthly weights revealed resident had a weight loss of 1.60% in 6 months and .79% in one month. Review of the medical records for Resident #89 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Gastrostomy status. Review of the Physician's Orders Sheet for August 2024 revealed Resident #89 had orders that included but not limited to: Enteral Feed-four times a day Jevity 1.5 at 65 ml/hr. x 20 hours via PEG (1200 ml total formula volume in 24 hours), off at 5:00 AM, on at 7: 00 AM. Enteral Feed-four times a day auto water flush 50 ml/hr. x 20 hours (1000 ml total auto flush volume in 24 hours) via PEG, off at 5:00 AM-700 AM and off at 5:00 PM-700 PM. Record review of Resident #89 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns unable to be determined. Section GG for Functional Abilities documented dependent for care, substantial assistance required. Section K for Nutritional Status documented no unknown weight loss/gain. Section O for special Treatments documented resident is receiving oxygen therapy, suctioning and tracheostomy care. Record review of Resident # 89's Care Plans Reference Date 07/19/2024 revealed the resident is dependent on enteral feeding for nutrition and hydration with potential for dehydration/ nutrition deficit related to Diagnosis of: Nontraumatic Subdural Hemorrhage; Respiratory Distress; Dysphagia; Anemia. Resident # 157 During Observation on 08/19/24 at 09:16 AM Resident #157 was in bed asleep, enteral feeding Glucerna running at 70 ml/hr., automatic water flush at 50 ml/hr. Glucerna supplement dated 08/16/2024 with no start time, water flush dated 08/15/2024 with no start time (Photo available). On 08/19/24 at 09:18 AM Registered Nurse (Staff B) confirmed with the surveyor the dates observed on the water flush and Glucerna supplement, stated she will check to see what is going on with the resident's feeding, left the room and came back with Registered Nurse Supervisor (Staff C) On 08/19/24 at 09:22 AM Registered Nurse Supervisor (Staff C) stated; this date on the feeding and water is probably a mistake, the feeding is changed daily or as it is needed if it runs out. Record review of the Resident #157's monthly weights revealed resident had a weight loss of 5.17% in 6 months and 1.59 % in one month. Review of the medical records for Resident #157 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Persistent vegetative State and Encounter for attention to Gastrostomy. Review of the Physician's Orders Sheet for August 2024 revealed Resident #157 had orders that included but not limited to: Enteral Feed-two times a day 50 ml/hr., auto flush x 20 hrs (1000 mls daily) Start time: 2:00 PM; End time: 10:00 AM or until complete. Enteral Feed-two times a day Glucerna 1.5 at 70 ml/hr. x 20 hrs (total volume 1400 mls daily) Start time: 2:00 PM; End time: 10:00 AM or until complete. Record review of Resident #157 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns unable to be determined. Section GG for Functional Abilities documented dependent for care, substantial assistance required. Record review of Resident # 157's Care Plans Reference Date 08/17/2024 revealed the resident requires tube feeding related to Dysphagia. The resident will be free of aspiration and will maintain adequate nutritional and hydration, stable weight, no signs and symptoms of malnutrition or dehydration through review date. Resident #194 During observation on 08/19/24 at 08:53 AM Resident #194 was in bed awake, Enteral feeding Glucerna running at 750ml/hr. water flush 750ml/hr. Glucerna supplement dated 08/18/2024 with no start time, water flush dated 08/18/2024, syringe dated 08/19/24 (Photo available). Record review of the Resident #194's monthly weights revealed resident had a weight loss of 3.65 % in one month and a weight gain of 11 pounds in 6 months. Review of the medical records for Resident #194 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Malignant Neoplasm of Larynx, unspecified. Review of the Physician's Orders Sheet for August 2024 revealed Resident #194 had orders that included but not limited to: Enteral Feed-two times a day Glucerna 1.5 at 70 ml/hr. x 20 hours via PEG, on at 2: 00 PM, off at 10:00AM or until completed (1400 ml total formula volume). Enteral Feed-two times a day Auto water flush 50 ml/hr. x 20 hours via PEG, on at 2:00 PM, off at 10:00AM or until completed (1000 ml total auto flush volume). Record review of Resident #194 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score 7, on a 0-15 scale indicating the resident is cognitively impaired. Section GG for Functional Abilities documented dependent for care, partial assistance required. Nutritional Status documented no unknown weight loss/gain. Review of Resident # 194's Care Plans Reference Date 09/13/2024 revealed the Resident is at risk for complications related to tube feeding such as aspiration, infection, intolerance to feeding, fluid overload/deficits, etc. Resident will tolerate tube feeding without signs/symptoms of complications and will have stable weights through next review date. Interview on 08/21/24 at 01:29 PM Registered Nurse (Staff B) 7:00 AM to 3:00 PM shift, 2 South Unit reported regarding enteral feedings: I check the resident's orders to see what supplements they are on and the flow rate order, on the supplement I record the resident's name, room number, date and start time, and the flow rate, on the water we record the same information as the supplement, every morning on the 11:00 AM to 7:00 AM shift a new syringe is placed on the feeding tube poll and dated with the current date. When we the nurses are doing rounds, we are supposed to check the enteral feedings . the pump, make sure the feeding orders are being followed, the flow rate, check the date and start time on the supplements, water and the syringe. The supplements are changed daily, or every 24 hours as ordered. During an interview on 08/21/24 at 02:18 PM the Director of Nursing (DON) and Assistant director of Nursing (ADON) reported; Supplements can be hung for 24 hours, it is important to note that some residents have a gut rest time during their feedings, the date and the start time on the enteral feedings are very important because the nurses need to know when the residents' feedings were started and when the 24 hours hang time for the feeding is up/completed. Review of the facility policy titled Enteral Nutrition dated -3/2020 states: It is the policy of this facility to ensure accurate administration and adequate nutrition/hydration of enteral nutrition support for the residents, this protocol is to enhance the residents' participation in their daily activities. Procedures: 1. A telephone orders defines the formula, the rate, total volume and calculating the timeframe the nutrition support will run. 2. A telephone order defines the water flush inclusive of the rate and the timeframe the flush will run. 3. Hang product up to 48 hours after initial connection with clean technique and only one new feeding set is used, otherwise hang no longer than 24 hours. 4. Enteral feeding flush bag is to be changed every 24 hours. 5. The nutrition support will be initiated by the nurse will reset the pump to zero ensuring total volume is met.

Based on observation, record review and interview facility failed to implement the plan of care for one resident (Resident #75) out of five sampled as evidenced by no communication form filled out by nursing staff prior to dialysis. The findings Included: On 8/21/24 at 9:15 AM Resident #75 was observed in the Dialysis room. The Dialysis Home Program supervisor, Registered Nurse (RN) stated the floor nurse did not fill out a dialysis communication form for today but gave a verbal report to the Dialysis Patient Care Technician (PCT). On 8/21/24 at 9:18 AM dialysis PCT reported a verbal report was received from the nurse. Review of the demographic sheet for Resident#75 revealed an admitted [DATE] and a readmitted [DATE] with diagnosis that included: End Stage Renal Disease (ESRD), Dependence on Renal Dialysis. Record review of Resident #75's Quarterly Minimum Data Set (MDS) with reference date 6/24/24, Section C (Cognitive status) revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognition was intact. Section O (Special Treatment) revealed Dialysis. Record review of Resident #75's care plan for hemodialysis initiated on 2/22/22 and revised on 8/15/23 revealed the potential for developing complications related to hemodialysis for diagnosis of ESRD received in house starting at 1:00 PM on Mondays, Wednesdays, Fridays with a goal of not developing complications related to hemodialysis through the next review date. Interventions included: Coordinate resident's care in collaboration with dialysis center and communicate with dialysis center regarding medication, diet, and lab results. Record review of Resident #75's physician order sheet revealed order dated 4/6/24 directions: In house dialysis with [] Dialysis Monday, Wednesday and Friday. Chair time 9:30 AM completion time 1:30 PM. (Resident must go with communication sheet. Every day shift every Monday, Wednesday, Friday related to ESRD). Record review of Resident #75's progress notes revealed no note documentation for 8/22/24 prior to dialysis. On 8/21/24 at 10:14 AM Staff G, RN stated: I am responsible for filling out the Dialysis communication form before a resident is transported to dialysis and I give that form to the whoever picks up the resident. On the form I fill out the resident's name, the Unit, the date, and pre dialysis blood pressure. If I have a concern, I speak directly with the dialysis RN because sometimes the Certified Nursing Assistant takes the resident to dialysis. Today, [Staff H, RN, Supervisor] took [Resident#75] to dialysis this morning and filled out the communication form. On 8/21/24 at 10:19 AM Staff H, RN, supervisor for 1st floor stated: We fill out the pre blood pressure part of the form; I did not fill out the communication form because the nurse usually does it. I did not give report to the dialysis staff today because there was nothing to report. If the dialysis center has an issue, they call the unit. On 8/22/24 at 2:34 PM, the Director of Nursing reported every resident has a schedule for dialysis so the nurse knows what time the resident has dialysis. The floor nurse assesses the resident before transferring to dialysis, records the vital signs on the communication form, transports the resident to dialysis and gives report to the dialysis nurse. Record review of The Policy and procedure titled: Resident Right- Right to Participate in Planning of Care Issued: 2/2020 Policy: It is the policy of the facility to provide care and services in such a manner to acknowledge and respect resident rights. Exercising rights means that residents have autonomy and choices, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. Procedure: 1. The resident's right to participate in the development and implementation of his or her person centered plan of care, including but not limited to: d. The right to receive the services and /or items included in the plan of care.

Based on observation, record review and interview, the facility failed to accommodate a resident's choice for food preferences for one resident (Resident number 63) out of two residents reviewed for choices and preferences. There were a total of 217 residents residing in the facility at the time of this survey. The findings included: Record review of the Resident Rights Policy and Procedure (Implemented 11/27/2019) documented: Policy-The facility will inform the resident both orally and in writing in a language the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Policy Explanation and Compliance Guidelines: 1) Prior to or upon admission, the social service designee or another designated staff member, will inform the resident and/or the resident's representative of the resident's rights. Resident Rights: 1) The resident has the right to a dignified existence, self-determination and communication with and access to persons and services inside the facility; 5) Respect and Dignity: c) The right to resident and receive services in the facility with reasonable accommodation of resident needs and preferences and 6) Self-determination: The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice: b) The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. Review of the Resident Right-Right to Participate in Planning Care Policy and Procedure (Issued 2/2020) documented: Policy-It is the policy of the facility to provide care and services in such a manner to acknowledge and respect resident rights. Exercising rights means that residents have autonomy and choice about how they wish to live their everyday lives and receive care. Procedure: 2) The planning process will: c) Incorporate the resident's personal and cultural preferences in developing goals of care. Observation and interview with Resident number 63 on 8/19/24 at 1:24 PM revealed the resident sitting up in bed, with a nasal cannula and watching television. A lunch tray was sitting in front of her and she refused to eat it. She stated, I have talked to the dietitian and dietary people over and over and they still serve me chicken and fish. I told them I don't want no fish or chicken. They gave me mashed potatoes today and I like rice and beans. I requested a hamburger for lunch. Observation of the lunch tray revealed Baked Chicken, Mashed Potatoes and [NAME] Peas. The meal ticket documented NCS/NAS (No Concentrated Sweets/No Added Salt) Regular diet. Review of the Demographic Face Sheet for Resident number 63 documented the resident was admitted on [DATE] with a diagnoses to include chronic obstructive pulmonary disease, diabetes mellitus, hypertension, congestive heart failure and atrial fibrillation. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident number 63 dated 7/17/24 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 15 out of 15 indicating no cognitive impairment and the resident was able to make her needs known. The resident required partial/moderate assistance for ADLs (Activities of Daily Living), supervision with setup for eating and therapeutic diet. Review of the Physician's Order Sheets dated June 2024, July 2024 and August 2024 for Resident number 63 documented the resident was on a No Concentrated Sweets (NCS), No Added Salt (NAS) diet with Regular texture and Thin consistency liquids. Review of Resident's number 63's Nutrition/Hydration care plan (written 5/02/22) documented the resident was at risk for nutrition deficit and potential for dehydration related to: multiple medical diagnosis, multiple medications and need for therapeutic diet; Goals: Resident will be 1) free from signs and symptoms of dehydration by the next review date and 2) Weight will have no unplanned sig weight changes by next review date; Interventions: Provide diet as ordered; honor food preferences and substitute for dislikes. Review of the Dietary Progress Note for Resident number 63 documented the following: Dated 11/01/2023 13:26: Resident was seen at bedside provided RD (Registered Dietitian) with food preferences and concerns, the dietary manager was informed of resident food preferences and has updated meal tickets; Dated 12/29/2023 13:24: Resident was seen this afternoon regarding reports of meal dissatisfaction, RD assured resident that her meal tickets will be updated to reflect her likes/preferences, post room visit dietary manager was informed of concerns/preferences and dated 1/25/2024 13:00: Per daughter, resident cannot tolerate full chef's special meal most days related to unspecified GI (gastrointestinal) discomfort, reviewed current diet order with daughter, Food preferences updated with kitchen. Review of the Food and Beverage Preferences for Resident number 63 dated 10/12/23 documented the residents food likes and dislikes. Review of the Week At A Glance for General WEEK 1 Menu documented: Tuesday Lunch: Golden [NAME] Oven Fried Chicken, Macaroni & Cheese, Mixed Vegetables, Sugar Cookie; Wednesday Lunch: Picadillo, Rice, Fried Plantain, Chilled Peaches, Cornbread. Observation and interview with Resident number 63 on 8/21/24 at 12:57 PM revealed the resident sitting in a wheelchair in her room, wearing nasal cannula, eating lunch and watching television. The lunch tray consisted of: Ground Beef, [NAME] Rice, Carrot Slices and Mixed Fruit Cup. She stated, Since you came in to talk to me on Monday, they have been coming in here everyday in the morning to ask me what I want to eat. I shouldn't have to eat chicken for lunch and dinner. Why did it take you coming here for them to give me what I asked for. On 8/22/24 at 11:08 AM, interview with the Registered Dietitian (RD). She stated, The resident is on a NCS, NAS diet, Regular texture with thin liquids. She had a weight trend down in April but now is going up. We have several progress notes with her concerning her food preferences. She agreed that the resident's food preferences should be honored. On 8/22/24 at 11:15 AM, interview with the Staff A, RD Eligible. She stated, I am not a RD, but took the course and the internship but not the test. I went to see her on 8/19/24 about food preferences. I removed the chicken from the likes food preferences. Review of the Dietary Progress Note for Resident number 63 documented the following: Dated 8/19/2024 16:58: Visited the resident today and reviewed her food preferences. The dietary department was made aware of food preferences, and meal tickets were updated.