Every finding on record at Crestpark Forrest City, LLC

Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to report suspicion of sexual abuse within the two-hour allotted time frame per Center for Medicare and Medicaid Services (CMS) guidelines, for one (Resident #2) of one resident reviewed for allegations of sexual abuse discovered on 04/27/2026 at 10:15 AM and was reported on 04/28/2026 at 11:45 AM. The findings include: A review of an admission Record revealed that the facility admitted Resident #2 on 04/10/2025 with diagnoses that included muscle weakness, obesity, altered mental status, dementia, and hearing impairment. A review of a re-entry Minimum Data Set (MDS), with an Assessment Reference Date of 04/16/2026, revealed Resident #2 had a Brief Interview for Mental Status score of 3 which indicated the resident had severe cognitive impairment. The MDS revealed Resident #2 was dependent on staff for toileting, showering, and upper and lower body dressing. Resident #2 required supervision touch assistance with rolling from left to right. Other mobility skills such as sitting to lying, lying to sitting, sitting to standing, toilet and shower transfer were not attempted due to medical conditions or safety concerns. A review of Resident #2's Care Plan dated 04/13/2026 thru 06/23/2026, revealed the resident was unable to take self to activities, needed assistance with activities of daily living, had nightmares at times with yelling, had impaired cognitive skills and impaired communication, Interventions included to assist the resident to the activity, use a mechanical lift for all transfers, turn every two hours, out of bed in medical reclining chair, monitor frequency of nightmares and determine the underlying cause. A review of a Medication Administration Record and Treatment Administration Record (MAR-TAR) dated 06/01/2026, revealed Resident #2 had medications for dementia and nerve damage. A review of a facility document titled Reportable, revealed an allegation of rape with a discovery date of 04/27/2026 at 10:15 AM which was not reported to the State Agency until 04/28/2026 at 11:45 AM, by the Director of Nursing (DON). During an interview on 06/24/2026 at 9:55 AM, the DON indicated that the facility's policy should match the CMS guidelines. The DON indicated the report was started on 04/27/2026 and was completed within 24 hours unless it was a little late. The DON indicated that per the facility's policy she had 24 hours to report any abuse unless bodily injury was involved. The DON stated that the accusation of rape could be considered bodily harm. During an interview on 06/24/2026 at 10:39 AM, the Business Office Manager indicated abuse should be reported immediately and We have to have the report to Office of Long-Term Care (OLTC) within the day, at least before we leave. During an interview on 06/24/2026 at 11:10 AM, the Administrator stated, We have about three to four hours to report abuse. A review of an undated facility policy titled Protecting Resident During a Suspected Abused revealed, If there is a suspected abuse an internal investigation will take place immediately. OLTC will be notified by 11:00 am next day.

Based on record review, interview and facility policy review, it was determined the facility failed to report alleged violations involving abuse and misappropriation to the proper state agency within the allotted time frame for three (Resident #18, Resident #39, and Resident #43) of three residents reviewed. The findings include: Resident #18 Review of Resident #18's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/15/2025, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also indicated no pain medication was received scheduled or as needed . No pain medications were listed on the MDS. Review of Resident #18's admission Record revealed the facility admitted the resident with diagnoses which included contracture of right knee, chondromalacia patellae (degeneration of the cartilage under the knee cap causing knee pain), and intentional self-harm by firearm discharge. Review of Page 73 of the Narcotic Book on 12/19/2025 at 12:40 PM, revealed on dates 09/29/2025, 10/01/2025, 10/03/2025, 10/06/2025, and 10/07/2025 there was documentation that pain medication was administered to Resident #18 by Registered Nurse (RN) #1. During an interview on 12/19/2025 at 12:40 PM, the Director of Nursing (DON) stated Resident #18 was interviewed about the dates of administration of narcotic pain medication and the resident denied requesting or receiving pain medication on those dates. During an interview on 12/19/2025 at 2:23 PM, Resident #18 stated pain medication had not been administered in a while and they take [over the counter pain medication] instead of [narcotic pain medication]. Resident #39 Review of a quarterly MDS with an ARD of 11/16/2025, revealed Resident #39 had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS also indicated no scheduled pain medication was received but that Resident #39 had received as needed pain medication, and non-medication interventions. Review of the admission Record for Resident #39 revealed the facility admitted the resident with diagnoses which included chronic obstructive pulmonary disease (COPD), and a bladder infection without blood noted in the urine. Review of the Narcotic Book on 12/19/2025 at 12:40 PM, revealed on dates 10/02/2025, 10/03/2025, and 10/06/2025 there was documentation that pain medication was administered to Resident #39 by RN #1. During an interview on 12/19/2025 at 12:40 PM, the DON stated Resident #39 was interviewed about the dates of administration of narcotic pain medication and the resident denied requesting or receiving pain medication on those dates. During an interview on 12/19/2025 at 2:27 PM, Resident #39 stated they receive pain medication at times but seldom and that they just take regular [name brand over the counter pain medication] for their aches. During an interview on 12/19/2025 at 12:09 PM, the DON confirmed the two residents (Resident #18 and Resident #39) had narcotic diversions by the nurse in the reported allegation and the facility did not report it to the Office of Long-Term Care (OLTC). She stated, we investigated it, interviewed the residents, and terminated the employee. When asked about the documentation of the investigation, the DON stated there was not any documentation other than we flagged it in the narcotic book. The DON stated it was discussed in a nursing meeting and did not know if it was discussed at the Quality Assessment and Assurance (QAA) meeting. No QAA minutes were provided when requested from the DON by this surveyor. During an interview on 12/19/2025 at 2:44 PM, Licensed Practical Nurse (LPN) #2 revealed she was one of the nurses that reported the diverted medication of Resident #18 and Resident #39 to the DON. LPN #2 stated she was the Charge Nurse and saw on the medication administration record (MAR) that the residents had been administered pain medications only on the dates the alleged nurse was working the medication cart. LPN #2 stated she interviewed the residents to see if they had been having pain and both residents denied having pain. During an interview on 12/19/2025 at 3:20 PM, the Administrator revealed all drug diversions should be reported to the OLTC. He stated the department head and the administrator were responsible for investigating alleged abuse. If after the investigation the employee was proven to be guilty, that employee would be terminated. The Administrator stated all investigations were documented. Resident #43 Review of an admission Record, indicated the facility admitted Resident #43 with diagnoses that included type II diabetes, peripheral vascular disease (narrowing or blocked blood vessels), absence of right and left legs above the knee, osteomyelitis (inflammation of bone or bone marrow) and sepsis (the body's negative response to infection.) Review of an admission MDS with an ARD of 08/27/2025, revealed Resident #43 had a BIMS Score of 15, which indicated the resident was cognitively intact. The MDS also revealed the resident required partial to moderate assistance with toilet transfer and chair/bed-to-chair transfer. Review of a Facility Incident Report (FRI) dated 08/25/2025 at 9:35 AM, revealed Resident #43 reported to the DON that Certified Nurse Assistant (CNA) #8 had grabbed the resident's arm causing a bruise . Resident #43's report indicated CNA #8 stated that Resident #8 was disrespectful for not having shorts on, and that CNA #8 threw shorts at the resident and threw a trash can in the room. The FRI had a discovery date of 08/25/2025 at 9:30 AM and was submitted to the OLTC on 08/26/2025 at 9:34 AM. During an interview on 12/22/2025 at 2:00 PM, the DON stated the allegation was not called to her attention until the next morning on Monday,08/25/2025. She stated she reported the incident to the OLTC, contacted the police, physician and attempted to contact the family of Resident #43.The DON stated she started an investigation and suspended CNA #8 pending the investigation. The DON stated that Resident #43 reported the allegation to RN #6, the charge nurse for the shift on 8/24/2025 at 9:15 PM. RN #6 reassigned CNA #8 to another hallway to work with other residents. The DON stated, the RN should have called me, the administrator, and sent the CNA home, then started the process as a reportable. By not sending the CNA home, the RN put other residents and staff at risk. Review of a facility policy titled Protecting Residents during a suspected abuse indicated If there is a suspected abuse an internal investigation will take place immediately. Office of Long Term (OLTC) will be notified by 11:00 AM next day. Any willful act of abuse, neglect, involuntary seclusion, or misappropriation of resident's property will be subject to immediate termination and OLTC will be notified by 11:00 AM the next day. All written reports will be completed and faxed/mailed to OLTC according to Arkansas State Law.

Based on record review, interviews and facility policy review, the facility failed to ensure immediate protective measures were implemented and maintained until a thorough investigation was initiated. The facility also failed to immediately report to the Office of Long-Term Care (OLTC) to enable the state agency to provide the necessary oversight of the facility's efforts to investigate and protect residents from potential harm for one (Resident #43) of one resident reviewed. The findings include: Review of an admission Record, indicated the facility admitted Resident #43 with diagnoses that included type II diabetes, peripheral vascular disease (narrowing or blocked blood vessels), absence of right and left legs above the knee, osteomyelitis (inflammation of bone or bone marrow) and sepsis (the body's negative response to infection.) Review of an admission MDS with an ARD of 08/27/2025, revealed Resident #43 had a BIMS Score of 15, which indicated the resident was cognitively intact. The MDS also revealed the resident required partial to moderate assistance with toilet transfer and chair/bed-to-chair transfer. Review of a Facility Incident Report (FRI) dated 08/25/2025 at 9:35 AM, revealed Resident #43 reported to the Director of Nursing (DON) that Certified Nurse Assistant (CNA) #8 had grabbed the resident's arm causing a bruise. The report also indicated Resident #43 was told by CNA #8 that the resident was disrespectful for not having shorts on. Resident #43 reported that CNA #8 threw shorts at the resident and threw a trash can. The FRI had a discovery date of 08/25/2025 at 9:30 AM and was submitted to the OLTC on 08/26/2025 at 9:34 AM. Review of a Witness Statement dated 08/25/2025 at 2:30 PM, written by Registered Nurse (RN) #6, revealed on 08/24/2025 at 9:15 PM, RN #6 went into Resident #43's room to check an IV and the resident told her that CNA #8 had come in the night before and found resident naked. Resident #43 indicated CNA #8 told them that was indecent exposure. The Witness Statement indicated CNA #8 told the resident to put on clothes and threw some at Resident #43. Later that shift, another CNA, who the RN could not recall the name of, told RN #6 that the night before, a couple revealed Resident #43 told them, CNA #8 had grabbed the resident's left arm leaving redness on the arm. RN #6 went back to Resident #43's room and was told the same allegation by the resident. RN#6 then assigned Resident #43 to another CNA. RN #6 planned to report the allegation to the DON the next morning. A review of an Employee Detail Report for the night of 08/23/2025, revealed CNA #8 worked from 10:57 PM to 6:05 AM, then again for the night of 08/24/2025 from 9:55 PM to 6:00 AM, before being suspended on 08/25/2025 through 08/28/2025 pending investigation. During an interview on 12/22/2025 at 2:00 PM, the DON stated the allegation was not called to her attention until the next morning on Monday, 08/25/2025. She stated that she reported the incident to the OLTC, contacted the police, physician and attempted to contact the family of Resident #43. She stated that she started an investigation and suspended CNA #8 pending the investigation. The DON stated that Resident #43 reported the allegation to RN #6, the charge nurse for the shift, on 8/24/2025 at 9:15 PM. RN #6 reassigned CNA #8 to another hallway to work with other residents. The DON stated that the RN should have called me, the administrator, and sent the CNA home, then started the process as a reportable. By not sending the CNA home, the RN put other residents and staff at risk. A review of an undated facility policy titled Protecting Residents During a Suspected Abuse indicated If there is a suspected abuse and internal investigation will take place immediately. OLTC will be notified by 11:00 a.m. next day. Residents who have voiced an abuse complaint will be protected from any further harm during the period of investigation. This will be accomplished by QA (Quality Assurance) members appointing a supervisor or trusted employee to observe resident continually thru out the time period involved in this investigation. If possible, the resident would be moved to convenient area for continual observation.

Based on record review and interviews it was determined that the facility failed to ensure the Five Rights of Medication was performed by nursing staff before giving a resident's family/representative the incorrect medications upon discharge from the facility and failed to ensure the discharge instructions were confirmed with resident's family/representative upon discharge effecting two (Resident #42 and Resident #12 ) of two residents reviewed. The findings include: A review of Facility Reported Incident indicated on 05/01/2025 at 2:45 PM, it was discovered that Resident #12's medication that included medicine for hypertension, congestive heart failure, Dementia, high cholesterol and atrial fibrillation (rapid, irregular heartbeat) was given to a family/representative of Resident #42 upon Resident #42's discharge on [DATE]. The facility reported/submitted to the state Office of Long-Term Care (OLTC) on 05/06/2025 at 6:42 PM. The incident report indicated Resident #42's family/representative contacted the facility to question the discharge instructions and medicines issued at time of discharge on [DATE]. Resident #42's family/representative stated the charge nurse gave the medications, the discharge instructions and instructed family member to sign the discharge instruction form without going over the medications with the family/representative. The initial investigation revealed that the 3:00 PM -11:00 PM charge nurse (LPN #2) had prepared the discharge instruction paperwork and pulled the resident's medications. The medications pulled were the medications of another resident (Resident #12) and the medication regimen information on the discharge instruction form were those of the resident she had pulled the medications from. The 7:00 AM – 3:00 PM charge nurse (RN #5) admitted she did not review meds with resident's family. During an interview on 12/17/2025 at 1:30 PM Licensed Practical Nurse (LPN) #2 stated, she had been working with Resident #12 when she was told that another resident, Resident #42 was going home. She thought she would get Resident #42's things together before the resident discharged . She pulled the medication, counted and listed them, then placed them in a bag with the discharge instructions. LPN #2 stated the family/representative did not come to get Resident #42 during her shift, so she advised the oncoming nurse Registered Nurse (RN) #5 that the medications were ready to go. LPN #2 stated she was in a hurry but should have slowed down and paid better attention, but she was doing too many things at one time and got the residents mixed up. LPN #2 continued that protocol for discharging a resident was to verify that all medications are accounted for, to go over each medication with the family, educate the family, then ask if there were any questions. LPN #2 said after the incident, she was counselled and educated on the 5 Rights of Medication Administration, Medication Pass, Health Insurance Portability and Accountability (HIPPA) and proper discharge instructions. There were not any documented competencies on the 5 Rights of Medication Administration, Medication Pass, HIPPA and Discharge Instruction prior to incident. During a phone interview on 12/17/2025 at 2:45 PM, RN #5 said LPN #2 had bagged the medicine to send home with Resident #42's family before ending her shift, then told RN #5 that the medicine was ready to go. RN #5 stated she neglected to check the medications herself to ensure they were correct, and she should have checked the resident's name, date of birth (DOB) with the medication list, then compared the medication to the release/discharge form. During an interview on 12/18/2025 at 11:25 AM, the Director of Nursing (DON) stated Resident #12's medications were sent home with the wrong resident (Resident #42). RN #5 did not review the paperwork nor the resident's medication but handed the family/representative the medications. The family/representative asked RN #5 for instructions but was told by RN #5 that she did not have time to go over the medications. The DON indicated RN #5 had not reviewed the medications prior to giving them, nor took the time to go over the discharge instructions. The DON confirmed that it was important to go over discharge instructions and medications with residents or family/representatives and to ensure they know how to administer the medicine for continuity of care. The DON stated that an in service was done on 05/16/2025, covering the 5 Rights of Medication, Medication Pass, Proper discharge instructions, and HIPPA. A review of an in service titled Abuse/Neglect, the 5 Rights of Medication, Medication Administration & Storage, Med Pass, DC Instructions and HIPPA, initiated 05/01/2025 revealed 16 CNAs, 6 LPNs, 1 RN and various other staff signatures. The facility re-educated LPN #2 following the incident on 05/01/2025, on the 5 Rights of Medication Administration, Medication Pass, Health Insurance Portability and Accountability (HIPPA) and proper discharge instructions. Per an in-service initiated on 05/01/2025, all staff including LPN #2 and RN #5 were educated on abuse/neglect, the 5 rights of medication, medication administration and storage, medication pass, discharge instructions and HIPPA. These actions were performed before the survey team entered the facility, resulting in this finding being cited at past non-compliance.

Based on record review, interview, and facility policy review, it was determined the facility failed to ensure residents were free from misappropriation of resident property for three (Resident #19, #18, and #39) of three residents reviewed. The findings include: A review of Resident #18's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 09/15/2025, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also indicated no pain medication was received by Resident #18, either scheduled or available as needed. There was no pain medication listed on the MDS. A review of Resident #19's annual MDS with ARD 11/17/2025, revealed Resident #19 had a BIMS score of 03, which indicated the resident was severely cognitively impaired. The MDS also indicated Resident #19 had no pain medication scheduled or available as needed. There was no pain medication listed on the MDS. A review of Resident #39's quarterly MDS with ARD 11/16/2025, revealed Resident #39 had a BIMS score of 15, indicated the resident was cognitively intact. The MDS indicated no scheduled pain medication was received by Resident #39. Resident #39 had received as needed pain medication and non-medication interventions. During an interview on 12/17/2025 at 1:30 PM, Licensed Practical Nurse (LPN #2) stated when narcotics were delivered by the pharmacy, they were double bagged, the name, and amount verified, and immediately logged in the narcotic book. Before the pharmacy delivery staff left, the medication was checked off with them, the invoice was signed by Registered Nurse (RN) #1 and signed again on the electronic device. The narcotic book was counted at the beginning and end of each shift. LPN #2 stated, the facility does not have a policy on pharmacy deliveries. She stated when the count was off, it was reported to the Director of Nursing (DON). LPN #2 stated when Resident #19's narcotic was taken by RN #1, and that the staff member was terminated. LPN #2 stated LPN #3 gave RN #1 the locked narcotic box key to place the narcotic in the lock box when she was not supposed to do that. During an interview on 12/17/2025 at 4:17 PM, the Director of Nursing (DON) indicated she was notified by LPN #3 of the incident with Resident #19's narcotic delivery and count. Resident #19 had not arrived from the hospital when the delivery was made, and the count was found to be incorrect. The DON stated the staff looked for the signed invoice and the plastic wrapping that was around the medication, and neither were found. The DON stated she received a copy of the invoice where RN #1 signed in the count of the narcotic as 20. The narcotic book had 19 logged with one of the pills punched out. The DON called in RN #1 and LPN #3 for a drug test. RN #1 was terminated for not following facility policy on pharmacy deliveries. The DON stated only certain staff can accept pharmacy deliveries. The DON stated she had provided an in-service for receiving medications from the pharmacy. The DON stated the facility did not have a policy on who could accept pharmacy deliveries, but staff had been in-serviced on this. During an interview with LPN #4 on 12/18/2025 at 9:09 AM, LPN #4 stated the only nurse to accept deliveries were the ones that were charge nurses for that shift. The charge nurse was the one that had the medication cart keys. She stated, You can't give those keys to anyone else, unless you are leaving your shift. A narcotic count was done with two nurses at the end and beginning of every shift. LPN #4 stated they received an in-service after the incident with Resident #19's drug diversion, specifically on how to accept medication from the pharmacy. During an interview on 12/18/2025 at 10:32 AM, LPN #3 stated she was the nurse that reported the diversion to the DON. LPN #3 stated she was in the middle of medication pass when pharmacy delivery arrived. She stated she informed the delivery staff she would be right there. When LPN #3 arrived to the Nurses' Station, RN#1 had already accepted the pharmacy delivery and signed the medications in. LPN #3 stated Resident #19 had not made it to the facility from the hospital at the time of delivery. LPN #3 stated I opened the narcotic box and RN #1 placed the drug card in the box and I locked it back. I didn't think anything about it. LPN #3 indicated during the middle of her shift, she decided to check the narcotics and noticed the count that was in Resident #19's book and card with one punched out. LPN #3 stated, I went to look for the invoice to see the count and could not find the invoice, nor the drug wrapping. I checked the shred box and trash. LPN #3 stated she called the DON, who wanted LPN #3 to send a picture of the card front and back. LPN #3 called the pharmacy to check with them on the count, and it was verified there were 20 tablets delivered, not the 19 which was signed in the narcotic book and count of the card. LPN #3 stated they had another in-service the day after it happened and was told that whoever had the medication cart key was the only one to get in the medication cart. During an interview with Owner/Consultant on 12/18/2025 at 11:16 AM, the owner/consultant revealed they did not have a policy on pharmacy deliveries of narcotics. She stated when narcotics were delivered, they were in a tamper resistant bag. It was double bagged. You had to cut the bag open and once you cut the outer bag, the narcotic was in another bag. The nurse receiving the medication signed the invoice as well as the mobile device accepting the medication and the count of the narcotic. The nurse that had the medication cart keys were supposed to be the only one with access to the narcotic box contents. LPN #3 was the nurse with the medication cart key and should have been the only one dealing with the narcotics. During an interview on 12/18/2025 at 12:14 PM, RN #1 stated sort of like a fill in nurse for whatever was needed. RN #1 stated on the day of the incident, LPN #3 was busy in medication pass, so she accepted the pharmacy delivery. She stated part of acceptance was signing the delivery slip. RN #1 stated, I was in the middle of checking multiple medications when the Charge Nurse (LPN #3) arrived to the Nurses' Station. The Charge Nurse stood right next to me while I finished the counts. LPN #3 watched while RN #1 completed the delivery acceptance. RN #1 stated, I reached over and got the narcotic book off the top of the med cart and started logging the counts. RN #1 stated LPN #3 picked up the invoice slip and reviewed all the medications to make sure we had everything. RN #1 stated LPN #3 unlocked the locked narcotic box and I placed the narcotic card for Resident #19 in. RN #1 stated, after we restocked the med cart it was the end of RN #1's shift. RN #1 stated the DON called her the following morning for a miscount on a narcotic. The DON informed RN #1 that she was suspended until further investigation. RN #1 stated she did the drug screen, and it was negative. RN #1 stated the DON informed her that she was the only one that was being disciplined for this matter even though the other nurse did not follow the rules. RN #1 stated the Charge Nurse could accept deliveries, and she had always helped the other nurses. During an interview with DON on 12/19/2025 at 12:09 PM, the DON revealed the process when controlled drugs were ordered was when the drug arrived to the facility, they were counted and entered into the narcotic book. They were reconciled with a slip that came with them. The DON stated, I found out the invoices are put in the shred box and have not been able to locate them. DON stated LPN #3 was responsible for the medication cart on the incident day of 10/15/2025. DON stated it was her understanding that LPN #3 opened the lock box and allowed RN #1 to put the card in there. The DON stated she did not ask LPN #3 why a narcotic count was not done with another nurse getting into the narcotic box. DON stated LPN #3 was not disciplined for not following policy by allowing another staff member to get in the medication cart and I can't give you an explanation for that. The DON stated a picture of LPN #3's controlled drug prescription bottle in the reportable, because if her drug test was positive, she would be covered. The DON did not know if LPN #3 took her controlled drugs before or during the time LPN #3 was working and did not know how it would affect her ability to function because it affected everyone differently. The DON stated the facility did not have a policy for nurses working while taking a controlled drug. The DON stated, everyone functions differently while taking narcotics and did not know if staff was working while taking narcotics even for the safety of the residents. The DON stated there were two other residents (Resident #18 and Resident 39) with drug diversion with RN #1 taking their narcotics. The DON stated these two investigations were not reported to the Office of Long-Term Care (OLTC). The DON revealed the investigation process consisted of resident interviews, nurses notes, review of the narcotic book, and the investigation was not documented anywhere. The DON stated we discussed narcotics in our nurses meeting and could not tell me if it was discussed at Quality Assessment and Assurance (QAA) meeting. During an interview with the Administrator on 12/19/2025 3:20 PM, the Administrator revealed he expected staff to be terminated if it was proven a drug diversion took place. The Administrator stated, the QAA committee would be notified of a drug diversion and may have input toward it but not have the final say as to what happens. I have the final say. The Administrator stated there are times staff may not get disciplined but may have a note placed in their personnel file. The Administrator stated, it was not appropriate for the charge nurse with the key to the narcotic box to open it and allow another nurse access to the contents and he/she should be reprimanded but there should be a count of the narcotic and be correct. The Administrator said all drug diversion should be reported to the state agency. A review of an undated facility policy titled, Protecting residents during a suspected abuse , indicated the facility will take appropriate steps to prevent the occurrence of abuse and misappropriation of resident property and to ensure that all alleged violations of Federal and State Laws which involve abuse and misappropriations of resident property are reported to the Administrator of the facility and to State agencies in accordance with existing state law. The facility shall take the following steps to prevent, detect, and report abuse, and misappropriation of resident property: screening, training, prevention, identification, protection, reporting, investigation, corrective action, and documentation.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 2 of 2 ice machines in the facility, one in the kitchen and one on the 400 Hall were maintained in clean and sanitary condition to prevent food and beverage contamination; dairy products stored in the refrigerator were sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; kitchen ceiling tiles were cleaned to provide a sanitary environment for food preparation. The failed practices had the potential to affect 46 residents who received meals from the kitchen (total census: 48), as documented on a list provided by Dietary Manager #11 on [DATE]. The findings are: 1. On [DATE] at 9:46 AM, the ice machine panel in the kitchen where ice touches before dropping into the ice collector had brown colors on it. Dietary Manager #11 was asked to wipe the area. The brown residue easily transferred to the tissue. Dietary Manager #11 was asked to describe what was observed on the panel. He stated, It was black and brown dirt. Dietary Manager #11 was asked, Who uses the ice from the ice machine and how often do you clean it? He stated, We clean weekly, and we use it in the kitchen to fill beverages served to the residents at mealtimes. 2. On [DATE] at 9:48 AM, an opened zip top bag that contained slices of cheese, was on a shelf in the refrigerator. The bag was not sealed. 3. On [DATE] at 9:55 AM, the following observations were made in the storage room. a. There were 5 bags of grits on a shelf in the storage room with an expiration date of [DATE]. b. There were 8 bags of cream of wheat with an expiration date of [DATE]. c. There were 3 containers of fajita marinade and seasoning with an expirations date of [DATE]. d. An opened box of salt, the box was not covered. e. A container of rubbed sage with an expiration date of [DATE]. f. Eight of 8 boxes of tea with an expiration date of [DATE]. g, Four of 4 bottles of lemon juice with an expiration [DATE]. h. An opened gallon of barbeque sauce, the manufacturer's specification on the gallon specified, refrigerate after opening. i. Two opened gallon containers of soy sauce, the manufacturer's specification on the gallon specified, refrigerate after opening. 4. On [DATE] at 10:35 AM, the following observations were made in the walk-in refrigerator in a room leading to the dining room and the kitchen: a. The ceiling tiles had an accumulation of black and grayish dust stuck on it. The surveyor asked Dietary Manager #11 to describe the condition of the ceiling tiles. He stated, That is an accumulation of black and gray dirt. b. A half-gallon of butter milk in a milk crate with an expiration date of [DATE]. c. An opened box of fresh buttery taste spread with an expiration date of [DATE]. Dietary Manager #11 stated, We don't use them. d. A box that contained 20 cartons of probiotic yogurts had an expiration date of [DATE] 5. On [DATE] at 10:48 AM, the ice machine panel in the break room on the 100 Hall, where ice touches before dropping into the ice collector, had wet black and brown colors on it. Dietary Manager #11 was asked to wipe the area. The wet black and brown residue easily transferred to the tissue. Dietary Manager #11 was asked to describe what was observed on the panel of the ice machine. He stated, It was black and brown dirt. Dietary Manager #11 was asked, Who uses the ice from the ice machine and how often do they clean it? He stated, The maintenance man cleans it, and that's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms. On [DATE] at 11:13 AM, the Maintenance Supervisor was asked how often they cleaned it. He stated, By-weekly. 6. On [DATE] at 10:53 AM, Dietary [NAME] (DC) #2 pushed a food cart that contained a pan of fried chicken towards the food preparation area. Without washing her hands, she removed gloves from the glove box and placed them on her hands, contaminating the gloves. She then used her contaminated gloved hands to debone chicken to be ground and or pureed to serve the residents on mechanical soft diets and pureed diets. The surveyor asked what should have done after touching dirty objects and before handling food items and or handling clean equipment? She stated, Washed my hands. 7. On [DATE] at 11:25 AM, Dietary Aide (DA) #3 turned on the hand washing sink faucet and washed her hands. After washing her hands, she turned off the sink faucet with her hands, contaminating her hands, she removed tissue paper and dried her hands. Without rewashing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing foods items to be served to the residents who required pureed diets. When DA #3 was about to pour food items into a blender to puree, the surveyor immediately stopped her and asked what should have been done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 8. On [DATE] at 11:58 AM, the temperature of the broccoli with cheese when checked and read by Dietary Aide #4 on the steam table was 117 degrees Fahrenheit. The surveyor asked Dietary Aide #4 what should you do when food items are not hot enough to serve. DA #4 stated, Reheat it. 9. A facility policy titled, Handwashing and Glove Usage in Food service stated, When Food Handlers must wash their hands .Before starting work.After leaving and returning to the kitchen/prep area .After touching anything else such as dirty equipment, work surfaces or cloths.

Based on observation, record review, and interview, the facility failed to ensure refrigerated narcotics were stored in a permanently affixed storage box to prevent misappropriation of resident medications. The findings are: On 8/07/2024 at 9:30 AM, during an observation of the medication storage area, the surveyor observed the red controlled medication lockbox was not secured inside the refrigerator. The box contained controlled medication. On 8/07/2024 at 9:45 AM, during an interview with Licensed Practical Nurse (LPN) #13, when asked why it is important to secure the box inside the refrigerator, LPN #13 admitted it would be very easy to conceal the medication box due to the size and remove it from the facility. Reviewed the facility's undated policy (received on 8/07/2024 at 10:39 AM from the Administrator) titled, Controlled Medication (Schedule II, III, IV, &V) Receiving, Recording, Storage, Accountability, and Disposition Of stated under the section labeled Storage, that narcotics will be kept in a locked container affixed inside a locked cabinet, inside the medication room.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to 3 affect residents who received regular diets from 1 of 1 kitchen according to a list provided by Dietary Manager #11 on 08/06/24 at 9:33 AM. The findings are: 1. On 08/05/24, the noon meal menu documented the residents who received regular diets were to receive 4 ounces of fried chicken. 2. On 08/05/24 at 12:16 PM, during the noon meal service Dietary [NAME] (DC) #1 served 2 fried chicken legs to 6 residents and 2 chicken wings to 5 residents. 3. On 08/05/24 at 12:36 PM, the surveyor asked Dietary Aide (DA) #4 to weigh the same amount of chicken legs served to the 6 residents for lunch, and the same amount of chicken wings served to the 5 residents for lunch. She did and the 2 legs weighed 2.5 ounces and the 2 wings weighed 1.2 ounces, instead of 4 ounces of fried chicken as per the menu. DA #4 stated, We should have given them more chicken.

Based on observation, record review, and interview, the facility failed to ensure meals were served in a method that maintained the appearance of hot products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 24 residents who received their meal trays in the dining room, 12 residents who received their meal trays in their rooms on the 100 Hall and 200 Halls, and 8 residents who received their meal trays in their room on the 700 Hall, as documented on a list provided by Dietary Manager #11 on 08/05/24 at 9:33 AM. The findings are: 1. On 08/05/24 at 11:34 AM, Resident #23 stated the food is cold by the time it gets to us. 2. On 08/05/24 at 12:30 PM, an unheated food cart that contained 17 lunch trays was delivered to the dining room by Dietary Aide (DA) #3. At 1:08 PM, immediately after the last residents received their trays in their rooms in the dining, the temperatures of food items on a test tray were checked and read by DA #4 with the following results: a. Vegetable blend - 97.7 degrees Fahrenheit. b. English peas - 92.4 degrees Fahrenheit. c. Ground fried chicken with no gravy - 92.6 degrees Fahrenheit. 3. On 08/06/24 at 7:29 AM, an unheated food cart that contained 12 breakfast trays for the 100 and 200 Halls were delivered to the 200 Hall by Certified Nursing Assistant (CNA) #6. At 7:35 AM, the food cart was pushed to the 100 Hall by CNA #8. At 7:49 AM, immediately after the last residents received their trays in their rooms on the 100 Hall, the temperatures of the food items on the trays used as test tray were checked and read by the CNA #8 with the following results: a. Milk - 46.9 degrees Fahrenheit. b. Sausage links - 91.9 degrees Fahrenheit. c. Scrambled eggs - 103.6 degrees Fahrenheit. d. Ground sausage - 84.5 degrees Fahrenheit. 4. On 08/06/24 at 7:30 AM, an unheated food cart that contained 8 breakfast trays was delivered to the 700 Hall by Certified nursing Assistant (CNA) #7. At 7:00 AM, immediately after the last residents received their trays in their rooms on the 700 Hall, the temperatures of food items on the trays used as test trays were checked and read by CNA #7 with the following results: a. Milk - 45.5 degrees Fahrenheit. b. Scrambled eggs - 106.6 degrees Fahrenheit. c. Ground sausage - 88.1 degrees Fahrenheit. 49596 5. On 08/06/24 at 2:07 PM, Resident #23 stated the hot food was not hot at lunch today.

Based on observation, interview, and facility policy review, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 2 residents who received pureed diets. The findings are. 1. On 08/05/24 at 10:30 AM, a bowl that contained pureed strawberry cake was observed on the counter. Dietary [NAME] (DC) #1 stated, That is pureed strawberry cake, she covered the bowl with a lid and placed it in refrigerator to be served to the residents who required pureed food items. The consistency was runny, lumpy, and not smooth. There were pieces of strawberries in the mixture. 2. On 08/05/24 at 11:37 AM, Dietary Aide (DA) #3, used a 4 ounce spoon to place 2 servings of English peas into a bowl with its juice from a pan on the steam table. 3. On 08/05/24 at 11:38 AM, DA #3 poured 2 servings of English peas into a blender and pureed. At 11:40 AM, DA #3 poured the pureed English peas into a bowl. The consistency of the pureed peas was running and not formed. 4. On 08/05/24 at 11:43 AM, Dietary Aide (DA) #3 used a 4 ounce spoon to place 2 servings of vegetable blend from a pan on the steam table into a bowl and poured it into a blender and pureed. At 11:44 AM, DA #3 poured the pureed vegetable blend into a bowl. The consistency of the pureed vegetable blend was running and not formed. There were pieces of carrots in the mixture. 4. On 08/05/24 at 11:47 AM, DA #3 poured 2 servings of deboned chicken breast into a blender, added chicken broth, and pureed. At 11:48 AM, DA #3 poured the pureed fried chicken into a pan and placed it on the steam table. The consistency of pureed fried chicken was gritty and not smooth. There were pieces of chicken visible in the mixture. 5. On 08/05/24 at 11:58 AM, a pan of pureed bread with milk was on the steam table. The consistency of the pureed bread was too thick. 6. On 08/05/25 at 12:38 PM, DA #5 was asked to describe the consistency of the pureed bread with milk, pureed vegetable blend, pureed peas, and pureed cake. DA #5 stated, Pureed meat was gritty and not smooth, pureed vegetable blend was runny and had piece of carrots in it, and pureed bread with milk was too thick. 7. On 08/05/24 at 8:00 AM, the pureed sausage served to the residents on pureed diets was gritty, not formed and was not smooth. There were pieces of meat in the mixture. 8. On 08/06/24 at 8:04 AM, the surveyor asked Certified Nursing Assistant #9 who was assisting residents in the dining room to describe the consistency of the pureed sausage served to the residents on pureed diets. She stated, It looks more like ground meat. It is supposed to be like pudding. 9. On 08/06/24 at 8:08 AM, the surveyor asked Dietary Manager #11 to describe the consistency of the pureed sausage served to the residents on pureed diets. He stated, It looks more like mechanical soft meat. 10. On 08/06/24 at 8:09 AM, the surveyor asked DA #3 to describe the consistency of the pureed sausage served to the residents on pureed diets. DA #3 stated, It looks more like mechanical soft meat. 11. A facility policy titled, Consistency Alteration of Food & Fluid Mechanically Altered Foods & Thickened Liquids initiated 12/11/2010 indicated, .Pureed Consistency -Pureed items should be completely smooth without any pieces or chunks. -Mouth feel should be smooth and the consistency of PUDDING or MASHED POTATOES. -This texture requires very little to no effort to chew. -As presentation is important, gravy and smooth condiments should be added on top for visual appearance and taste, ex. ketchup/mustard on pureed hit dog with bun (to individual's preference). -When items are served, staff should always express to the patient what each food item is. -Refer to your facility spreadsheets/extension sheets for correct serving size .

Based on observations, interviews, and review of the facility's policies and state requirements, the facility failed to ensure a safe and secure environment as evidenced by not adhering to the facility's policies and procedures after an accident/fall for 2 (Resident #48 and Resident #251) of 2 residents reviewed for a fall with serious injury. The findings are: On 08/06/2024 at 8:35 AM, observed Resident #48 during medication administration. Noticed extensive bruising to the resident's face. When asked what happened, Resident #48 stated, I rolled out of bed, and fell on the floor. I'm always doing that. When asked if she hurt herself, the resident stated, My left hip hurts. I'm afraid to get up and walk. On 08/06/2024 at 8:45 AM, during an interview Licensed Practical Nurse (LPN) #12 stated she received report this morning and was told Resident #48 fell out of bed, but no injuries were noted. LPN #12 stated [LPN #14] notified the family but did not notify hospice or the provider to determine need to have resident evaluated. Nurse initiated neuro checks but did not advise on coming nurse of the continuing neuro checks. When asked what the protocol is when residents fall, LPN #12 stated, Assess the resident, obtain vital signs, call provider and hospice is applicable. Notify family, complete I&A [Incident and Accident] report, notify Director of Nursing (DON), continue to monitor resident or follow orders from provider. Upon record review and interviews with Licensed Practical Nurse (LPN) #14, it was discovered resident fell two days prior as well on 08/04/2024. Hospice or the provider were not notified Resident #48 was not sent to the hospital for evaluation for either fall. On 08/06/2024 at 8:56 AM, during an interview with Licensed Practical Nurse (LPN) #14 regarding the fall on 08/06/2024 LPN #14 stated, I walked into the room to check on resident, found her on the floor beside her bed. I assessed her, took vital signs, I didn't see any injuries on the resident except scratches on the back. I notified the son of the accident. I didn't notify hospice or the doctor, but the nurse on dayshift said she would call them since I didn't. When asked what the protocol is for a fall. She stated, assess the resident, notify the doctor and hospice if they are hospice residents, call the family, send them out if needed. LPN #14 further stated, I was under impression, we don't call the doctor if they aren't hurt, so I didn't. On 08/6/2024 at 9:05 AM, during an interview with the Director of Nursing (DON) regarding the recent falls, she stated, I was unaware until about fifteen minutes ago that the resident had had falls. I don't know why this resident's provider or hospice was not notified per our policy. We will be providing follow up training to ensure everyone is on the same page.

Based on observation, record review, and interview, the facility failed to follow enhanced barrier precautions when flushing a feeding tube for 1 (Resident #3) of 1 sampled resident reviewed feeding tube care and on enhanced barrier precautions (EBP). The findings are: A review of Resident #3's Face Sheet revealed diagnoses to include Parkinson's, depression, and PEG (percutaneous endoscopic gastrostomy) tube management. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/27/2024 suggested a Brief Interview for Mental Status (BIMs) a score of 6 (0-7 indicates severe cognitive impairment). Section K0520B3 indicated Resident 3 had a feeding tube. a. During an interview with the Director of Nursing (DON) on 08/06/24 at 2:59 PM, the DON confirmed the facility does not have Enhanced Barrier Precaution (EBP) signage, but they place a small bedside dresser outside the room with personal protective equipment (PPE). The DON stated all staff know that a small dresser outside the room is a sign of EBP. It was confirmed Resident #3 was on EBP due to a feeding tube, and staff knew because there was a small dresser outside the door. b. Review of the Physician's Orders revealed there was not an order for Enhanced Barrier Precautions. c. On 08/07/2024 at 9:30 AM, during a concurrent observation and interview, Licensed Practical Nurse (LPN) #12 was observed checking Resident #3's feeding tube for residual tube feeding, throwing away the overnight feeding and tubing and then flushing the feeding tube with 30cc [cubic centimeters] of free water. LPN #12 was not wearing any Enhanced Barrier Precautions (EBP) other than gloves. The Surveyor asked if Resident #3 was on Enhanced Barrier Precautions and LPN #12 confirmed Resident #3 was not on EBP and confirmed that she cannot think of any reason to put on PPE. The Surveyor observed a small dresser outside the door. The bottom drawer was slightly open with blue gowns visible. d. During an interview with the Administrator on 08/07/2024 at 4:00 PM, she confirmed a drawer outside the resident rooms indicated EBP, staff have been in-serviced, and she confirmed staff were expected to wear PPE when flushing a feeding tube because microbes could be transferred to the resident. e. On 08/07/2024 at 4:13 PM, the Administrator provided a policy titled Gastrostomy Feedings that did not apply to EBP. f. On 08/07/2024 at 4:16 PM, review of an Inservice Training dated 07/26/2024 on Enhanced Barrier Precautions (EBP) and other topics revealed, EBP recommendations now include use of EBP for residents with feeding tubes during high-contact resident care activities regardless of their multidrug-resistant organism status. g. On 08/07/2024 at 4:20 PM, the Administrator provided a letter stating .[Facility Name] facility does not have a policy on Enhanced Barrier Precautions at this time .

Based on interviews, record review, facility document review, it was determined the facility failed to ensure the care plan was revised to accurately indicate wandering behaviors with interventions to prevent the potential for elopement for 2 (Resident #1 and Resident #3) of 3 residents reviewed for wandering behaviors. Findings include: On 06/12/2024 at 9:19 AM, the Administrator stated the facility did not have a policy for care plans. A review of the Face Sheet indicated the facility admitted Resident #1 with diagnoses that included unspecified dementia, unspecified fall, and pneumonia. The 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. Section E regarding wandering and frequency of wandering indicated Resident #1 had wandering behavior of this type occurring 1 to 3 days. A review of the Initial Elopement and Wandering Risk Assessment for Resident #1 dated 01/03/2024 documented, Resident is at risk for elopement/wandering at this time. A care plan for wandering/elopement risk will be initiated identifying appropriate preventive interventions. A review of Resident #1's Baseline Care Plan on 01/03/2024, revealed the resident was a wanderer. The baseline care plan did not have any interventions documented. A review of Resident #1's undated Nursing Assistant Care Plan (Closet Care Plan) revealed the resident was an elopement risk. The closet care plan did not have any interventions documented. A review of the Face Sheet indicated the facility admitted Resident #3 with diagnoses that included unspecified dementia, Alzheimer's disease with late onset, and anxiety disorder. The Admission MDS with an ARD of 05/22/2024 revealed Resident #3 had a BIMS score of 9 which indicated the resident had moderate cognitive impairment. A review of the Initial Elopement and Wandering Risk Assessment for Resident #3 dated 05/10/2024 documented, Resident is at risk for elopement/wandering at this time. A care plan for wandering/elopement risk will be initiated identifying appropriate preventive interventions. A review of Resident #3's Baseline Care Plan dated 05/10/2024, did not indicate wandering and elopement risks and no interventions were in place. A review of Resident's #3's Care Plan for 05/10/2024 through 05/09/2025 did not indicate wandering and elopement risks and no interventions were in place. During an interview on 06/11/2024 at 9:07 AM, the MDS Coordinator confirmed Resident #1 had a baseline care plan completed and did not have any interventions included. The MDS Coordinator confirmed Resident #1 was only admitted for 13 days and did not complete a comprehensive care plan.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to provide adequate supervision to prevent a resident with moderate cognitive impairment and exit seeking behaviors from exiting the facility unsupervised for 1 (Resident #1) of 3 residents reviewed for elopement. Findings include: A review of the facility's undated policy titled, Wandering Resident Policy indicated, In an effort to prevent resident from wandering away from the facility, [Facility name] has door alarm systems on all appropriate doors. This system is to help alert any unauthorized exits of residents who may try to wander outside the facility unsupervised .staff will monitor all residents and those who have been identified as wanderer's on an ongoing basis to ensure all resident safety and privacy. A review of the Face Sheet indicated the facility admitted Resident #1 with diagnoses that included unspecified dementia, unspecified fall, pneumonia, and chronic prostatitis. The 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. Section E regarding wandering and frequency of wandering indicated Resident #1 had wandering behavior of this type occurring 1 to 3 days. A review of Resident #1's Baseline Care Plan on 01/03/2024, revealed the resident was a wanderer. The baseline care plan did not have any interventions documented. A review of Resident #1's undated Nursing Assistant Care Plan (Closet Care Plan) revealed the resident was an elopement risk. The closet care plan did not have any interventions documented. A review of Initial Elopement and Wandering Risk Assessment revealed Resident #1 was at risk for elopement/wandering at this time and a care plan for wandering/elopement risk will be initiated identified appropriate preventive interventions. A review of Progress Note dated 01/05/2024 on the 3:00 PM to 11:00 PM shift documented, .ambulatory in the hall with his belongings stating he's going home . A review of Progress Note dated 01/11/2024 at 10:20 PM documented, Resident found in another resident room with just a tee shirt on . A review of Progress Note dated 01/12/2024 on the 3:00 PM to 11:00 PM shift documented, Confused to location. Thinks he is at home. Wandered x2 into another resident room . A review of Progress Note dated 01/13/2024 on 7:00 AM to 1:00 p documented, .Ambulates with unsteady gait wandered in another resident's room . A review of Progress Note dated 01/14/2024 at 10:32 AM documented, Resident ambulating with walker. Resident ambulated to double doors and pushed on door causing door alarm to go off. CNA [Certified Nursing Assistant] and writer rushed to door and removed resident from area . A review of Progress Note dated 01/15/2024 at 10:50 AM documented, Admin [Administrator] informed resident not in room. Female resident informed staff she thought he was by the door. Upon looking outside of the doors, it is noted that 2 pairs of socks and glasses were on the ground outside the door. 1057 [10:57 AM] resident around side of building next to alternate exit approximately 60 feet from exit site. Resident states I was looking for my care. Resident brought back into facility . During a concurrent observation and interview on 06/10/2024 at 12:04 PM, the Administrator and Surveyor walked out the double doors the resident went through and walked to the area where the resident was found. Resident #1 was found approximately 60 from the exit. The Administrator verbalized Resident #1's room was next to the double doors the resident exited. The Administrator confirmed Resident #1 was out of the facility approximately seven minutes.

Based on record review, observation and interview the facility failed to ensure incontinent care was provided in a timely manner for 1(Resident #1) of 3 (Resident #1, #2 and #3) sampled residents who depended on staff for incontinent care. The findings are: A Care Plan with a problem date of 08/14/23 noted Resident #1 was to be provided prompt care as needed for incontinent episodes. A Physicians Order dated 10/17/23 noted Resident #1 was on Contact isolation for 10 days. On 10/23/23 at 11:34 AM, Resident #1 was on Droplet Precautions. The Surveyor asked Resident #1 how often staff checked on her. She stated, They brought me breakfast this morning and they didn't say a word to me. I haven't been changed this shift. I think I'm wet now. Resident #1 pulled her blanket back. Her brief and sheet were soaked with urine. She stated, I can't get out of bed or nothing. Sometimes I have to lay here in poop and pee all day. I figure they are busy, so I don't complain. On 10/23/23 at 11:51 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 why Resident #1 was not checked on all day. She stated, Earlier today I had to give my other residents their showers. I get to my patients on isolation after I do all my showers. I am on my lunch break now. The Surveyor asked if Resident #1 should have to wait for long periods of time to receive care just because she is on isolation. She stated, I do her last because I don't want to get the other residents infected. The Surveyor asked how often Resident #1 should be checked for incontinence. She stated, Every two hours. On 10/24/23 at 1:35 PM, during an interview CNA #2 stated she checks on her residents at least every two hours and just because they have Covid doesn't mean I go around them. On 10/24/23 at 1:47 PM, during an interview CNA #3 stated she checks on her residents every two hours and that she does her isolation residents first. On 10/24/23 at 1:54 PM, during an interview CNA #4 stated she checks on her all residents at least every two hours.

Based on observation and interview, the facility failed to ensure resident rooms were maintained in good repair, clean, and free of odors in 5 (Resident Rooms 113, 119, 120, 121 and 209) of 5 rooms on the 100 and 200 Halls. The findings are: 1. On 08/14/23 at 8:39 PM, the Surveyor entered Resident room [ROOM NUMBER] and observed a black substance on the vents of the air conditioning unit. Food debris was on the couch, the floor and in the air conditioning unit. A fall mat was lying under the bed smelled strongly of urine and was wet. a. On 08/17/23 at 9:17 AM, the Surveyor entered Resident room [ROOM NUMBER] and observed food debris on the floor, in the air conditioner unit, and on the couch cushions. The air conditioner had a black substance on the vents. A fall mat under the bed was adhered to floor and smelled strongly of urine. 2. On 08/15/23 at 8:01 AM, the Surveyor entered Resident room [ROOM NUMBER] and observed the air conditioner to have a black substance on the vents. The air conditioner filter was dirty and covered with a black substance. The molding at the base of the wall directly below the sink was peeled away from the wall and protruded 12 inches into the room. a. On 08/17/23 at 9:50 AM, the air conditioner and filter in Resident room [ROOM NUMBER] were partially covered in a black substance. The molding below the sink was peeled away from wall and protruded into the room. 3. On 08/15/23 at 8:06 AM, the Surveyor entered Resident room [ROOM NUMBER] and observed the air conditioner and filter to be dirty and partially covered with a black substance. The molding at the base of the wall below the sink was peeled away from the wall and protruded into the room. a. On 08/17/23 at 9:40 AM, the Surveyor observed in Resident room [ROOM NUMBER], 10 inches of molding below the sink peeled away from wall and protruding into the room. The air conditioner had a black substance on the vents and was visible on the inside behind the vents. 4. On 08/15/23 at 8:18 AM the Surveyor entered Resident room [ROOM NUMBER] and observed a black substance on the air conditioner vents and a hole in the bottom of the wall behind the bed. The hole had chew marks around it. a. On 08/17/23 at 10:02 AM, in Resident room [ROOM NUMBER] the black substance remained on the air conditioner vents and the hole behind the bed remained in the wall. 5. On 08/14/23 at 11:17 AM, the Surveyor entered Resident room [ROOM NUMBER] and observed that the window had a white cotton fabric bundled up between the screen and the glass window. The Surveyor asked the Resident why the fabric was placed there. The Resident stated, Because it leaks. The Surveyor asked who put it there. The Resident stated, I don't remember. a. On 08/15/23 at 9:30 AM, the Maintenance Supervisor accompanied the Surveyor to Resident room [ROOM NUMBER] and was shown the window. The Resident in the room stated, Someone put it in there because it was leaking, but I don't remember who. The Maintenance Supervisor stated, I know that I recently fixed the ceiling due to a leak, but I didn't know that the window was leaking. It looks like the window is cracked. The Surveyor asked the Maintenance Supervisor how he knows when there is something that needs to be fixed. The Maintenance Supervisor stated Staff will fill out a form and put it in my mailbox. I didn't know anything about this. 7. On 08/17/23 at 3:32 PM, the Administrator reported the facility did not have a policy on facility upkeep and maintenance.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed; Physician Orders for a pimento cheese sandwich was provided on a supper tray for 1 (Resident #20) of 1 sampled resident. The failed practices had the potential to affect 2 residents who received pureed diets, 2 residents who received pureed meat only and 9 residents who received mechanical soft diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 08/15/23 at 2:37 PM and 3 residents who had Physician Orders for sandwiches at supper according to a list provided by the Director of Nursing (DON) on 08/18/23 at 9:35 AM. The findings are: 1. The 08/14/23 lunch menu documented the residents who received pureed diets were to receive a #8 scoop of crunchy ranch chicken, a #8 scoop of pureed squash, a #8 scoop of pureed peas and a #8 scoop of pureed hummingbird cake. The residents on mechanical soft diets were to receive ground crunchy ranch chicken. 2. On 08/14/23 at 12:07 PM, the following observations were made during the noon meal service. a. Dietary Employee (DE) #1 used a 2 ounce (1/4) cup spoon to serve a single portion of pureed ham, pureed peas and pureed squash, instead of a #8 scoop (4 ounces or 1/2 cup) as specified on the menu. b. DE #1 used a 2 ounce (1/4) cup spoon to serve a single portion of pureed ham, instead of 4 ounces of crunchy ranch chicken. c. On 08/14/23 at 12:25 PM, the Surveyor asked DE #4 the reason residents on mechanical soft diets and pureed diets were served ham, instead of crunchy ranch chicken. She stated, There was no reason. d. On 08/14/23 at 12:32 PM, the Surveyor asked DE #1 what size spoon she used when serving pureed food items. She stated, I used a two ounce spoon to serve pureed meat, pureed peas, and pureed squash. The Surveyor asked how many servings she gave to each resident. She stated, I gave a serving each. 43262 3. Resident #20's Physicians Order dated 09/01/20 documented, .Diet: ***Pimento cheese sandwich with supper tray*** . a. On 08/16/23 at 1:55 PM, Resident #20 was seated in a recliner in her room. She was crying and stated, I don't like tuna sandwiches and they didn't give me anything else. I'm [AGE] years old I should be able to eat what I want. The Surveyor asked, Did you ask for something else and tell them you didn't like tuna? Resident #20 stated, No, I don't want to cause problems or be a bother. b. On 08/16/23 at 2:40 PM, the Surveyor asked the Dietary Manager (DM), What did [Resident #20] have for dinner last night? The DM stated, Tuna salad sandwich, soup, crackers, and a chocolate eclair. The Surveyor asked, Did [Resident #20] have a pimento cheese sandwich on her tray last night? The DM stated, I wasn't here for supper. The girls read the menu we leave and serve from the menu. The girls that were working last night will be back tomorrow between 11:30 AM and 7:00 PM. c. On 08/17/23 at 11:28 AM, Resident #20 was in her room. The Surveyor asked, Did you eat dinner last night? Resident #20 stated, No, I got a sandwich and took one bite of it. It was not good, and the meat was all red and blue and looked wrong. The surveyor asked, Did you get a pimento sandwich on your supper tray last night? Resident #20 stated, No. Resident #20 took a foil wrapped sandwich from the bedside table and stated, Look, I saved it. Would you want to eat this? d. On 08/17/23 at 2:40 PM, the Surveyor asked Dietary Employee (DE) #3, Can you tell me what was on [Resident #20's] supper tray last night, and on 08/15/23? DE #3 replied, A tuna fish sandwich, chicken noodle soup, and pudding. I wasn't here last night, but I can get the person that was for you. The Surveyor asked, Was there a pimento cheese sandwich on the super tray on 08/15/23? DE #3 stated, We are out of pimento cheese, but we just ordered it. The Surveyor asked, Do you ever go out and talk to the residents about their food preferences? DE #3 stated, I have a few times but not specifically [Resident #20]. I know she likes souse. [Resident #20] requested we include a souse sandwich every night if we have it. The Surveyor asked if there is a change in a resident's diet, how is the kitchen made aware. DE #3 replied, We get an order from the Director of Nursing (DON) or the nurse. The Surveyor asked if the physician made a change to a resident's diet how is the kitchen informed. DE #3 stated, An order is brought to the kitchen. e. On 08/17/23 at 2:44 PM, the Surveyor asked DE #5, Are you familiar with [Resident #20]? DE #5 replied, No. The Surveyor asked, Can you tell me what was on [Resident #20's] supper tray last night? DE #5 stated A burger and french fries. The Surveyor asked, Was there a pimento cheese sandwich on the supper tray last night? DE #5 stated, No. The Surveyor asked, Was there any kind of sandwich on [Resident #20's] supper tray last night? DE #5 stated, No. The Surveyor asked, Do you ever go out and talk to the residents about their food preferences? DE #5 stated, Only the dining room, we don't go down to the 700 Hall. I don't even know what [Resident #20] looks like. The Surveyor asked if there is a change in a resident's diet, how is the kitchen made aware. DE #5 stated, One of the Certified Nurse Aids [CNAs] tell us. The Surveyor asked if the Physician makes a change to a resident's diet how is the kitchen informed. DE #5 stated, On a card. f. On 08/17/23 at 2:56 PM, Resident #20's dietary meal card documented, .Likes .Breakfast: eggs, cereal, sausage, bacon, muffin .Lunch: chicken, pork chops, hamburger .Dinner: potatoes, green beans, cabbage, fruit . No dislikes were noted on the dietary card. g. On 08/17/23 at 2:58 PM, the Surveyor asked DE #5, Are you aware if [Resident #20] has any dislikes? DE #5 stated, No, we never hear about any dislikes because they never bring it to the kitchen. h. On 08/18/23 at 10:05 AM, the Surveyor asked the Dietary Supervisor in Training, Have you seen a physicians order for a pimento cheese sandwich to be added to [Resident #20's] supper plate every night? He stated, No, I haven't. The Surveyor asked, How does the kitchen receive diet orders? He stated, The DON brings the diet orders, we get slips. We don't get the physician's orders. The Surveyor asked who lets dietary know the resident's likes and dislikes. He stated, The Certified Nurses Assistants [CNAs] or the DON. i. On 08/18/23 at 10:23 AM, the Surveyor asked the DON, how dietary was notified of a new or changed dietary order. The DON stated, We use a form that is printed and taken to dietary. Every month they get a report for diets, enhanced meals or snacks, and nighttime snacks. If there is a change, they get a dietary slip. j. On 08/18/23 at 10:35 AM, the Surveyor asked the DON, Do you have a diet slip for the pimento cheese sandwich for [Resident #20]? The DON stated, That is before my time. k. On 08/18/23 at 10:45 AM, the Surveyor asked the Dietary Supervisor in Training, Do you have a dietary slip for [Resident #20]? He stated, I'm not sure we save them. When they send them down, we make changes to the dietary card. l. On 08/18/23 at 10:49 AM, the Dietary Supervisor in Training showed the Surveyor, Resident #20 ' s dietary card documenting, .Please don ' t give Tuna fish Please give pimento cheese sandwich with supper tray .

Based on observation, record review, and interview, the facility failed to ensure hot foods were served hot and cold foods were served cold to maintain palatability and encourage adequate nutritional intake for 1 of 1 meal observed. The findings are: 1. On 08/15/23 at 7:30 AM, an unheated food cart that contained 4 trays for the breakfast meal was in the kitchenette area in the Dining Room. The Surveyor asked the Dietary Supervisor how long the food cart had been out. She stated, It was sent out at 7:20 AM. At 7:43 AM, Certified Nursing Assistant (CNA) #1 removed a tray from the food cart to be delivered to the resident. The Surveyor asked the Dietary Supervisor to check the temperatures of the food items on the tray. She did and stated: a. Milk - 47 degrees Fahrenheit. b. Oatmeal - 102 degrees Fahrenheit, c. Scrambled eggs - 98.5 degrees Fahrenheit. d. Pureed sausage - 96.8 degrees Fahrenheit. 2. On 08/15/23 at 7:48 AM, the Surveyor asked Resident #11 if his breakfast meal was hot, warm, or cold. He stated, The oatmeal is cold.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 2 residents who received pureed diets and 2 residents who received pureed meat only, as documented on the list provided by the Dietary Supervisor on 08/15/23 The findings are: 1. On 08/14/23 at 11:56 AM, the following observations were made on the steam table: a. A pan of pureed ham, the consistency of the pureed ham was lumpy and was not smooth. b. A pan of pureed peas, the consistency of the pureed peas was gritty and was not smooth. c. A pan of pureed bread with milk, the consistency was sticky and thick. 2. On 08/15/23 at 7:50 AM, the pureed sausage served to the residents on a pureed diet was gritty and not smooth. There were pieces of meat visible in the mixture. The Surveyor asked Certified Nursing Assistant (CNA) #1 to describe the consistency of the sausage served to the residents who required pureed diets. She stated, It was gritty. a. On 08/13/23 at 7:51 AM, the Surveyor asked CNA #2 to describe the consistency of the pureed sausage. She stated, It was gritty.

Based on observation and interview, the facility failed to ensure foods stored in the dry storage area, refrigerator, and freezer were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; and 2 of 2 ice machines were maintained in clean and sanitary condition to prevent contamination of airborne particles. These failed practices had the potential to affect 42 residents who received meals from the kitchen, as documented on a list provided by the Assistant Dietary Supervisor on [DATE] at 2:37 PM. The findings are: 1. On [DATE] at 10: 27 AM, the following observations were made in the kitchen: a. An opened box of iodized salt was on the counter. The box was not covered. b. An opened 8 pound bag of powdered sugar was on the counter. The bag was not sealed. c. An opened 24 ounce bottle of grape jam was on the counter. The manufacture specification on the bottle, documented, Refrigerate after opening. d. An open bag of bread was on the counter. The bag was not sealed. 2. On [DATE] at 10:29 AM, Dietary Employee (DE) #1 was wearing gloves on her hands when she pushed a cart that contained trays with dessert towards the refrigerator. She lifted the trash can lid and threw away tissue paper. Without changing gloves and washing her hands, she used her contaminated gloved hand to pick up paper bowls to be used in serving dessert and placed them on the counter with her gloved fingers inside of them. At 10:30 AM, she picked up a slice of hummingbird cake to place in a bowl. The surveyor immediately asked her what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 3. On [DATE] at 10:31 AM, a pan liner used to line the inside of the ice scoop holder had gray/brown residue on it. The Surveyor asked the Dietary Supervisor in Training to describe what was observed on the liner where ice scoop was resting in direct contact with residue. He stated, It was gray/brown dirt. The Surveyor asked how often you clean it. He stated, They are supposed to clean it daily. 4. On [DATE] at 10:32 AM, the back wall interior surfaces of the ice machine in the kitchen had an accumulation of black/brown residue on it. The Surveyor asked the Dietary Supervisor in training to wipe the black/brown residue. He did so, and the black/brown residue easily transferred to the tissue. The Surveyor asked the Dietary Supervisor in training, How often do you clean the ice machine and who uses the ice from the ice machine? He stated, We clean it weekly. We did not see that area when we cleaned it At 1:06 PM, the Surveyor asked the Dietary Supervisor who uses the ice from the ice machine. She stated, The CNAs use it to fill beverages served to the residents at meals. 5. On [DATE] at 10:44 AM, DE #1 was wearing gloves on her hands when she opened the refrigerator and removed a bottle of diet green tea and placed it on the counter, contaminating the gloves. Without changing gloves and washing her hands. She started to pick up slices of cake and place in a bowl to be served to the residents for lunch. The Surveyor immediately asked her what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have removed the gloves and washed my hands. 6. On [DATE] at 10:46 AM, the following observations were made in the 3 door freezer: a. A 3 gallon container of vanilla ice cream was on a shelf. The lid was partially off. There was an ice scoop on top of the ice cream. The Surveyor asked the Dietary Supervisor in training to describe the appearance of the ice cream. He stated, It is refrozen ice cream. That should have been thrown away. b. A box of vanilla ice cream was in the freezer. The ice cream had ice cycles on it. The Surveyor asked the Dietary Supervisor in training to describe the appearance of the ice cream. He stated, It was refrozen and has ice cycles on it. 7. On [DATE] at 10:49 AM, the following observations were made in the refrigerator: a. A half-gallon of Bulgarian style cultured butter milk was on a shelf. The container documented, Best if used [DATE]. b. A container of whipping cream was on a shelf had an expiration date of [DATE]. c. A 24 ounce container of cottage cheese was on a shelf and had an expiration date of [DATE]. d. An opened ziplock bag of cheese slices was on a shelf in the refrigerator. The bag was not sealed. 8. On [DATE] at 11:03 AM, a box of buttery spread that contained 113 butter cups was on a shelf. The box documented, Best by [DATE]. 9. On [DATE] at 11:11 AM, an opened box of bread sticks was on a shelf in the freezer. The box was not covered or sealed. 10. On [DATE] at 11:19 AM, four 5-pound bags of grits were on a shelf in the storage room. The bags had an expiration date of [DATE]. 11. On [DATE] at 11:33 AM, the following observations were made in the walk-in refrigerator: a. Four half gallons of buttermilk was in a milk crate with an expiration date of [DATE]. b. A 5 pound container of tuna salad was on a shelf, the container had an expiration date of [DATE]. c. A 5 pound container of cottage cheese was on a shelf, the container had an expiration date of [DATE]. d. Eight 32 ounce boxes of whipping cream was in a box on a shelf. The boxes documented, Best if used by [DATE]. e. A bag of shredded slaw was on a shelf in the refrigerator, the box had no received date on it. f. Two 8 pound containers of classic regular potato salad were in a box on a shelf. The boxes had an expiration date of [DATE]. 12. On [DATE] at 11:59 AM, DE #3 was wearing gloves on her hands when she pushed a cart that contained bowls of dessert close to the steam table, contaminating the gloves. At 12:03 PM, without changing gloves and washing her hands, she picked up slices of humming bird cake with her contaminated gloved hands and placed them on the tray compartments to be served to the residents for lunch. 13. On [DATE] at 1:05 PM, the interior surfaces of the ice machine located in the ice room on the 200 Hall had an accumulation of gray/brown residue on the back and sides. The Surveyor asked the Dietary Supervisor to wipe the gray/brown residue. She did so, and a black residue easily transferred to the tissue. The Surveyor asked the Dietary Supervisor, How often do you clean the ice machine and who uses the ice from the ice machine? The Dietary Supervisor stated, CNA's use it. The CNAs use it for the water pitchers in the residents' rooms. I think the Maintenance Man. 14. On [DATE] at 2:11 PM, the Maintenance Man stated, The storage service company cleans it 3 times every year. I will start cleaning it every week. 15. On [DATE] at 11:59 AM, DE #2 turned on the 3-compartment sink faucet and rinsed a spatula. She then turned off the faucet. Without washing her hands, she placed gloves on her hands contaminating the gloves. She picked up a clean blade and attached it to the base of the blender. When she was ready to pour peas into the blender to puree, the Surveyor immediately asked her what she should have done after using a tissue paper that you had used to dry your hands to wipe your face. She stated, I should have removed the gloves and washed my hands.

Complaint # (AR 782) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to prevent elopement, as evidenced by failure to ensure staff monitored residents at risk for elopement more closely during periods when visitors were frequently entering and exiting the facility, as per the plan of care; failure to ensure door alarms and keypads were consistently monitored and maintained in proper working order; and failure to ensure all staff responsible for care and monitoring of residents at risk for elopement were aware of the frequency at which the residents' whereabouts should be observed to prevent elopement for 1 (Resident #1) of 5 (Residents #1, #2, #3, #4, and #5) case mix residents who were at-risk for elopement. The failed practices resulted in Immediate Jeopardy (removed), which caused or could have caused serious harm, injury or death to Resident #1, who exhibited frequent exit-seeking behaviors, left the facility unnoticed by staff on 7/14/18, and was found approximately 0.8 miles from the facility. The failed practices also had the potential to cause more than minimal harm to 5 other residents who were at-risk for elopement, according to a list provided by the Director of Nursing (DON) on 7/20/18 at 8:30 a.m. The facility removed the Immediate Jeopardy on 7/14/18, prior to the survey entrance date; however, related deficient practices remained at the time of the survey. The Administrator was informed of the Immediate Jeopardy condition on 7/19/18 at 5:20 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/16/18 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), and was independent with most activities of daily living. a. The Certified Nursing Assistant Care Plan (not dated) documented, .Elopement Risk . b. A Nurse's Note dated 5/3/18 at 1:00 p.m. documented, .Resident admitted from hospital to this room . c. A Nurse's Note dated 5/4/18 at 6:30 p.m. and written by Licensed Practical Nurse (LPN) #1 documented, .Resting on low bed with safety mats in place. Up for supper this p.m. (evening). Amb (ambulates) ad lib (as desired), but monitored closely per staff due to elopement risk . d. The Plan of Care dated 5/16/18 documented, .Elopement Risk . Monitor resident for tailgating when visitors are in the building . Use verbal and if necessary physical cues for redirection to persuade exit seeking behaviors . Use diversional activities when exit seeking behavior is occurring . Provide direct staff supervision for resident when attending an out-of-facility activity. e. A Nurse's Note dated 6/5/18 at 10:00 a.m. documented, .Resident at entrance door asking how to leave. Attempt to redirect with difficulty . f. A Nurse's Note dated 6/6/18 at 9:00 a.m. documented, .Resident attempting to leave facility, very angry. Very difficult to redirect. Stomping down hall . 12:30 p.m. Res angrily ambulating stating, 'How do you leave this place?' Very difficult to redirect . MD (Medical Doctor) contacted. NO (New Order) received for Senior Care referral. Senior Care contacted, res (Resident) accepted and transferred to facility . g. A Nurse's Note dated 6/13/18 at 11:00 a.m. documented, .Res (Resident) readmitted to facility. No N.O. (new orders) . h. A Nurse's Note dated 6/24/18 at 8:40 a.m. documented, .Patient ambulating hallway attempting to elope (stating) 'I'm going to work on the cars.' Pulling at doors. [MEDICATION NAME] 0.5 mg (milligrams) offered but refused. Patient states, 'You take it.' Not redirectable. Assist back to room. Remains argumentative. Will continue to monitor for safety and behaviors . i. A Nurse's Note dated 7/14/18 at 8:15 p.m. and written by LPN #1 documented, .Resident resting in bed with eyes closed at present time with no complaints voiced. Water at bedside, call light in reach. 8:45 p.m.Received call from former employee that she saw what looked like one of our residents walking on (Street Name) Road. Bed check done immediately with resident noted to be gone from his room. Gathered staff and sent vans out to look for resident. Call placed to (Police Department) to report missing resident and informed at such time that they had resident in custody at (High School) where they found him walking at approximately 8:45 p.m. and they would hold resident there until the (facility) van arrived. 9:20 p.m. Resident arrived back at (facility) with (LPN #2) at this time. Body audit revealed no skin tears, bruises, or abrasions. Resident incontinent of bowels with peri care given at this time . j. An Office of Long Term Care (OLTC), Division of Medical Services (DMS) form 7734 dated 7/14/18 documented, .On 7/14/18, bed check done at 8:15 p.m. with resident in bed resting. Bed check done at 8:45 p.m., resident not in bed. Staff immediately began search. Called (Police Department), informed police had resident. Resident returned to facility. No s/s (signs / symptoms) injury noted . k. A Police Report dated 7/16/18 documented, .On (MONTH) 14, (YEAR) a resident from (facility) (Resident #1), left the facility without permission. (Police Officers) located the subject on (street) and an employee from (facility) came and picked him up without incident . l. On 7/19/18 at 8:30 a.m., according to Google maps, the location where the resident was found on the night of 7/14/18 was 0.8 miles from the facility. m. On 7/19/18 at 12:00 p.m., LPN #2 was asked to explain what she remembered about the incident on 7/14/18. She stated, I was on the 700 Hall. (LPN #1) called me and said the police had (Resident #1) and it was on (Street Name) Road. I'm the one who brought him back here. She was asked if the police had the resident at the school and stated, He was a little bit past the school, and there were three different police cars with him. He said, 'She knows me, and she can take me home.' He got in my car; I buckled him up and brought him back. She was asked if she was familiar with the resident prior to this incident and stated, I have never taken care of him before, but I knew him if I saw him. I knew he wandered a lot and that he had tried to get out one time, but I wasn't familiar with him. I had not seen him at all that evening, but that's not unusual. She was asked if she knew how he got out of the building that evening and stated, I'm not aware if they figured out how he left. n. On 7/19/18 at 12:26 p.m., the Maintenance Director was asked what he remembered about the incident on 7/14/18 and stated, (LPN #2) called me and had me to come check the exit doors around 10:00 p.m. I didn't find any that had a problem, so I don't know how he got out. The fire alarm didn't go off, no doors were signaling, and they were all closed. He was asked if all of the exit doors had keypads that required codes to open and stated, Nearly every door is coded. This one here close to you is coded, but you can go out it, but an alarm will sound. He was asked if it was possible the resident went out a window and stated, I doubt it. Ninety percent of them have screens and they're pretty high up. He was asked if he checked the windows that night and, after pause, stated, Uh, yes. I didn't find any open windows. He was asked if the facility used the wander guard system and stated, No. They don't have that here. He was asked how often he checked the doors and stated, Once every day. He was asked if he documented this anywhere, such as on a log. He stated, Yes. He was asked to provide the log and stated, Since he got out, I've started documenting it. He was asked, what about before the resident eloped? He stated, No. The Maintenance Director provided a copy of the log documenting the door alarm checks every day. He was asked how he checked the doors. He stated, I hold the doors open to make sure they alarm. The surveyor informed him she had not heard any door alarms go off all morning. He stated, Not all alarms can be heard all over the building. He was asked, the door alarm check log documented you checked the doors every day except 7/15/18. He stated, I don't work on Sundays. o. On 7/19/18 at 1:05 p.m., the exit doors of the facility were checked by the surveyor and Maintenance Supervisor. One door on the 500 Hall had a key pad that required entry of a code to open the door. The Maintenance Supervisor punched in the code and opened the door. He held the door open waiting for the alarm to sound; however, it did not. He closed the door and then was able to open the door again without re-entering the code. No alarm sounded. The Maintenance Supervisor reached up, dusted off the magnet, and bumped the sensor. The alarm then started working. He was asked when he last checked the door and stated, I checked it yesterday and today, and it was working. p. On 7/19/18 at 2:24 p.m., Certified Nursing Assistant (CNA) #2 was asked about the incident on 7/14/18 and stated, I was working 400 Hall. I came back from my lunch break, and the transport aide was about to walk out, and I asked her where she was going, and she said (Resident #1) had got (sic) out. That's the first I had heard. She was asked if she was familiar with the resident before the incident and stated, Yes. I had worked with him before. She was asked if she knew he was at-risk for elopement prior to the incident and stated, Yes. She was asked how often residents who were at-risk for elopement were monitored and stated, I check them a little more often than everyone else. We had not been given a certain time frame, but since the incident, we were told to check on them every 15 minutes. She was asked how the resident got out that evening and stated, I don't know. There was a family with a new resident on 500 Hall that evening, so he may have gotten out that way. They were moving stuff in and out. I know when I was getting ready to leave for my lunch break, they were here then. She was asked if the residents who were at-risk for elopement were monitored more closely during the time the new resident's family was going in and out the 500 Hall door and stated, No. q. On 7/19/18 at 2:46 p.m., CNA #1 was asked about the incident on 7/14/18 and stated, That was my first day here. They were walking me around the building, and I met him. And they told me about the yellow sign, and to keep a check on him because he wanders. I saw him in the bed at 8:15 p.m. He didn't have a shirt on. I was headed to lunch. She was asked which hall she was working that evening and stated, I was working his hall with another CNA. When I came back from lunch, they were looking for him. She was asked if she knew how the resident got out that evening and stated, On our hall, we had some people bringing in chairs and a TV, and the alarm was going off, so I bet he walked right out, and they didn't know he wasn't supposed to. A family was bringing stuff in for another resident on the hall. I remember going down there twice and shutting the alarm off, because it goes off if you hold the door open too long. She was asked how the resident was when he came back and stated, He said, 'I made it back!' I asked him, 'how did you get out?' He said, 'The door was open, so I just walked right out.' r. On 7/19/18 at 3:03 p.m., LPN #1 was asked about the incident on 7/14/18 and stated, It was a typical evening. I had seen him about 8:15 p.m. He was in bed. Then I got a phone call from a lady who used to work here. I immediately thought about him. I went, and he was not in his room. She told me about where she had seen him, so we got the van to go look for him. I called the police department, and they said they had him. She was asked if she knew that the resident was at-risk for elopement prior to the incident and stated, Yes. She was asked if she had any idea how he got out that evening and stated, I don't know. He wouldn't have known the code. She was asked if there were visitors that evening and stated, We have visitors a lot on the weekends. She was asked what interventions the facility had implemented since the incident to prevent recurrences and stated, Before the incident, we just tried to watch them real close and redirect. Since the incident, we make sure and keep an extra watch on them. She was asked if there were any new interventions to prevent recurrence, since those two statements essentially meant the same thing. She stated, Just extra monitoring. She was asked how frequently the at-risk residents were being monitored and stated, I would say every 30 minutes. She was asked if she had been in-serviced and stated, Yes. The Social Worker was going around talking to everybody. She was asked if Social spoke with her and stated, Yes she did. She was asked if the Social Worker in-serviced her on how often the residents who were at-risk for elopement were to be monitored. She did not answer. She was asked if she remembered being told that the residents at-risk for elopement were to be checked every 15 minutes and stated, I thought it was every 30 minutes. She was asked if she had worked any shifts since the incident on 7/14/18 (Saturday) and stated, I worked Sunday, Tuesday, Wednesday and today. On 7/19/18 at 5:35 p.m., the Social Director was asked if she told all the staff that she had in-serviced how often to check on the residents who are at-risk for elopement. She stated, Yes. Every 15 minutes. s. On 7/19/18 at 4:04 p.m., the Director of Nursing (DON) was asked how the facility monitored the effectiveness of their in-services and stated, Tomorrow, we were going to do that at a mass in-service. We are still in our investigative time frame. She was asked if it was determined how the resident got out of the building that evening and stated, No. t. The facility removed the immediate jeopardy and decreased the scope / severity to E on 7/14/18, prior to the survey entrance, as evidenced by the following: 1.) A Nurse's Note dated 7/14/18 at 8:15 p.m. and written by LPN #1 documented, .9:25 p.m. Call placed to Sr. (Senior) Care to see if they could take resident (Resident #1) on emergency basis . 9:35 p.m. Received return call from (nurse) at Sr. Care who stated that (physician) said resident could be admitted to Sr. Care . 10:00 p.m.Resident taken to (emergency room ) at this time per CNAs x (times) 2 . 2.) The Office of Long Term Care (OLTC), Division of Medical Services (DMS) form 7734 dated 7/14/18 documented, .Q15 (every 15) minute checks initiated on all at-risk residents. In-service conducted with all staff per shift . 3.) On 7/19/18 at 10:00 a.m., the Administrator provided documentation of the following facility interventions: i.) .7/14/18 - Initiated every 15 minute checks on all at-risk residents; DON (Director of Nursing) / ADON (Assistant Director of Nursing) ensured all at-risk residents had proper visual alerts posted outside of rooms; Maintenance supervisor ensured all exit alarms were functioning properly . ii.) 7/15/18 - In-serviced staff per shift regarding monitoring and identifying at-risk residents and increased monitoring of exit doors, alarms and resident supervision; Administrator notified all QA (Quality Assurance) members, and QA Committee will monitor at-risk residents, exit doors, and alarms. Any negative findings will be reported to DON / Admin (Administrator) immediately for corrective action . iii.) 7/16/18 - Contacted mural artist (exit / diversion mural) to paint exit doors while maintaining proper identification for emergency purposes; Administrative staff in process of revising admission criteria for at-risk for elopement residents . 4.) On 7/19/18 at 12:00 p.m., LPN #2 was asked how the facility had intervened to prevent recurrences since the incident and stated, We initiated Q15 minute checks for those at-risk. Everybody was in-serviced. The big yellow bird signs for flight-risk are on the doors, but those have been there ever since I came . 5.) On 7/19/18 at 1:50 p.m., the Maintenance Supervisor provided a Daily Check List of the exit doors in the facility. The documentation on the Daily Check List indicated he had checked all exit doors once a day on 7/16/18, 7/17/18, 7/18/18 and 7/19/19. He was asked why the doors were not checked on 7/15/18, the day after the resident eloped, and stated, I don't work on Sundays.

Based on observation, record review and interview, the facility failed to ensure nutritional needs were promptly assessed, nutritional parameters were monitored, actual weight loss was promptly identified, and interventions evaluated for effectiveness to prevent further weight loss for 1 (Resident #2) of 3 case mix residents (Residents #2, 3 and 4) who were at nutritional risk or had experienced weight loss. The failed practices resulted in a pattern of actual harm for Resident #2 who experienced a severe weight loss within the past 30 days and had the potential to cause more than minimal harm for 15 residents who were at risk for weight loss as identified by the Director of Nurses (DON) on 1/21/11 at 1:03 p.m. The findings are: 1. A Policy and Procedure titled Weight Assessment and Intervention received from LPN #2 on 1/20/11 at 9:14 a.m. documented: " Policy: All resident weights will be monitored monthly and more often as indicated by the resident ' s condition, physicans orders, etc. Procedure: ...2. The charge nurse will notify the Dietary Manager by the last day of the month of weight variances. 3. Weight variance - Calculate weight loss or gain every time a Resident is weighed. Significant weight variance must be brought to the attention of the consulting Dietitian. ... 5. The Physician will be called by the charge nurse within 48 hours each month regarding weight variances problem situations. ... " 2. Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 11/19/10 documented the resident had severely impaired cognitive skills for daily decision making, required total assistance with meals, had no swallowing problems, weight was 176, nutritional approaches included a feeding tube, a mechanically altered theraupeutic diet and 51% or more of the residents total calories was received through tube feeding. a. The Nutritional assessment dated [DATE] and signed by the Registered Dietitian (RD) documented the resident required 2085 calories per day and 96 grams of protein. b. The November 2010 Physicians Orders sheet documented, " Glucerna 1.2 infuse per pump via PEG Tube (at) 100 cc (cubic centimeter) / HR (hour) x 12 hours with total Cal (calories) per PEG Tube x 24 HRs = 1440 Cal. Give (at) ON 6 AM, OFF 6 PM ...11/19/10 Diet: Regular MT Puree RCS (restricted concentrated sweets) assist as needed. ...Glucerna MT 1 can TID (three times per day) (with) meals. " c. The Dietary Progress Notes dated 11/19/10 documented, "Back from the hospital today - Tube feeding continuous Glucerna 1.2 100 cc/hr (cubic centimeters per hour) x 12 hours. Has order for Reg (Regular) Pureed RCS Diet Glucerna 1 can po (by mouth) TID (three times daily) (with)meals - Cont. (continue) with new approaches. " d. The Care Plan dated 12/2/10 documented, " Problem: Nutrition ...at risk for poor nutritional status she receive a regular diet pureed RCS assist as needed. ...Weigh and monitor results monthly and PRN (as needed). Monitor and report to the physician: Signs/symptoms of [MEDICAL CONDITION] significant weight loss chewing/swallowing problems. Administer nutritional support as ordered (see current physician order/MAR): Supplements: Mechanically altered diet: Tube Feeding. Provide/monitor intake of diet/fluids allow adequate time to eat. Report to nurse any s/s (signs and symptoms) chewing/swallowing or other problems consuming meals. Glucerna TID with meals. " e. The November 2010 (from 11/9 - 30/2010) and the December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" The MARs documented the formula was administered daily as ordered. The MARs also documented, " Diet Reg Pureed RCS assist as needed. ..Glucerna (one) can TID. " The MARs documented no oral intake for breakfast, lunch or dinner and no oral intake of the glucerna as indicated by an initial and zero %. f. On 1/21/11 at 12:30 p.m., LPN #1 stated that the resident had [DIAGNOSES REDACTED] and diarrhea a lot from admission (11/8/10) through December and "we were aware that her nutrition was not met." On 1/21/11 at 12:30 p.m., LPN #2 stated, "She (resident) had diarrhea several times and we knew it caused a (weight) loss. When asked what was done about it, she stated I have put interventions in place for residents who don't eat a certain amount of meals prior to the RDs visit. g. On 1/21/11 at 1:30 p.m., the Infection Control Log for the month of December, 2010 documented the resident was treated for [REDACTED]. h. Nurses Notes dated 12/23/10 at 10:45 a.m. documented new treatment orders for, "2 cm x 1-1/2 cm unstageable pressure area to Lt. (left) heel ..." The Skin Assessment sheets dated 12/27/10 and 1/3/11 documented, "unstageable to L (left) heel ..." i. The Dietary Progress Notes for December, 2010 and January, 2011 documented the following: 12/16/10 : "No Dec. (December) wt. (weight) available. Cont. (Continue) to receive RCS Pureed Glucerna 1 can w/ each meal and tube fed Glucerna 1.2 100cc/hr x 12 hrs. Water 30-60cc before and after meds and feedings and 250 cc q (every) shift--will follow up as needed." 1/20/11: "(January) Wt. (Weight) 150, Dec.173, Nov.(November) 176 down 15% in 2 mo.(months) down 15% in 1 month. (Receive) tx (treatment) to L (left) heel unstageable decub(decubitus) ...Po intake is very poor. Dietary Consult 1-19-11 Glucerna 1.2 increase 120cc/hr x12 hours and provide liquid protein BID (twice daily)-added from Glucerna 1.2, 288 cal (calories) 14 gms (grams) protein ...Provide 120 cal and 30 gms protein - Totals 1848 calories, 114 gms protein ...Est (estimated) needs: 2050 calories, protein 105 gm... Increase feeding time to 14 hours - 120 cc/h x 14 hrs = 1680 cc/2016 calories and protein 101gm Cont. (continue) [MEDICATION NAME], vit.C..." (As of 1/19/11 the resident received Glucerna 1.2 at 100 ccs for 12 hours for a total of 1440 calories and 72.9 gms protein. The MARS documented the resident did not consume meals or Glucerna supplement as ordered by physician. Caloric needs requirement were 2448 with 1.2 injury factor (unstageable pressure sore onset 12/23/10) with needs assessment at 2448 until 1/19/11.) j. On 1/20/11 at 1:30 p.m., the RD was asked if she had been informed of the significant weight changes and the need for a consult. She stated LPN #2 or a nurse would inform her of weight changes but no one had called for a significant weight loss." k. On 1/19/11 the following meal services were observed: At 7:40 a.m., the resident was served pureed sausage and biscuit, pureed oatmeal, pureed scrambled egg, 1 pat margarine, 8 ounces (ozs) of water, 8 ozs of whole milk, 4 ozs of grape juice and (1)-8 oz can of 1.2 Glucerna. The resident ate 0 per cent of the food and beverages. At 12:18 p.m., the resident was served pureed ham, pureed white beans, pureed okra, pureed bread, applesauce, 8 ozs of water, 12 ozs of orange kool-aid and (1)-8 oz can of Glucerna shake. The resident ate 0 per cent of the food and beverages. At 12:35 p.m., Certified Nurse Assistant (CNA) #1 who assisted the resident stated, "She never eats anything" as she put the resident's tray on the return cart. l. The January 2011 MAR (from January 1 thru 19) documented, " 11/9/10 Glucerna 1.2 infusing per pump via PEG tube at 100 cc (per) hr (hour) x 12 hrs with total cal on (at) 6 p.m., off (at) 6 a.m. " The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. ...Glucerna (one) can TID. " The MAR indicated [REDACTED]. m. On 1/19/11 at 3:00 p.m., the facility ' s weight record documented the following weights (the form only documented the year and month): November 2010 weight: 176 lbs (pounds) December 2010 weight: 173 lbs January 2011 weight: 150 lbs This was a 13.29 percent weight loss in 1 month from 173 pounds in December 2010 to 150 pounds January 2011. n. On 1/19/11 at 12:35 p.m., Licensed Practical Nurse #1 (LPN) was asked who was responsible for weighing residents. He stated that he weighed residents with an aide on the Friday or Monday before the third Tuesday of the month before the doctor visited. o. A Physician telephone order received from the Director of Nursing on 1/21/10 at 11:26 p.m. documented, " 1/19/11 (no time) 1: (Increase glucerna 1.2 to 120 cc/hr x 12 (hrs) 1728 calories. 2: provide sugar free protein 15 grams per tube BID (two times per day) to (increase) protein intake. " p. On 1/21/11 at 3:06 p.m., the Administrator was asked how the facility monitored the effectiveness of the RD recommendations? She stated, "Nothing, getting orders, putting them in place." When asked how they follow up on recommendations, she stated the RD turns her reports into the Administrator and DON, "I depend on her (RD)." The Administrator also stated the calculated needs for the resident were in the resident's charts, not on the reports.