Every finding on record at Creekside

Based on facility document review, clinical record review, staff interviews, and policy review, the facility failed to identify a malfunctioning door which resulted in a resident elopement from the unit and the building for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 35.Findings include:Resident #1's Minimum Data Set (MDS) completed on 4/30/26 revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Active diagnoses included Alzheimer's disease (progressive brain disorder) and dementia (cognitive decline). Resident #1 didn't use an assistive device to walk independently. The Care Plan last reviewed on 5/18/26 identified Resident #1 as an elopement (wandering away) risk due to aimless wandering. Interventions included placing a picture on Resident #1's door for ease of finding the room and identifying Resident #1 as a wander alert so they'd find their room easily. The Incident Report labeled Elopement dated 5/6/26 at 5:45 AM detailed a Certified Nursing Assistant (CNA) found Resident #1 outside. The report didn't note any injuries. The facility document titled Timeline & Investigation outlined the following approximated events:On 5/6/26 at 5:00 AM staff last visualized Resident #1 eating in the dining room.On 5/6/26 at 5:15 AM Resident #1's ELPAS (electronic locator system) wander alert triggered, indicating Resident #1 neared the unit's east exit door.On 5/6/26 at 5:45 AM Staff A, Certified Nursing Assistant (CNA), found Resident #1 sitting outside a hallway exit door. Staff A and Staff B, Certified Medication Aide (CMA), both assisted Resident #1 back inside the building. Staff A notified Staff C, Licensed Practical Nurse (LPN), during this time.On 5/6/26 at 5:50 AM Staff C completed a head-to-toe assessment on Resident #1 and didn't find any injuries. This document summarized that Resident #1 exited the unit through the door because it didn't latch completely shut. Since it didn't latch properly, the door didn't close all the way and the door alarm disengaged. A review of facility maintenance work orders didn't indicate that the unit door malfunctioned prior to the elopement event. On 7/6/26 at 11:45 AM the Director of Nursing (DON) identified the doors Resident #1 used to exit the unit and the building. Once Resident #1 left the unit, Resident #1 got outside the building through a hallway exit door. This door sat approximately 20 feet away from the unit door and didn't lock or alarm. The DON opened the door freely. On 7/7/26 at 9:10 AM Staff C noted Resident #1 didn't typically seek exits. Resident #1 typically walked a path to and from their room to the unit's public bathroom, dining room, or common area. The morning of the incident, Staff C explained that staff last saw Resident #1 eating toast in the dining room at an unknown time. Staff didn't identify any concerns. Staff C went to complete cares with another resident. As Staff C finished up cares, Staff C received a call from Staff A that someone found Resident #1 outside. Staff C clarified that when the unit door latched shut, the only way out required a key fob, which disengaged the door alarm, or pushing the crash bar. When someone pushed the crash bar, the door alarm sounded. Staff C noted the hallway exit door, which allowed Resident #1 to get outside, didn't lock or alarm. Staff C explained all residents wore their call lights, either like a watch or necklace. Since staff noted Resident #1 as a wander alert, the call light on their wrist also activated a text alert to staff notifying them when Resident #1 neared an exit door inside the unit. Staff C believed the system triggered the morning of the elopement when Resident #1 neared an exit door. However, staff didn't know Resident #1 left the unit because they cared for others, and the system didn't track exits. On 7/7/26 at 10:05 AM Staff A acknowledged finding Resident #1 outside the building the morning of 5/6/26. Staff A explained they walked through the hallway to return to the unit when Resident #1 started banging on the door. The hallway exit door remained shut, and Resident #1 sat outside on the sidewalk. Staff A went to alert unit staff. Staff A and Staff B both assisted Resident #1 back inside. After the nurse completed the assessment, Staff A helped redress Resident #1 and ensured Resident #1 felt content in their room before leaving. Staff A noted they didn't know Resident #1 exited the unit or the building. They felt quite startled when Resident #1 started banging on the door. Staff A didn't remember a text indicating Resident #1 neared a unit exit door. Staff A noted their work phone should've received call light notifications or alerts for residents throughout the facility and not just a single unit. On 7/7/26 at 12:50 PM Staff B acknowledged serving as the covering staff for the unit the morning of 5/6/26. Staff B described Staff A as the float who went between both units in the facility. Staff B recalled working a 12-hour shift, starting at 2:00 AM, and voiced Resident #1 stayed up more than usual and sat a lot. After fixing toast for Resident #1, Staff B sat to document and then went to address another resident's call light with Staff A's assistance. Resident #1 still sat in the dining room or common area of the unit. At one point during the cares, Staff B no longer needed Staff A's assistance. Staff A left the room, and Staff B remained to finish. Staff B didn't know where Staff A went. Once finished, Staff B noted the alert on their work phone indicating Resident #1 neared an exit. Staff hadn't cleared this alert yet. Staff B felt unsure how long the alert remained active. Staff B went to Resident #1's room to look for them. At this time, Staff A contacted Staff B to say Resident #1 stayed outside. Staff B called Staff C to notify them that Resident #1 stayed outside. At the time of the call, Staff C didn't seem to know about the alert or that Resident #1 left the unit. On 7/7/26 at 11:30 AM Staff D, Household Coordinator, explained the facility's ELPAS system functioned as an all-in-one system. It alerted staff to resident call lights, door alarms, and wander alerts. Staff D confirmed the system sent a text alert if a wander-alert resident neared a unit exit door and not if the resident went through the door. Staff D stated employees working in a specific unit connected only to the ELPAS channel associated with the unit and not the facility as a whole. Staff D stated staff on each shift completed the Head Count Sheet. Staff needed to visualize each resident and verify the ELPAS pendant's presence. Staff also completed a door safety check to ensure all doors functioned properly. On 7/7/26 at 2:45 PM the Facility Administrator acknowledged the unit's exit door didn't function properly the morning of 5/6/26. This allowed Resident #1 to push open the door freely without setting off the door alarm. The Facility Administrator believed that at some point during the evening shift, the door didn't latch correctly as staff went in and out of the unit. The Facility Administrator explained facility maintenance and an outside door company both addressed the door's failure to correct the issue. The Facility Administrator also noted the hallway exit door didn't feature locks or alarms, but they planned to alarm it. On 7/7/26 at 3:10 PM the DON acknowledged Staff B and Staff C represented the only two employees who received the text alert stating Resident #1 neared the unit's exit door the morning of the incident. Since Staff A served as the float and went between two separate units, they had to change the ELPAS channels to match their current unit. The DON also described a nursing channel within the ELPAS system, which allowed a staff member to receive all messages within the facility. Staff didn't know what channel Staff A utilized. The Security/Call Pendent System policy dated December 2025 instructed the following:On a daily basis, the charge nurse or designee must conduct a test of security doors by opening the door and setting off the alarm.Staff must check doors on fully locked units to ensure they remain securely closed and locked.Employees must maintain a tablet or other device to receive event notifications, including pressed call lights, pressed emergency buttons, or pressed doorbells.Employees must respond appropriately to each alert.

Based on clinical record review, observation, staff and resident interviews, policy review, and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to implement Enhanced Barrier Precautions (EBP) for 2 of 2 residents reviewed for infection control (Resident #2 and #40).Findings include:1. The Minimum Data Set (MDS) dated [DATE] identified Resident #40 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated he received hemodialysis (mechanical process to remove wastes from the body, due to poor functioning kidneys) while a resident and upon admission. The Electronic Health Record (EHR) indicated Resident #40 had diagnoses of unspecified kidney failure and Stage 5 kidney disease. In addition, she had a surgical wound to her right anterior neck from a right jugular dialysis catheter (used for getting dialysis). The Care Plan initiated 7/27/20 indicated that Resident #40 refused EBP due to not wanting the extra clutter. The Electronic Treatment Administration Record (ETAR) indicated to maintain EBP for line cite and wounds every shift. The ETAR included documentation staff completed the task for all 3 shifts on 12/16/25. The Physician's Orders indicated that EBP for line site and wounds every shift was discontinued on 12/17/25. The Progress Notes indicated on 12/16/25 at 8:26 AM Staff C, Household Coordinator, documented Resident #40 requested to be removed from EBP. Staff C removed the precaution materials from the room. During an observation on 12/17/25 at 8:00 AM observed Resident #40 with an external catheter to right upper chest for hemodialysis. The room lacked a sign for EBP, or Personal Protective Equipment (PPE) supplies noted in their room. In an interview on 12/17/25 at 9:48 AM Staff D, Certified Nurse Assistant (CNA), stated Resident #40 is not in EBP but was last year sometime. She is independent in her room, so staff don't go in often to help her. In an interview on 12/17/25 at 10:10 AM Staff E, Licensed Practical Nurse (LPN), stated Resident #40 is not in EBP anymore as she signed a waiver not to have it anymore. She added Resident #40 would have the dialysis shunt for the rest of her life. In an interview on 12/17/25 at 12:29 PM Staff F, Infection Preventionist (IP), stated EBP is not used for Resident #40 as her port is covered and they don't mess with it. Staff F added Resident #40 said she didn't want EBP and she signed something to not have EBP. Staff F added another resident, Resident #2, with a urinary catheter also declined EBP. In an interview on 12/18/25 at 9:09 AM Resident #40 stated the staff didn't use gowns when helping her. She added she recently signed something for the supplies to be removed from her room as they didn't wear them anyway. She denied that she did not like the clutter. In an interview on 12/17/25 at 1:30 PM the Director of Nursing (DON) stated that Resident #40 is not in EBP as they didn't want the precautions. The DON felt they had a right to refuse the precautions as they were to protect them and she had them sign a waiver. In a policy titled Transmission Based Precautions Isolation and PPE Use effective April 2019, lacked documentation about resident refusing EBP and signing a waiver. The Centers for Disease Control and Prevention (CDC) indicated document dated June 2021 titled Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities that skilled nursing facilities should consider EBP for residents with wounds or indwelling medical devices, regardless of Multi Drug Resistant Organisms (MDRO) colonization status or infection or colonization with an MDRO. In Quality and Safety Oversight (QSO)-22-08-NH, dated 3/20/24, the Centers for Medicare and Medicaid Services (CMS) indicated that in July 2022, the CDC released EBP recommendations and CMS is updating its infection prevention and control guidance accordingly. The new guidance related to EBP was being incorporated in F880 Infection Prevention and Control to assist LTC surveyors when evaluating the use of enhanced barrier precautions in nursing homes. Indwelling medical devices and wounds are risk factors for colonization with a MDRO. Once colonized, these residents can serve as sources of transmission within the facility. The expansion of EBP for all residents with wounds or indwelling medical devices is intended to protect these high-risk individuals both from acquisition and from serving as a source of transmission if they have already become colonized. 2. Resident #2's (MDS) dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS documented Resident #2 had an indwelling catheter (a thin flexible tube left inside the bladder to drain urine into a bag). Resident #2's Care Plan revised 10/16/25 documented the indwelling catheter with intervention of Resident #2 declining EBP and has signed a negotiated risk agreement. On 12/17/25 at 11:00 AM watched Staff B, CNA, emptied Resident #2's indwelling catheter. Staff B didn't wear a gown per EBP policy. In addition, Resident #2's room didn't have a EBP sign outside the door. On 12/17/25 at 11:10 AM Nurse A, LPN, verbalized EBP was not used per Resident #2's request for dignity and he signed a negotiated risk. On 12/18/25 at 9:15 AM Resident #2 verbalized he signed a form so staff wouldn't wear the gown.

Based on observation, interview, and record review, the facility failed to ensure the code status documented in the electronic health record (EHR) matched the code status documented in the Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 41 residents. Findings included: Review of the Minimum Data Set (MDS) assessment for Resident #11 dated [DATE] listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further revealed Resident #11 was severely impaired in regards to making decisions regarding tasks of daily life. The Care Plan with a focus area of Advance Directives/Care Preferences initiated [DATE] with a goal revision date of [DATE] directed staff to record any completed Advanced Directives in the resident record. Review of the EHR for Resident #11 revealed scanned facility form titled Resuscitation Orders dated [DATE] directed staff to attempt cardiopulmonary resuscitation (CPR). Review of facility form titled Resuscitation Orders for Resident #11 dated [DATE] located in the IPOST binder directed staff to not attempt CPR. During an interview, [DATE] at 10:10 AM the Director of Nursing (DON) revealed it is an expectation that code statuses should only be kept in the IPOST binder and not in the EHR. The DON acknowledged Resident #11's code status located in the EHR did not match the code status located in the IPOST binder. -

Based on observation, clinical record review and interviews the facility failed to clean and disinfect the carpet after bowel movement contacted the carpet for 1 of 5 residents (Resident #4) observed. The facility identified a census of 41 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] showed Resident # 4 with a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive loss. The MDS identified the resident had inattention and disorganized thinking that would fluctuate. The resident required extensive assistance with dressing, toileting, and personal hygiene. The MDS documented Resident #4 with frequent incontinence of urine and bowel. The MDS listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated 09/14/20 directed the staff to check routinely and as needed for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. The Care Plan also directed to keep the path to the bathroom unobstructed. On 5/23/21 at 11:17 a.m. upon entrance into Resident #4's room the Surveyor noted bowel movement (BM) on the floor in two areas on the carpet. One 2 x 2 inch area in front of the television and a 3 x 4 inch area two feet in front of the entrance to the bathroom. Both areas had BM rubbed into the carpet. Staff A, Certified Nursing Assistant, (CNA), stated the resident does occasionally throw BM on the floor. Staff A proceeded to pick up the BM off the carpet and dispose of it. Staff A did not lay anything over the BM smears on the carpet or clean the carpet at that time. Staff A and Staff B, CNA, assisted Resident #4 out of bed and walked the resident to the bathroom to complete peri-cares. After the completion of peri-cares, Staff B ambulated the resident with hand held assistance from the bathroom out to the hallway crossing through the BM smears on the carpet. Staff A reported to the Surveyor they were done in the room and exited the room without cleaning the carpet. Surveyor kept room under constant observation. As of 11:44 a.m., no staff had reentered the room to clean the carpet. On 05/23/21 at 3:12 p.m. Staff, C, Registered Nurse, (RN), walked Resident #4 from front lounge to the resident's room through the area with the BM smears to the carpet to the bathroom. The resident completed toileting and oral care. Then Staff C walked the resident across the BM smeared carpet out of the room to the front lounge. On 5/23/21 at 3:45 p.m., Surveyor observed the two BM smears remained on the carpet in Resident #4's room. On 05/24/21 at 7:30 a.m., the resident lay in bed with eyes closed resting. The BM smears remained on the resident's room carpet. On 5/24/21 at approximately 1:45 p.m. Staff D, Household Coordinator, reported the CNA's clean the resident's rooms twice a week. During an interview on 05/25/21 at 11:46 a.m. Staff, E, CNA, reported the staff clean the resident's rooms. She reported they dust, disinfect high touch surfaces, vacuum the carpet, and clean the bathrooms twice a week. They do have a spot cleaner that they can use on the carpet if needed. During an interview on 5/25/21 at 1:53 p.m., Staff E reported if a resident gets BM on the carpet, they should use the carpet cleaner to clean it up right away. On 05/24/21 at 1:55 p.m. The resident lay in bed with eyes closed resting. The Surveyor observed the 2 x 2 BM smear in front of the bedside stand had faded and was very noticeable. The 3 x 4 inch BM smear two feet in front of the entrance to the bathroom remained visible. On 5/25/21 at 2:00 p.m., the Household Coordinator stated that if a resident throws or get BM on the carpet, she would expect that staff would use the carpet cleaner and clean the area right away. On 05/25/21 at approximately 2:05 p.m., the resident lay in bed with eyes closed resting. The Surveyor along with the Household Coordinator observed the 2 x 2 inch BM smear in front of the bedside stand was very noticeable. The 3 x 4 inch BM smear, two feet in front of the bathroom entrance remained visible. The Weekly Cleaning Schedule and Responsibilities List, dated 05/03 (no year) thru 05/25 (no year) failed to identify or document any cleaning of Resident #4's carpet. On 5/25/21 at 3:01 p.m., the Director of Nursing, DON, reported if BM gets on the carpet she would expect that staff would clean the carpet right away so the resident would not be walking through it and spreading out to the facility. On 5/26/21 at 9:25 a.m., the House Coordinator reported they have a cleaning service come to clean the carpets monthly. She reported she did not know if she had any carpet cleaning records on Resident #4's room as she just tells the cleaning service which rooms to clean. She did not know if the cleaning service kept records of which rooms got the carpet cleaned, but the facility did not keep carpet-cleaning records. On 5/26/21 at 10:25 a.m., the Household Coordinator reported the carpet cleaning service does not keep a record of which rooms they clean carpet in. The Service only keeps a count of the number of carpets they clean. She reported that generally a deep clean is only done when a resident moves out or a room opens up. The Vacated Room Deep Clean Checklist, undated, provided by the facility failed to address carpet cleaning. The Room Checklist, undated, provided by the facility listed the following: Pick up trash or empty cans/glasses from room Straighten closet/drawers. Check for dirty clothes that may have been hung or folded up Strip bed and wash bedding Make Bed Dust under and around objects Wash windows Vacuum under and around furniture and along base board with attachment Check carpet for stains and use extractor as needed Sanitize door handles and light switches The Environmental Services General Guidelines and Cleaning Procedures, revised March 2014, provided by the facility identified a policy to ensure cleanliness in all areas of the nursing center. The Procedure, under general cleaning identified the following: Rooms will be thoroughly cleaned utilizing the following procedures: Empty wastebaskets, replace liner Wipe down all bathroom fixtures with correct cleaning solution including sink, counter areas, resident provided fixtures, furniture, or equipment. Clean stool with correct cleaning solution - put cleaning solution in stool, brush to clean flush, wipe off rim, seat, and entire outer shell of stool. Clean mirror Wipe and clean light fixtures Wash window as needed Clean and fill soap dispenser (if supplies) Clean and fill towel dispenser Wipe down all walls of restrooms (as necessary) Wipe down shelves, end tables, nightstand, bed, etc. Wet mop restroom Wet mop living area. General cleaning will be conducted in each resident's room, the halls, and common areas daily per the general cleaning procedure. Deep cleaning will be conducted in each resident room per the deep cleaning schedule. The deep cleaning schedule will commence on the first day of each month. The Procedure further instructed staff for resident rooms: Change gloves before entering and when exiting resident room. Dry mop floor. Move light objects to clean beneath and behind them, with special attention to the corners, cobwebs, and under the bed; dry and wet mop these areas before returning moved objects to their original positions. Clean mop boards if needed. Empty trash and replace liner Disinfect telephone. Wipe down and disinfect doorframe, light switches, and doorknobs. Wet mop and place wet floor sign. The Environmental Services General Guidelines and Cleaning Procedure failed to address carpet cleaning. -

Based on observation, record review of manufacturer's directions and staff interviews, the facility failed to ensure professional standards of insulin administration for 1 of 2 residents reviewed (Resident #142). The facility reported a census of 41 residents. Findings include: Minimum Data Set (MDS) assessment dated [DATE] documented Resident #142 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) documented a score of 15 indicative of intact cognition. The Care Plan with a focus area initiated date 5/18/21 revealed Resident #142 had an alteration in endocrine system related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan directed staff to administer diabetes medication as ordered by the physician. Review of Resident #142's blood sugar summary from 5/5/21-5/25/21 revealed blood sugar ranges from 48- 341. Review of FlexTouch insulin pen manufacturer instructions revealed the FlexTouch needle is to remain in the skin after the dose counter has returned to 0 in order to get the full dose with directions to slowly count to 6 following administration of the insulin. Observation on 05/25/21 07:21 a.m. revealed Staff F, Licensed Practical Nurse (LPN), administered 50 units of Linspro insulin subcutaneously using a FlexTouch insulin pen to Resident #142. Following administration, Staff F, LPN held the FlexTouch pen in place for 2 seconds. Interview 5/25/21 07:23 a.m., Staff F, LPN, revealed it is an expectation to hold the FlexTouch insulin pen in place subcutaneously for 2-3 seconds following administration of the insulin. Interview 5/26/21 at 10:09 a.m., the Director of Nursing (DON) revealed it is an expectation staff follow the manufacturer's instructions in regards to administering insulin utilizing the FlexTouch insulin pen. -

Based on clinical record review, resident and staff interview, the facility failed to complete a Baseline Care Plan within 48 hours of admission and ensure the resident received information on their initial plans for service and care delivery for 1 of 3 newly admitted residents reviewed (Resident #143). The facility reported a census of 41 residents. Findings include: The Face Sheet for Resident #143 revealed an admitted [DATE] with documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet further revealed Resident #143 was the responsible decision maker in regards to her care. Review of the initial Care Plan for Resident #143 revealed it was initiated 5/24/21. The Progress Notes lacked documentation that facility staff reviewed the initial care plan with the resident or her representative or provided a copy of the baseline care plan to the resident or her representative. Review of facility policy titled Care Plans with an effective date of April, 2019 revealed the following regarding Baseline Care Plans: a. Must be developed within 48 hours of resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to, initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan is developed within 48 hours of the resident's admission. d. The facility must provide the resident and their representative with a summary of the baseline care plan that includes but it not limited to the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility and any updated information based on the details of the comprehensive care plan, as necessary. During an interview 5/25/21 at 2:35 p.m., Resident #143 revealed she had not received a baseline plan of care from the facility with information regarding her initial plans for service and care delivery. During an interview 05/26/21at 10:05 a.m., the Director of Nursing (DON) revealed it is an expectation the 48 hour Baseline Care Plan is completed upon admission and is part of a checklist. -

Based on observation, clinical record review and staff interview, the facility failed to assess bed rails and/or obtain consent for use for five of 15 residents reviewed. (Resident #2, #10, #30, #31 & #45) The facility census was 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. During initial pool screening on 7/21/19 at 10:42 a.m., observation revealed hand assist bars on the resident's bed. No consent for use of the rails or assessment for the need for the hand assist bars could be found in the resident's health record. The Care Plan with an initiation date of 4/19/19, failed to identify the use of the hand assist bars. 2. The MDS assessment dated [DATE], documented Resident #10 had [DIAGNOSES REDACTED]. During initial pool screening on 7/21/19 at 10:52 a.m., observation revealed hand assist bars on the resident's bed. No consent for use of the rails or assessment for the need for the hand assist bars could be found in the resident's health record. The Care Plan with a revision date of 11/20/18 failed to identify the use of the hand assist bars. 3. The MDS assessment dated [DATE], documented Resident #30 had [DIAGNOSES REDACTED]. During initial pool screening on 7/21/19 at 10:45 a.m., observation revealed hand assist bars on the outer side of the bed. Review of the Side rail Assessment form dated 10/9/18 documented notification of the primary care provider and family for the use of the rails/bars. No consent for the use of the hand rails was found in the resident's health record. During interview on 7/22/19 at 1:50 p.m., the Legacy Household Coordinator, Staff I, stated the side rail assessments was completed as part of the admission process. During interview on 7/22/19 at 4:20 p.m., the Director of Nursing (DON) stated her expectations are side rail assessments and consents are obtained on admission. The DON stated they should be addressed on the individual resident's plan of care so that staff know what to do for the residents. 4. The MDS assessment dated [DATE], listed [DIAGNOSES REDACTED]. During observation on 7/23/19 at 7:58 a.m., the resident was in bed with turn bars in the upright position on the bed the side closest to the door. During interview on 7/24/19 at 8:19 a.m., Staff F stated she had seen the resident attempt to use the turn bar to reposition. 5. The MDS assessment dated [DATE], listed [DIAGNOSES REDACTED]. During observation on 6/18/19 at 2:12 p.m., the resident was lying in bed with the top quarter rail in the upright position on the bed. Clinical record review revealed the side rail evaluation assessment was 462 days overdue.

Based on observation, policy review and staff interview, the facility failed to ensure staff served resident food items under sanitary conditions in order to reduce the risk of food-borne illness during the observation of two meal services. The facility census was 48 residents. Findings include: 1. Observation on 7/21/19 at 11:45 a.m., in the Heritage Household revealed Staff A, Hospitality Staff, was assigned to serve the lunch meal. Staff A washed hands and donned gloves. Staff A began cutting up the ham and sweet potatoes and touched the food with her gloved hands. Staff A wearing the soiled gloves touched the counters, stove and numerous resident plates. Staff A continued to touch the food with her gloved hands throughout the lunch service. Staff B, certified nurse aide, CNA, entered the kitchen at 11:52 a.m., and began helping to plate the lunch items. Staff B donned gloves and touched the ham while cutting it up on the plates. Staff C, CNA, entered the kitchen and began helping plate the food. Staff C cut up the ham and touched the ham with gloved hands. Staff touched various plates and surfaces. During interview on 7/21/19, at 12:28 p.m., Staff B stated she was not aware to not touch the food with gloved hands. During interview on 7/21/19, at 12:42 p.m., Staff A acknowledged she touched the food with gloved hands and various surfaces throughout the kitchen. During interview on 7/22/19 at 2:38 p.m., the Executive Director Dietary Consultant stated glove use in the kitchen should be very limited and acknowledged gloves should not be used when touching the food directly and then touching kitchen surfaces. The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry requires single-use gloves be used for only one task, such as working with ready-to-eat food and used for no other purpose and discarded when damaged or soiled or when interruptions occur in the operation. 2. During observation of the noon meal service on 7/21/19 at 12:08 p.m., on the Legacy unit , Staff D, Hospitality Coordinator donned gloves at the start of meal service. Wearing the same gloves throughout the entire meal service she repeatedly touched drawer handles, plates, utensil handles and then used the same gloved hands to hold down green beans while she cut them with a pizza cutter, leveled the serving size of green beans in the serving spoon with gloved hands, transferred green beans from one plate to another with gloved hands, and used her gloved fingers too scrape pieces of pie off of the serving spatula of every piece served. During interview on 7/23/10 at 9:24 a.m., Staff L, Dietary Manager for Legacy stated the facility recognized they need to do extensive education with the dietary staff regarding gloves and food service.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure staff utilized proper infection control techniques in order to prevent infection of two of three residents reviewed. (Resident #40 & #31) The facility census was 48 residents. Findings include: 1. The Minimum Data Set (MDS) admission Medicare 5 day assessment dated [DATE], showed Resident #40 required extensive assistance with toileting and had a suprapubic catheter for bladder function. The Admission Record dated 6/29/19, showed the resident had [DIAGNOSES REDACTED]. Observation on 7/22/19 at 7:02 a.m., revealed the resident sitting in a wheelchair in the dining room waiting for breakfast to be served. The resident's Foley catheter bag covered by a blue dignity bag was fully open on the bottom and rested directly on the floor. Observation on 7/22/19 at 7:34 a.m., showed Staff H, House Coordinator, Certified Medication Aide (CMA) and Staff M, Licensed Practical Nurse (LPN), assisting the resident back to the room in the wheelchair. Staff H pushed the wheelchair in the hallway with the Foley catheter bag covered by the dignity bag, fully open on the bottom, dragged on the carpeted floor. After the resident returned to the room Staff H, Staff M and Staff N, Certified Nurse Aides, CNA, used the EZ stand (mechanical stand lift) to transfer the resident to bed. Once in bed, Staff N used the bed control to place the bed in low position revealing the Foley catheter and dignity bag, fully open on the bottom, resting directly on the floor. Observation on 7/22/19 at 8:46 a.m. showed the resident lying in bed with the Foley catheter bag covered with a dignity bag resting directly on the carpeted floor. Observation on 7/22/19 at 11:24 a.m., revealed the resident lying in bed with the Foley catheter bag covered by a dignity bag hanging on the bed frame. The Foley catheter and dignity bag rested directly on the carpeted floor. During observation on 7/23/19 at 9:00 a.m., Staff O, LPN, placed the catheter bag under the wheelchair with no dignity bag. Staff P, CNA assisted the resident to the dining room in the wheelchair with the catheter bag attached and no dignity bag covering the catheter bag. Observation on 7/23/19 at 10:38 a.m., showed the resident lying in bed with the Foley catheter bag covered by a dignity bag resting directly on the floor. During interview on 7/23/19 at 10:46 a.m., Staff H reported when a resident was in bed the catheter bag was to attach to the metal bed frame on the lower portion of the bed. She reported the bag and tubing should be moved side to side when repositioning the resident in bed. Staff H reported when a resident was sitting in a wheelchair the bag was to be hooked under the wheelchair with a blue bag covering it. Staff H stated the catheter bag and tubing should not touch the floor. An interview on 7/23/19 at 11:14 a.m. with the Director of Nursing (DON) reported the dignity bags snap closed at the bottom of the bag and staff must have had them upside down. The DON stated it is not acceptable for the catheter tubing or bag to touch the floor. Record review of the Catheter Care Policy, revised (MONTH) (YEAR), stated the purpose is to prevent infection and to reduce irritation. The procedure portion of the policy showed the following: (8) Place bag in dignity bag and keep off the floor. 2. The MDS assessment dated [DATE], documented Resident #31 had [DIAGNOSES REDACTED]. Review of the Care Plan with an initiated date of 5/3/18 revealed the resident had a suprapubic catheter. During observation on 7/22/19 at 8:30 a.m., Staff [NAME] and Staff F entered residents room and washed hands. Staff [NAME] performed catheter care and placed a barrier on the floor. Staff [NAME] emptied the urine into a graduate and went into the bathroom to empty the graduate. The catheter bag was placed directly on the floor mat, not on the barrier when Staff [NAME] went into the resident's bathroom. Staff [NAME] completed the rest of resident's cares and changed the catheter bag to a leg bag before getting the resident up for the day. During interview on 7/22/19 at 9:31 a.m., the Household Coordinator, Staff R acknowledged the catheter bag was placed on the fall mat and not on the barrier. .

Based on clinical record review and staff interview, the facility failed to ensure staff utilized non-pharmacological approaches prior to the administration of a [MEDICAL CONDITION] medication for one of 15 residents reviewed. (Resident #2) The facility census was 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. The Care Plan with a revision/initiation date of 4/19/19, identified a focus area of the use of [MEDICAL CONDITION] medications related to behavior management with increased confusion, combativeness, and aggressiveness. The Care Plan listed interventions of administering medications as ordered, monitoring for side effects and effectiveness. Monitor/record occurrence of target behavior symptoms and document per facility protocol. The (MONTH) Medication Administration Record [REDACTED] 1. On 7/4/19 at 8:47 p.m. 2. On 7/11/19 at 5:30 p.m. 3. On 7/12/19 at 7:03 p.m. 4. On 7/14/19 at 6:04 p.m. A document labeled [MEDICAL CONDITION] Medication directed three non-pharmacological interventions will be initiated prior to the use of PRN [MEDICAL CONDITION] medications. Nurse progress notes on 7/4/19, 7/11/19, 7/12/19 and 7/14/19 revealed the absence of documentation regarding interventions attempted with the resident prior to the administration of the PRN [MEDICATION NAME]. During interview on 7/22/19 at 10:14 a.m., Staff I, Household Coordinator for the Legacy unit stated alternatives tried before administering PRN [MEDICAL CONDITION] medications are to be documented in the nurse progress notes. During interview on 7/22/19 at 10:40 a.m., the Director of Nursing (DON) stated staff are to attempt three non-pharmacological interventions before administering PRN [MEDICATION NAME] and document the interventions in the nurse notes.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure appropriate perineal care was completed after an incontinence episode for one of six residents observed. (Resident #30) The facility census was 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #30 had [DIAGNOSES REDACTED]. During observation on 7/22/19 at 4:40 p.m., Staff J, certified nurse aide, CNA & Staff K, CNA, washed hands and donned gloves. Staff J unfastened the urine saturated incontinence brief and tucked the sides of it under each of the resident's hips. Using disposable wipes, Staff J cleansed the residents frontal urethral area using the same wipe in a scrubbing motion and repeating the action with a second wipe. The resident's abdomen and leg creases were not cleansed. The resident was assisted to roll onto the right hip. Staff J used one disposable wipe to cleanse the buttocks crease and half of the left buttock with a scrubbing motion, going over the same area with the same wipe repeatedly. She removed her gloves and donned new ones without performing hand hygiene. Staff rolled the resident onto the left hip. Staff J cleansed the right hip with one wipe in a scrubbing motion repeatedly going over the same area with the same wipe. Staff J removed her gloves, sanitized her hands and assisted Staff K to pull the resident's pants up. Staff K removed her gloves but did not perform hand hygiene. Review of a document labeled Procedure Perineal Care with a revision date of (MONTH) 2014 directed nursing staff to be sure to wash front to back and not to reuse soiled area of cloth. During interview on 7/23/19 at 3:15 p.m., the Director of Nursing stated staff should cleanse all areas that have come into contact with urine or feces, use a clean disposable wipe or cloth for each area and that they do not scrub over the same area of the skin with the same contaminated washcloth.

Based on clinical record review and staff interview, the facility failed to administer medication as physician ordered for one of 15 residents reviewed. (Resident #10) The facility census was 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #10 had [DIAGNOSES REDACTED]. A Physician order [REDACTED]. one tablet daily. Hold for systolic blood pressure < 120. Diagnosis: [REDACTED]. The (MONTH) Medication Administration Record [REDACTED].) daily on 4/27/19 upon return from a hospitalization . The medication was to be held if the resident's systolic blood pressure reading was below 120 millimeters of mercury (mm). The Weights and Vitals Summary for April, (MONTH) and (MONTH) of 2019, documented the medication was administered outside of the prescribed parameters on 4/29, 4/30, 5/2, 5/21, 5/22, 5/26, 5/28 and 7/11/19. The document revealed blood pressures were not consistently taken before the morning administration of the medication. During interview on 7/23/19 at 1:15 p.m., the Director of Nursing (DON) stated her expectation was for staff to follow physician orders [REDACTED].

Based on observation, clinical record review and staff interview, the facility failed to ensure one of 15 resident care plans included resident concerns identified upon admission. (Resident #5) The facility census was 48 residents. Findings include: 1. Resident #5's Admission Record dated 5/1/19, showed the resident had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], showed the resident weighed 151 pounds. The Care Area Assessment in the MDS showed the nutrition section triggered for this area to be care planned. A nutrition note dated 5/6/19, documented a requested for 4 ounces of Ensure at non-mealtime. The Physician order [REDACTED]. Observation on 7/21/19 at 12:14 p.m. revealed the resident at the dining room table eating the meal independently. The weight log sheet revealed the residents initial weight was 151 pounds and on 7/16/19 the resident was down to 128 pounds. During interview on 7/22/19 at 2:25 p.m., Staff G, Registered Nurse, RN acknowledged the weight loss and reported the Registered Dietician was required to identify and monitor all weight losses. The admission Care Areas Application triggered for nutrition to be care planned, yet she also noted it was not identified in the resident's care plan. The Mentor replied nutrition should have been addressed in the care plan. During interview on 7/23/19 at 9:06 a.m., the Registered Dietician, RD reported the resident had a lot of [MEDICAL CONDITION] and [MEDICAL CONDITION] and did not feel a lack of nutrition in itself needed to be a concern. The Care Plan dated 5/1/19, failed to show the resident had any nutritional concerns. There was no concerns identifying the continued weight loss of the resident and if interventions and monitoring were needed.

Based on clinical record review and staff interview, the facility failed to adequately inform residents of their right to appeal the decision for discontinuation of skilled services for 2 of 3 residents reviewed (Residents #25& #152) The facility census was 48 residents. Findings include: 1. Clinical record review revealed Resident #25 was discharged from skilled care on 3/21/19. The facility issued a notice of Medicare technical denial on 3/18/19. The facility failed to issue a Notice of Medicare Non Coverage (NOMNC) Centers for Medicare Services (CMS) Form . 2. Clinical record review revealed Resident #152 was discharged from skilled coverage on 6/7/19. The facility failed to issue a NOMNC, CMS Form . During interview on 7/23/19 at 9:37 a.m., the Administrator stated she was not able to produce the second notice of the or 4.

Based on clinical record review, staff interviews and observation, the facility failed to ensure a resident did not exit the facility without staff knowledge resulting in an immediate jeopardy. Resident #1 exited from the north lounge door in the unit and staff were not aware the resident was outside until hearing the resident knocking to come back inside. A concern identified for 1 of 3 residents reviewed. The facility reported a census of 55 residents. Findings include: According to the admission Minimum Data Set ((MDS) dated [DATE] Resident #1 had [DIAGNOSES REDACTED]. The resident required supervision of 1 staff for bed mobility, transfers, walking, dressing and toilet use. The resident did not utilize a mobility device to walk about the facility. Review of the care plan dated 1/10/19 informed staff Resident #1 was an elopement risk due to wandering behaviors and a history of attempts to leave the facility unattended. The care plan directs the staff to distract the resident from wandering, monitor and identify patterns of wandering, wear a wander alert bracelet and to monitor the resident on 1:1. Review of the Nurses Notes dated 1/9/19 revealed on 1/8/19 at 8:00 p.m. the Certified Nurse's Aides (C.N.A.s) heard knocking on the window/door of the facility. Upon investigating the staff discovered the knocking came from the north lounge door, the staff found Resident #1 outside the building knocking to come back in. The staff brought the resident into the facility, provided warm blankets to warm the resident. Review of an incident report dated 1/9/18 indicated Resident #1 eloped from the locked Dementia Unit on 1/8/19 at 7:00 p.m. The report revealed the staff heard knocking on the window/door by the dining room and found Resident #1 outside the north lounge exit door knocking to come back into the building. Review of a computer generated wander guard alert time line revealed Resident #1 left the building from the northwest lounge door at 7:01 p.m. and entered back into the building via the northwest lounge door at 7:10 p.m. The northwest lounge door exits to an enclosed courtyard. During an interview with Staff A-Administrator on 1/15/19 at 10:30 a.m., Staff A stated when the resident arrived to the facility on [DATE] the staff placed a wander guard bracelet on the resident and placed him on 1:1 supervision due to being upset about being at the facility and wanting to leave. Staff A stated the door the resident eloped from had a non-functioning egress door, the maintenance staff were aware of the non-functioning door in (MONTH) and placed a secondary alarm on the door, the door had a wander guard alarm and the secondary, magnetic alarm. Staff A said when she interviewed the staff working at the time of the incident, the staff admitted they didn't answer the wander guard alert that came over their ipods. During an interview with Staff B-LPN on 1/15/19 at 1:46 p.m., Staff B stated at approximately 7:00 p.m. on 1/8/19 she was in the den with dietary staff. Staff C-C.N.A. came out of a resident's room and reported to her that she and another aide heard a knocking noise. The staff started to investigate the knocking noise when they noted Resident #1 outside of the building, knocking on the window and doors to come back in. Staff B stated the door the resident eloped from had a wander guard alarm and a magnetic chirp alarm, Staff B admitted she could not hear the chirp alarm in the den. Later in the evening Staff B had another staff activate the chirp alarm on the north lounge door and Staff B could not hear the alarm in the den or nurses office area. Staff B assessed the resident and found no injury. The resident's hands were cold. Took resident to room and changed wet pants and provided resident warm blankets. The resident's vitals were normal. During an interview with Staff C-C.N.A. on 1/15/19 at 1:00 p.m., Staff C stated she worked the evening of 1/8/19 when the resident eloped. Around 7:00 p.m. she was with another aide helping with a resident transfer. Both aides heard a knocking noise. Staff C left the room and investigated to see where knocking came from. She got to the dining room windows and parted the blinds and found Resident #1 outside in the gated courtyard by the north lounge door. The staff opened the door and the resident walked back into the building. Staff C stated she did not hear the chirp alarm on the north lounge door as she was in a resident's room. Staff C stated it was cold outside but there was no snow. The resident was incontinent. During an interview with Staff D-Maintenance on 1/16/19 at 8:35 a.m. Staff D stated they had a number of doors in the building that didn't work after the building was constructed. The other doors were repaired except for the Legacy building-North lounge exit door. Staff D stated they were unable to fix the door so they installed a secondary audible alarm to the door in (MONTH) (YEAR). Staff D stated he knew the staff could not hear the secondary alarm thru the unit. The facility abated the immediate jeopardy on 1/10/2019 after initiating a QAPI plan by reviewing weekly report to check staff response, review daily checks, and initiate monthly elopement drill during the winter months. The facility educated staff on wander alerts. On 1/9/2019 the egress door was fixed.

Based on observation, clinical record review and staff interview, the facility failed to utilize proper infection control techniques during resident care for one of eight residents observed. (Resident #11) The facility census was 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #11 had [DIAGNOSES REDACTED]. During observation on 5/1/18 at 9:40 a.m., Staff A, Certified Nurse Aide, CNA held a Kleenex to the resident's mouth to cough and spit phlegm into. Staff A was not wearing gloves. Staff B, CNA donned gloves and took over for Staff A holding the Kleenex for the resident to spit into. Staff A did not perform hand hygiene before going to the closet to get clothes for the resident. Staff B disposed of the soiled Kleenex and wearing the same gloves put the resident's nonskid socks on, opened the drawers on the dresser to look for a gait belt, applied the gait belt and assisted Staff A to walk the resident to the bathroom. Staff B removed her gloves and washed her hands. Staff A, without performing hand hygiene, applied gloves and provided oral care. The resident continued to cough, spitting phlegm into Kleenex and toilet paper held by the CNA's. The CNA's dressed the resident while she sat on the toilet and assisted her to stand using a gait belt and walker. Staff A performed perineal care using disposable wipes. The CNA wiped down the left leg crease from front to back, came back up the right leg crease, wiping from back to front. Using the same wipe and without turning the wipe to a clean area, Staff A washed the central perineal area from back to front. Using a clean wipe, Staff A cleansed the posterior perineal area from front to back and removed her gloves. The CNA's assisted the resident into her wheelchair, removed the gait belt and then performed hand hygiene. During interview on 5/2/18 at 8:10 a.m., the Director of (DON) stated each time a staff person moved from a soiled area/task to a clean area/task they were to remove their gloves and wash their hands.

Based on observation and staff interview, the facility failed to ensure staff utilized proper handling of resident food items in order to prevent foodborne illness on the Heritage household. The facility census was 46 residents. Findings include: 1. During observation of the noon meal service on 4/30/18 at 12:15 p.m. Staff D, Hospitality Coordinator, wore gloves while preparing roast beef sandwiches for residents. Wearing the same gloves Staff D reached under the stove, pulled out a skillet, placed it on the stove, opened a bread sack and removed two slices of bread, buttered them and placed one slice in the skillet. Staff D opened a sack of cheese, placed a piece of cheese on the bread and covered it with second slice of bread. Still wearing the same gloves, Staff D pulled out another bun and placed it on a plate. Observed the dietician saying something to Staff D. Staff D removed her gloves at the time. Staff D picked up a spatula and flipped the grilled cheese in the skillet and donned clean gloves. Staff D opened the refrigerator and poured a glass of juice, placed it on a tray for staff to take to a resident and wearing the same gloves returned to the sandwich prep area to make more sandwiches. During interview on 5/3/18 at 8:00 a.m., Staff D stated she was aware she was not to touch cupboard doors, other cooking utensil handles, the refrigerator door handle and then touch bread and buns with the same gloves. Staff D stated she has been cooking for [AGE] years and knows she should have used tongs to get the buns out.

Based on observation, clinical record review and staff interview, the facility failed to keep unsecured chemicals secured in the food service area of the Reflection household main dining room. The facility census was 46 residents. Findings include: 1. Observation on 4/30/18 at 8:30 a.m., revealed an unlocked cabinet under the hand sink in the food service area of the main dining room in Reflection household that contained the following chemicals: a. Stainless Steel Cleaner b. Air Deodorizer aerosol spray c. Spic and Span d. Bleach wipes e. Glass Cleaner f. 409 g. Clorox Bleach cream cleanser At 8:35 a.m., the Hospitality coordinator (Staff C) stated they usually keep the half door to the kitchen closed, it was open at the time. The Hospitality coordinator agreed there was no lock on the cupboard and no lock on the half door to the kitchen directly adjacent to the open cupboard that contained the chemicals. Observation on 5/2/18 at 2:55 p.m., revealed the chemicals remained present in the unlocked cabinet under the hand sink in the food service area of the main dining room. On 5/2/18 at 3:05 p.m. the Director of Nursing stated the chemicals should be locked up. Clinical record review revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 10 and Resident #35 had a BIMS score of 9, indicating cognitive impairment. Both residents resided in the Reflection household and were independently mobile.