Every finding on record at Des Arc Nursing and Rehabilitation Center

Number of residents sampled: Number of residents cited: Based on facility policy and document review, observations, and interviews the facility failed to ensure staff performed hand hygiene during medication administration to prevent the spread of infection and cross contamination. This failed practice had the potential to spread infection to five (Resident #2, #62, #64, #44, and #28) of eight residents observed during medication administration. The findings include: During an observation of the evening medication administration by Licensed Practical Nurse (LPN #1) on 07/22/2026 the following were observed: At 4:19 PM, this surveyor observed that LPN #1 did not perform hand hygiene before medication administration to Resident #2. After Resident #2's medication was administered by LPN #1, LPN #1 pulled the next residents' medications from the medicine cart without performing hand hygiene. The medications observed during this administration were: a pain/fever reducer, nerve pain medication, iron supplement, seizure medication, and allergy nasal spray. At 4:28 PM, this surveyor observed that LPN #1 did not perform hand hygiene before medication administration to Resident #62. After Resident #62's medication was administered by LPN #1, LPN #1 pulled the next residents' medications from the medicine cart without performing hand hygiene. The medication observed during this administration were: nerve pain medication. At 4:31 PM, this surveyor observed that LPN #1 did not perform hand hygiene before medication administration to Resident #64. After Resident #64's medication was administered by LPN #1, LPN #1 pulled the next residents' medications from the medicine cart without performing hand hygiene. The medications observed during this administration were: an alpha blocker and a nerve pain medication. At 4:33 PM, LPN #1 did not perform hand hygiene after leaving resident #64 prior to preparing Resident #44's medications before medication administration to Resident #44. The surveyor observed Resident #44 holding the medication cup to their mouth, but the resident was unable to get the pills into their mouth. LPN #1 then assisted Resident #44 with taking the medication by placing the medicine cup to Resident #44's mouth with LPN #1 holding the medication cup. LPN#1 did not perform hand hygiene after touching Resident #44's medication cup before she pulled medication from the cart for the next resident's medication administration. Medications observed during the administration were: a medication to treat the symptoms of Parkinson's disease and a stool softener. On 07/22/2026 at 4:37 PM, LPN #1 did not perform hand hygiene before medication administration to Resident #28. LPN #1 was observed leaving Resident #28's room, lifting the hallway trash can lid and placing the resident's medication cup and water cup in the trash. LPN #1 did not perform hand hygiene after the trash disposal and before pulling the next residents' medications from the medicine cart. The medications observed during this administration were: a stool softener, probiotic, and a pain/fever reducer medication.This surveyor noted that throughout the remainder of medication administration and preparation LPN #1 did not perform hand hygiene before or after giving medications to the remaining residents during the evening medication pass. A review of Resident #2's admission Record revealed, Resident #2 had diagnoses which included: cerebral infarction, immunodeficiency, chronic kidney disease stage-3, major depressive disorder, type-2 diabetes mellitus with neuropathy, pain, and osteoarthritis. A review of Resident #62's admission Record revealed, Resident #62 had diagnoses which included: major depressive disorder, cardiomegaly, chronic pain, neuropathy, hypertension, atrial fibrillation, and congestive heart failure. A review of Resident #64's admission Record revealed, Resident #64 had diagnoses which included: major depression, hypertension, allergic rhinitis, heart failure, bipolar disorder, pain, and panic disorder. A review of Resident # 44's admission Record revealed, Resident #44 had diagnoses which included: gout, type-2 diabetes mellitus, pulmonary fibrosis (lung disease), Parkinson's disease, pain, and hypertension. A review of Resident #28's admission Record, revealed, Resident #28 had diagnoses which included: Parkinson's disease, major depressive disorder, hypertension, nonrheumatic aortic stenosis with insufficiency (narrowing of the aortic valve), low back pain, chronic kidney disease, cardiac murmur, and weakness. During an interview on 07/22/2026 at 5:05 PM, LPN #1 stated she should have performed hand hygiene before and after entering a resident's room and by not performing hand hygiene she could have spread bacteria by touching surfaces and the residents could get sick. LPN #1 stated, I should have performed hand hygiene and especially after touching the trash can. During an interview on 07/23/2026 at 10:24 AM, the Infection Preventionist Nurse (IPN) stated, Staff should perform hand hygiene before, after, and between each resident's medication administration. She stated they can either use the hand sanitizer on the walls or on their cart. The IPN stated when hand hygiene was not performed, it could be cross contamination and bacteria spreads. The IPN stated, if staff was not performing hand hygiene, she would do an in-service, education, checkoffs and discipline if it warranted it. During an interview on 07/23/2026 at 11:32 AM, LPN #2 stated if hand hygiene was not performed between residents the risk of disease transfer or infection would happen. LPN #2 stated during medication pass, hand hygiene should be performed before and after medication pass as well as washing with soap and water frequently. She stated, if she saw another nurse not performing hand hygiene, she would say something to them directly then report to the IPN. During an interview on 07/23/2026 at 12:39 PM, the Director of Nursing (DON) stated A nurse should perform hand hygiene before they pop out medication and between patients, if they touched anything, and if contaminated. The DON indicated that if staff were in an isolation room, soap and water should be used. The DON stated if a nurse touched a trash can to dispose of a prior residents' medication cup and water cup, he/she should perform hand hygiene before touching anything on the medication cart. The DON stated if hand hygiene was not performed, bacteria grows everywhere and we do not want to pass on illness to anyone else. The DON stated if a nurse did not perform hand hygiene, they would in-service that staff member, monitor them, and monitor the residents that could be affected. During an interview on 07/23/2026 at 1:16 PM, the Administrator stated, Hand hygiene during medication administration should be performed between each resident, before they pop out a resident's pills, after they give it, and before they start the next residents' medications. The Administrator stated, When the nurse touched the trash lid in the hall, she should have performed hand hygiene after touching the trash can, and before touching the medication cart because the nurse could spread germs or infections. A review of a facility in-service report titled, Hand Washing dated 12/15/2025, revealed staff should wash hands before caring for someone who is sick and after touching garbage. A review of a facility in-service titled, Infection Control dated 10/23/2025, revealed staff should perform hand hygiene before and after resident contact, after glove removal and after contact with bodily fluids. Staff is to follow standard precautions for everyone and practice proper hand hygiene every time. A review of a facility policy titled, Standard Precautions Infection Control dated 2022, revealed all staff are to assume that all residents are potentially infected or colonized with an organism that be transmitted during the course of providing resident care services. All staff shall adhere to Standard Precautions to prevent the spread of infection to resident, staff, and visitors. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub. During the delivery of resident care services, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. Standard Precautions Infection Control Protocol component of hand hygiene practices informs, after touching blood, body fluids, secretions, excretions, contaminated items; before and after removing personal protective equipment (PPE); between resident contacts; before meals and after using the restroom.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure the internal components of the ice machine were cleaned and the container for storing the ice scoop were cleaned when reviewed for safety and infection control to prevent waterborne illnesses. Findings include: On 01/16/2025 at 8:20 AM, the Administrator stated the facility did not have a policy for the ice machine. During an observation on 01/16/2025 at 8:00 AM, the Dietary Manager used a napkin to go around the edges inside the ice machine. Inside the ice machine was a metal border on the top portion of the machine. After wiping the metal plate, a black residue was noted to be on the napkin. After completing the ice machine, the ice scoop drawer was removed and inside the drawer was a pink/beige residue in the corners around the drawer. On 01/16/2025 at 8:05 AM, the Dietary Manager reported that the Maintenance Supervisor was responsible for cleaning the ice machine, and that the Dietary Department was responsible for washing the scoop holder. A review of the Ice Machine Cleaning Log on 01/16/2025, indicated that the ice machine had been wiped down to ensure there was no build up on the ice machine, and the hopper had been emptied out, and disinfected on 01/14/2025. During an interview on 01/16/2025 at 8:30 AM, the Dietary Manager confirmed that it was important for the ice machine to be cleaned because it could cause harm and make someone sick. The Dietary Manager then stated, we are going to shut it down and clean it. The Dietary Manager reported that the scoop drawer was on a cleaning schedule, but that there was no log for the cleaning to be recorded. During an interview on 01/16/2025 at 1:04 PM, the Maintenance Supervisor stated the ice machine was digital, and lets the facility know when it is time for it to be cleaned. The Maintenance Supervisor reported that even if the light was not on to indicate the ice machine needed cleaning, the ice machine was cleaned every two (2) weeks or monthly. The Maintenance Supervisor confirmed that the ice machine was descaled, and the ice machine hopper was emptied out every 2 weeks or as needed.

Based on observation, record review and interview, the facility failed to ensure call lights were placed in reach for resident's use and failed to ensure residents with functional limited range of motion call lights were placed in reach and accessible for use for 3 (Resident #27, Resident #35, and Resident #270) of 59 sampled residents. The findings are: 1. Review of the of Resident #27 ' s Admission Record reveal diagnoses of Alzheimer's disease and severe dementia with agitation. a. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/2024, indicated the resident had a Brief Interview for Mental Status (BIMS) of 00 which indicated severely impaired cognitive skills. b. On 01/13/2025 at 2:21PM this surveyor observed Resident #27 in bed. The call light was at the foot of the bed along the side of the wall. Resident #27 could not reach it. c. On 01/13/25 at 2:30 PM, Resident #27 was observed lying in bed with eyes closed. The call light was at the bottom of the bed along the side of the wall. The call light was not within reach of the resident. d. On 01/13/25 3:31 PM, Resident #27 was observed with the call light to be in the same location at the bottom of the bed along the side of the wall. The call light was not within reach of the resident. e. On 01/13/25 3:38 PM, during an interview, Certified Nursing Assistant (CNA) #1 was asked if the call light was in reach of Resident #27. CNA #1 confirmed the call light was not in Resident #27's reach, but it should have been. 2. Review of Resident #35 ' s Admission Record revealed diagnoses of severe dementia with agitation and anxiety disorder. f. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/01/24 indicated Resident #35 had a Brief Interview for Mental Status (BIMS) 00 which indicated the resident had impaired cognitive skills. g. On 01/13/25 at 2:32 PM, Resident #35 was observed lying in bed with eyes closed. The call light was located along the wall at the end of the resident's bed. The call light was not within the reach of the resident. h. On 01/13/25 at 3:39 PM, this surveyor observed CNA #2 reach back behind Resident 35's bed, pull the call light cord up, and clipped the cord on the blanket next to the resident. i. On 01/13/2025 at 4:00 PM, during an interview, Licensed Practical Nurse (LPN) #5 stated the call light should be placed within the resident's reach at all times. j. On 01/14/2025 at 9:00 AM, during an interview, the Director of Nursing (DON) stated the call light should always be placed within the resident's reach. k. On 01/16/2025, The DON stated there was no policy on placement of call lights. 3) A review of the Admission Record, indicated the facility admitted Resident #270 with diagnoses that included chronic obstructive pulmonary disease, acute and chronic respiratory failure, dysphagia, cognitive communication deficit, the need for assistance with personal care and quadriplegia. a. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/2024, revealed Resident #270 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact and had an impairment to one of the upper extremities and impairment to bilateral lower extremities. Resident #270 was using oxygen therapy and had non-invasive mechanical ventilator use. b. Review of Resident #270's Care Plan, initiated on 02/13/2024, revealed Resident #270's usual performance was weight bearing assist with Activities of Daily Living (ADL's). Interventions included: one (1) staff member to assist with bed mobility and Resident #270 used grab assist rails on bed for bed mobility. There was no indication in the current care plan of Resident #270's ability to use the call light. c. During an observation on 01/13/2024 at 11:35 AM, upon entering Resident #270's room, a therapist was noted to be leaving the room. Resident #270 was lying in bed with oxygen being delivered at four (4) liters per minute via nasal cannula. The call light for Resident #270's use was observed to be behind the lamp sitting on the nightstand and not within reach of Resident #270. d. During a concurrent observation and interview on 01/13/2024 at 11:37 AM, Registered Nurse (RN) #3 was asked to come into Resident #270's room and give the call light to the resident. RN #3 looked around and was unable to locate the call light button. This surveyor told RN #3 where the call light could be found. RN #3 then placed the call light in Resident #270's hand. RN #3 confirmed that the call light was not within reach of the resident while it was behind the lamp on the nightstand. e. During an interview on 01/14/25 at 10:00 AM, the Rehab Director was asked if the call light had been placed within reach of Resident #270 before leaving the room on 01/13/2025 at 11:35 AM. The Rehab Director stated, Yes, she had the little beige box in her hand. When it was explained that box was not the call light, but the bed control and that the call light was behind Resident #270's lamp and nightstand, the Rehab Director stated, I'm sorry, I thought it was the call light.

51477 Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure infection control processes are maintained for 2 (Resident #8 and #270) residents of 3 residents reviewed for improper handling of eating utensils and not being under contact isolation for communicable disease. Finding included: Review of a facility undated policy titled, PP Infection Control, indicated, The facility will establish and maintain an infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. A review of a facility policy titled, Transmission-Based (Isolation) Precautions, dated 2022, indicated, for a resident who is immuno-compromised; should be on contact isolation for herpes zoster (shingles). Review of the Admission Record, indicated the facility admitted Resident #270 with diagnoses that included: chronic obstructive pulmonary disease, acute and chronic respiratory failure; malnutrition, myocardial infarction, iron deficiency anemia, thrombocytosis and the presence of a cerebrospinal fluid drainage device. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/2024, revealed Resident #270 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A review of Resident #270's Care Plan, initiated on 01/10/2025, revealed the resident required enhanced barrier precautions related to indwelling medical device (feeding tube). Interventions included: was to wear disposable gloves and gowns when providing high contact care. Resident #270 had a Care Plan initiated 01/09/2025, for a yeast rash in between and to the right finger. Interventions included: to avoid scratching and keep hands and body parts from excessive moisture, evaluate rash weekly with skin audit, give antiviral medication as ordered. Observe for any adverse reactions. Notify medical doctor as needed and observe skin rashes for increased spread or signs of infection. A review of the Order Summary Report, revealed Resident #270 had enhanced barrier precautions related to feeding tube and an order for valacyclovir hydrochloride 1000 milligrams (mg) by mouth every eight (8) hours for rash to the right arm. A review of Medication Administration Record (MAR), revealed Resident #270 had been receiving enhanced barrier precautions since 01/10/2025. A review of the Infection Screening Evaluation completed 01/15/2025 at 11:09 AM, revealed Resident #270 had the symptom: vesicular rash. A review of the Skilled Note A Every 8 hours, dated 01/13/2025, revealed no documented rash or skin issue. A review of the Advanced Practice Registered Nurse (APRN) progress note dated 01/13/2025, revealed that Resident #270 had a new rash to right arm with small vesicles present. APRN observed erythematous, warm rash to inner aspect of right arm extending to fingers on right hand with small, closed blisters noted throughout the rash. Per the APRN note, Resident #270 denied itching but stated that the area was burning. The Assessment/Plan per the APRN included: 1. Herpes Zoster-acute, start valacyclovir 1000mg every 8 hours for 7 days. To keep the area clean and dry. To Keep area covered if blisters rupture/open. Isolation precautions as necessary. Notify the provider of any acute concerns. During an interview on 01/15/2025 at 1:28 PM, Director of Nursing (DON), stated the order for the Valacyclovir (antiviral) was written on 01/13/2025 at 11:00 PM. DON stated that the rash was noted by the certified nursing assistants who then went to the nurse and then the nurses went to assess the rash. DON was asked to review the nurse's notes and confirmed there was only a note stating that the medication had started. DON stated that the APRN had seen the resident that day (01/13/2024) and it was just uploaded into the electronic medical record on 01/15/2025. DON stated the resident had not been placed on isolation because the blisters were not ruptured and because Resident #270 had intact skin. DON stated that on 01/13/2025, per nursing documentation, there were no nurses notes that mentioned any skin issues. When asked if there was any antibiotic stewardship follow up on the infection, DON replied, it did not require antibiotic stewardship due to it being an antiviral medication. On 01/15/2025 at 7:39 AM, CNA #1 was assisting Resident #8 on the male unit with meal set up. Without washing her hands, after touching trays and opening containers, she picked up a fork by the tines (the end of the fork that goes into the mouth) and handed it to Resident #8. On 01/15/2025 at 8:45 AM, CNA #1 was asked if she should have picked the fork up by the tines and she stated, No, I should have handed it to him by the handle and washed my hands. On 01/16/2025 at 9:00 AM, the DON was asked if the CNA should have handled the fork by the tine, and stated she should have handed it to the resident by the handle.

Based on observations, interviews, and facility document review, it was determined that the facility failed to ensure mechanical soft food was ground to the right consistency to meet the needs of residents who required a mechanical soft diet during one (1) of one (1) meal service observed. The failed practice had the potential to affect eight (8) residents who required mechanical soft diets. The findings include: On 11/15/2025 at 7:36 AM, the Dietary Manager stated the facility did not have a policy for mechanically altered foods. On 11/14/2025 at 11:07 AM, [NAME] #4 stated the facility had 3 pureed and 8 mechanical soft diets and 2 regular diets who requested mechanical soft meat. After gathering supplies needed to begin preparing for mechanical soft, [NAME] #4 began by using the processor machine and added 10 pork chops to process into mechanical soft. After completing the blending process, [NAME] #4 poured the mechanically altered pork chops into a pan, covered the pan with aluminum foil, and placed on the steam table. During a concurrent observation and interview, on 11/14/2025 at 12:10 PM with [NAME] #4, the mechanically altered pork chop was at 157.8 degrees Fahrenheit temperature. [NAME] #4 was asked what the consistency was for the mechanical pork chop. [NAME] #4 responded, pork chops always have looked that way and [NAME] #4 stated it does appear to look like a thick paste. The Dietary Manager, at that time, came over to the steam table and was asked to describe the pork chops. The Dietary Manager stated, looks a little thick, and the Dietary Manager confirmed that the mechanically altered pork chops had a paste consistency. The Dietary Manager asked cook #4 if the processor machine had been pulsated and cook #4 replied, I just hit the green button. The Dietary Manager explained to [NAME] #4 that the green button was to be pushed, stopped, pushed and stopped again to pulsate. The Dietary Manager agreed that the thick paste-like mechanically altered pork chop could cause an issue with swallowing.

Based on record review, interviews, facility document review, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) for 1 (Resident #7) of 8 sample mix residents reviewed for MDS accuracy. The findings are: Review of Resident #7's Administration Record dated 05/2/2022, noted a diagnosis of Stroke (Cerebral Infarction). Review of Resident #7s Care Plan with a date of 07/11/2022, noted Resident #7 on prevention for blood clots from forming (antiplatelet) therapy related to stroke. Administer blood thinner (anticoagulant) medications as ordered by physician. Review of Resident #7's quarterly MDS with an Assessment Reference Date (ARD) of 12/12/2024, noted on Section N0415- High- Risk Drug Classes: Use and Indication, E. Anticoagulant: Yes. Review of Resident #7's Order Summary Report dated 01/14/2025, noted [Medication used to help prevent blood clots] tablet chewable 81 milligrams (MG) give 1 tablet by mouth one time a day for stroke (CVA), with a start date of 03/24/2023. Review of Resident #7's Order Summary Report Active, Completed, Discontinued, On Hold, dated 01/14/2025, noted the resident had not received an anticoagulant. During an interview with the MDS Coordinator on 01/16/2025 at 1:52 PM, she confirmed Resident #7 does not receive an anticoagulant, had not received one in the past and the MDS should have been coded for an antiplatelet.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 3 (Resident #20, # 37, 30) of 14 sample mix residents reviewed for care plans. The findings are: Review of Resident #37's Admission Record dated 10/07/2024, noted diagnoses for hypothyroidism, type 2 diabetes mellitus, chronic heart failure, schizophrenia, pain, depressive episodes, pain in joints, heart attack (myocardial infarction), and atrial fibrillation (A-Fib). Review of Resident #37's Care plan dated 10/7/2024, did not note medication names or black box warnings. Review of Resident #37's Order Summary Report with a date of 1/15/2025, noted [Name brand thyroid medication] oral tablet 75 micrograms (MCG) give 75 mcg by mouth in the morning related to low thyroid (hypothyroidism); [Name brand glucagon-like peptide-1 receptor agonist medication] (1 milligram (MG) per dose) subcutaneous solution pen-injector 4 MG per 3 (milliliter (ML) inject 2 mg subcutaneously one time a day every Thu related to Type 2 Diabetes; [Name brand diuretic] oral tablet 80 MG give 1 tablet by mouth two times a day related to Chronic Heart Failure; [Name brand angiotensin receptor neprilysin inhibitor medication]oral tablet 24-26 MG give 1 tablet by mouth two times a day related to Chronic Heart Failure;[Name brand atypical antipsychotic medication] oral tablet 10 MG give 10 mg by mouth one time a day related to Schizophrenia; [Name brand combination opioid pain medication]oral tablet 10-325 MG give 0.5 tablet by mouth at bedtime related to pain; [Name brand selective serotonin reuptake inhibitor medication]oral tablet 10 MG give 1 tablet by mouth one time a day related to Depressive episodes; [Brand name medication used to treat depression] oral tablet 100 MG give 1 tablet by mouth at bedtime related to Depressive episodes; [Brand name opioid agonist used to treat chronic pain] Oral Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for pain related to pain in joint; [Brand name anticoagulant] oral tablet 75 MG give 1 tablet by mouth one time a day related to Myocardial Infarction; [Brand name medication used to treat heart dysrhythmias] oral tablet 200 MG give 1 tablet by mouth one time a day related to Atrial Fibrillation; -[Brand name fast acting insulin] injection solution 100 unit per ML inject as per sliding scale starting at 200 subcutaneously two times a day related to Type 2 Diabetes. Review of Resident #30's Admission Record dated 1/31/2024, noted diagnoses of chronic pain, history of blood clot in the deep vein and artery blockage (venous thrombosis and embolism), and mild neurocognitive disorder due to known physiological condition with behavioral disturbance. Review of Resident #30's Care Plan dated 8/16/2024 did not note medication names or black box warnings. Review of Resident #30's Order Summary Report dated 1/16/2025, noted [Name brand anti-depressant medication] oral tablet 100 MG Give 100 mg by mouth one time a day related to Depression; [Brand name narcotic pain medication] tablet 300-30 MG Give 0.5 tablet by mouth three times a day related to Chronic Pain; [Brand name medication used to treat deep vein thrombosis]oral tablet 5 MG give 5 mg by mouth two times a day related to History of venous thrombosis and embolism; [Brand name anti-psychotic medication] oral tablet 0.5 MG give 0.5 mg by mouth two times a day related to Psychosis not due to a substance or known physiological condition. Review of an Admission Record indicated that the facility admitted Resident #20 with a diagnosis of paraplegia. The admission/ 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/22/2024, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. Review of Resident #20 ' s Care Plan revealed, that it did not have any therapy, nor black box warnings listed within the care plan. During an interview on 01/15/2025 at 10:39 AM, the MDS Coordinator reported that black box warnings alert an individual of certain medications and what to look out for. The MDS Coordinator stated, From what I understand, no, we don't care plan black box warnings. During an interview on 01/15/2025 at 10:57 AM, the DON (Director of Nursing) revealed that black box warnings were not in care plan and should be added to the care plan. During an interview on 01/16/2025 10:14 AM, the MDS Coordinator revealed Resident #20 came off therapy on the 14th of this month. The MDS Coordinator stated, therapy was not in care plan and that there are orders for therapy that need to be discontinued.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure Advance Directives were up to date in the electronic medical record (EMR) for 1 (Resident #24) of 1 resident reviewed for Advance Directives. The findings include: A review of the facility's undated policy titled Advance Directives, indicated that revocation will be documented in the resident's plan of care and/or the medical record. A review of the Admission Record, indicated the facility admitted Resident #24 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. A review of Resident #24's Care Plan, initiated on [DATE], revealed the resident had requested that no cardiopulmonary resuscitation (CPR) measures be performed and a code status of Do Not Resuscitate (DNR). Interventions included: communicate choice to all appropriate staff members and to follow the DNR instructions as detailed inside the Advance Directive &/or living will. A review of an Order Summary Report revealed Resident #24 had orders to: Admit to Palliative Care and DNR. A review of the Miscellaneous tab in the electronic medical record revealed Resident #24 had an advance directive dated [DATE], which was marked yes for CPR, life support/other artificial support, treatment of new conditions and tube feeding/intravenous fluids (IV). A review of the new Advance Directive Acknowledgement, signed and dated [DATE], supplied by the Director of Nursing (DON) on [DATE], indicated Resident #24 was a DNR and wished not to execute an Advance Directive. A review of a note from the Advanced Practiced Registered Nurse (APRN), dated [DATE], stated that Resident #24's wife wished to go with Palliative Care and that Resident #24 would not want CPR. The APRN's summary of the treatment plan based on the discussion with Resident #24's wife was that the resident would be changed to DNR status when the wife was available to sign papers and Resident #24 would admit to Palliative Care to be done by the facility. During an interview on [DATE] at 11:33 AM, Medical Records stated the Advance Directive dated [DATE], had not been scanned into the Electronic Medical Record, but that it would be. Medical Records reported an audit had been completed and it was found at that time. Medical Records responded that the nursing staff would have been trained on what paperwork would be needed if a resident was sent out to the hospital. During an interview on [DATE] at 11:40 AM, Registered Nurse (RN) 3, explained the process for sending someone to the hospital and what paperwork had to be sent. RN #3 reported that the Admission Record, order summary report and the Advance Directive/Code Status would be sent. During an interview on [DATE] at 11:50 AM, the DON confirmed that the paperwork that would be sent with a resident transferring to the hospital from the facility would include the face sheet, order, Emergency Medical Services (EMS)/DNR order and the Advance Directive, if the resident had one. The DON agreed that the most current Advance Directive dated [DATE], was scanned into the EMR on [DATE].

Based on observation, interviews, and record review, it was determined that the facility failed to ensure dignity was maintained for 1 (Resident #10) of 1 sampled resident reviewed for dignity while passing meal trays. Finding included: 1.Review of a facility policy titled Resident Rights and Responsibilities with no date indicated, The facility protects and promotes the rights of each resident admitted in order to provide a dignified existence. Review of an Admission Record indicated the facility admitted Resident # 10 on 12/14/2012, with diagnoses of bipolar disorder and generalized anxiety disorder. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/06/2025, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #10 was moderately cognitively impaired. On 01/15/2025 at 7:39 AM this surveyor observed Certified Nursing Assistant (CNA) #1 serving meal trays to the residents in the dining room. CNA #1 served all the residents in the dining room except Resident #10. CNA #1 left the dining room without serving Resident #10 a breakfast tray. Resident #10 yelled out to CNA #1 that the resident wanted a meal tray. CNA #1 stopped and provided him with his meal tray. Resident #10 was interviewed on 01/15/2025 at 7:45AM. Resident #10 stated that it was not right for the CNA to leave the dining room without passing all trays. On 01/15/2025 at 8:00 AM, CNA #1 was asked if all trays should have been served before leaving the dining room. She stated Resident #10's tray should have been served before leaving the dining room to pass other trays. On 01/15/2025 at 8:30 AM, Licensed Practical Nurse (LPN) #5 was asked if all trays should have been served before leaving the dining room. She stated she should have served Resident #10's tray before leaving the dining room to pass other trays. On 01/15/2025 at 3:00 PM, the Director of Nursing (DON) was interviewed and asked if CNA #1 should have served all the trays before leaving the dining room. The DON stated that CNA #1 should have served Resident #10's tray before leaving the dining room to pass other trays.

Based on observations, interviews, and record reviews, the facility failed to ensure residents with injuries of unknown sources were identified and reported in an appropriate and timely manner, to rule out the possibility of abuse for 1 (Resident #29) of 1 sampled resident who had an injury to the skin from an unknown source. This failed practice resulted in noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious injury, serious harm, and or possible death, and had the potential to cause more than minimum harm to 66 residents who resided in the facility according to the Roster Matrix provided by the Administrator on 1/8/2024 at 10:48 AM. The Administrator was informed of the Immediate Jeopardy condition on 1/11/2024 at 12:23 PM. The State Office accepted the Plan of Removal, and the Immediate Jeopardy was removed on 1/12/2024 at 9:50 AM. The findings are: A review of an Admission Record, indicated the facility admitted Resident #29 with a diagnosis that included Alzheimer's and Dementia. The Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #29 had a Staff Assessment for Mental Status (SAMS) score of 3, which indicated the resident was severely cognitively impaired and required maximum assistance for activities of daily living (ADLs). A review of Resident #29's Care Plan, revised on 6/2/2023, revealed the resident was at risk for impaired skin integrity related to incontinence, poor skin turgor, tinea unguium (a fungal nail infection) and decreased mobility. Interventions included, report any skin concerns to nurse, initiated on 6/2/2023; conduct body audit weekly, initiated on 6/16/2020. A review of the Incidents by Incident Type dated 7/9/2023 through 1/9/2024, did not document any incident for Resident #29. A review of the Body Audits dated 1/3/2024 and 1/10/2024 documented skin condition clear. A review of the Monthly Nursing Summary dated 1/6/2024 did not document any skin issues. A review of Resident #29's Progress Notes dated 12/31/2023 through 1/10/2024, did not document any skin issues for Resident #29. A review of Resident #29's Certified Nursing Assistant (CNA) Task, Skin Observation, dated 12/13/2023 through 1/11/2024, revealed no scratches, no red areas, no discolorations, no skin tears, and no open areas documented. A review of a policy titled, Abuse, Neglect, and Maltreatment Investigation & Reporting Policy indicated, The facility will endeavor to protect Resident/Elders from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of Resident/Elder property. All incidents of alleged or suspected Resident/Elder maltreatment, including neglect, or abuse, and misappropriation of Resident/Elder property must be reported immediately to the Administrator or the Administrator's Designees by a facility staff member or their immediate supervisor. On 1/08/2024 at 10:51 AM, observed Resident #29 in the dining room sitting in a wheelchair. A large purple, reddened area, approximately 6 centimeters (cm) in diameter was observed on Resident #29's right forearm. On 1/08/2024 at 12:50 PM, Resident #29 sitting in a wheelchair in the dining room on the secure unit. A large purple, reddened area, approximately 6 cm in diameter was observed on Resident #29's right forearm. On 1/11/2024 at 9:03 AM, Certified Nursing Assistant (CNA) #9 was asked what do you do if a resident receives a skin tear or a bruised area? CNA #9 stated, Notify the nurse and the wound nurse. CNA #9 was asked what is an injury of unknown source? CNA #9 stated, Skin tear or a bruise, or discoloration of skin. CNA #9 was asked what are you supposed to do if you find an injury of unknown source? CNA #9 stated, Report to the charge nurse immediately. On 1/11/2024 at 9:09 AM, CNA #8 was asked what is an injury of unknown source? CNA #8 stated, Broke leg or arm, skin tear, or bruise. CNA #8 was asked what are you supposed to do if you find an injury of unknown source? CNA #8 stated, Report to the nurse. CNA #8 was asked to raise Resident #29's right shirt sleeve and identify the reddened/purple area to the right forearm. On 1/11/2024 at 9:14 AM, Resident #29 was sitting in a wheelchair in the dining room on the secure unit. A large, fading, reddened, purple area, approximately 6 cm in diameter was observed on Resident #29's right forearm. CNA #8 was asked how did Resident #29 obtain the reddened/purple area to the right forearm? CNA #8 stated, I haven't seen it. I don't know how it happened and don't know how long it's been there. On 1/11/2024 at 9:18 AM, Licensed Practical Nurse (LPN) #1 was asked what is an injury of unknown source? LPN #1 stated, A bruise or skin tear, where we don't know how it happened or occurred. LPN #1 was asked what are you supposed to do if you find an injury of unknown origin? LPN #1 stated, The CNAs will usually find it nine out of ten times and report it to the treatment nurse and if the treatment nurse isn't available, they will notify the floor nurse. We go and assess, report it to the Physician, the Director of Nursing (DON), and the family and do an I & A (Incident and Accident Report). LPN #1 was asked has anyone reported any new skin issues with Resident #29. LPN #1 stated, No, there is a place on the face, but nothing else has been reported to me. On 1/11/2024 at 9:25 AM, LPN #2 was asked what is an injury of unknown source? LPN #2 stated, An injury that the team can't figure out how it happened. LPN #2 was asked what staff do if a resident receives a skin tear or a bruise. LPN #2 stated, Alert the supervisor or me. LPN #2 was asked who does the resident body audits? LPN #2 stated, I do. LPN #2 was asked did you perform the body audit dated 1/10/2024 on Resident #29? LPN #2 stated, I did, there were no skin issues. There is a place on the cheek, and sometimes Resident #29 will pick at it, and we'll have to do a treatment, but we aren't doing anything to it right now. LPN #2 was asked when you do the body audits, what do you look at? LPN #2 stated, I look at what is documented on the body audit. LPN #2 was asked do you look at the residents' arms and legs? LPN #2 stated, Yes. LPN #2 was asked how Resident #29 received the reddened/purple area to the right forearm. LPN #2 stated, I don't know. LPN #2 was asked did you report this to anyone. LPN #2 stated, If it's been there, we don't report it, and that's been there. I saw it yesterday when I did the body audit. On 1/11/2024 at 9:46 AM, the Infection Control Preventionist (ICP) was asked what staff are supposed to do if a resident receives a skin tear or a bruise. The ICP stated, Notify the charge nurse. The ICP was asked what is an injury of unknown source? The ICP stated, Any injury where we don't know how it happened. The ICP was asked how did Resident #29 receive the reddened/purple area to the right forearm, and has anyone reported it to you? The ICP stated, I don't know, and it has not been reported. On 1/11/2024 at 9:55 AM, the Director of Nursing (DON) was asked what are staff supposed to do if a resident receives a skin tear or a bruise? The DON stated, Report to the charge nurse and the treatment nurse, do an I & A. The DON was asked what is an injury of unknown source? The DON stated, A bruise or skin tear that we are not aware of how it happened. The DON was asked are you aware of the reddened/purple area to Resident #29's right forearm? The DON stated, I am not aware. The Immediate Jeopardy was removed on 01/12/24 at 09:50 AM when the following Plan of Removal was implemented: Plan of Removal F609 1. On 1/11/2024 at 10:00am it was reported to the administrator that an elder on 500 hall had discolored areas of unknown origin on her right forearm and 2 small areas on her left forearm. On 1/11/2024 at 10:30am the administrator immediately began a reportable investigation for an injury of unknown origin to the Office of Long-Term Care. The report was completed on 1/11/2024 at 11:59am. On 1/1112024 at 10:20am the ADON [Assistant Director of Nursing] started body audits on all residents on the 500 hall. This was completed on 1/11/2024 at 10:40am. No injuries of unknown origin were noted. On 1/11/2024 at 10:00am the DON [Director of Nursing] conducted staff interviews on staff on duty on the 500 hall. This was completed on 1/11/2O24 at 10:03am. On 1/11/2024 at 10:30 am the nurse consultant in serviced the treatment nurse on completing a body audit to include head to toe assessment and reporting injuries of unknown origin. This was completed on 1/11/2024 at 10:40am. On 1/11/2024 at 10:45am the nurse consultant in serviced all staff on reporting abuse/neglect with focus on reporting injuries of unknown origin. This was completed on 1/11/2024 at 11:30am. On 1/11/2024 at 12:28pm the HR [Human Resources] and BOM [Business Office Manager] began interview of all staff on duty for any potential unreported abuse. This was completed on 1/11/2024 at 3:00pm with no abnormal findings. On 1/11/2024 at 12:28pm the ADON, floor nurses, and MDS [Minimum Data Set] nurse began body audits including head to toe of all residents. This was completed on 1/11/24 at 3:20pm. No injuries of unknown origin were noted. On 1/11/2024 at 1 :30pm all residents with a BIMS [Brief Interview for Mental Status] score of 12-15 were interviewed by Medical Records to ensure they have not been abused, witnessed another resident being abused, and that they feel safe reporting any abuse. This was completed 1/11/24 at 3:25pm. With no abnormal findings. 2. The failed practice had the potential to affect 66 residents that reside within the facility. 3. To prevent re-occurrence: The DON/designee will 5 days a week interview 6 staff members for any potential unreported abuse. The DON/designee will 5 days a week interview 6 residents for being abused or witnessing abuse. The DON/designee will 5 days a week audit 6 body audits done by the treatment nurse for accuracy and reporting of injuries of unknown origin. 4. Completion: 1/11/2024 3:30pm

Based on observations, interviews, and record reviews, the facility failed to ensure residents with injuries of unknown sources were identified and reported in an appropriate and timely manner, which resulted in failure to thoroughly and immediately investigate and rule out the possibility of abuse, for 1 (Resident #29) of 1 sampled resident who had an injury to the skin from an unknown source. This failed practice resulted in noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious injury, serious harm, and or possible death, and had the potential to cause more than minimum harm to 66 residents who resided in the facility according to the Roster Matrix provided by the Administrator on 1/8/2024 at 10:48 AM. The Administrator was informed of the Immediate Jeopardy condition on 1/11/2024 at 12:23 PM. The State Office accepted the Plan of Removal, and the Immediate Jeopardy was removed on 1/12/2024 at 9:50 a.m. The findings are: A review of an Admission Record, indicated the facility admitted Resident #29 with a diagnosis that included Alzheimer's and Dementia. The Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #29 had a Staff Assessment for Mental Status (SAMS) score of 3, which indicated the resident was severely cognitively impaired and required maximum assistance for activities of daily living (ADLs). A review of Resident #29's Care Plan, revised on 6/2/2023, revealed the resident was at risk for impaired skin integrity related to incontinence, poor skin turgor, tinea unguium (a fungal nail infection) and decreased mobility. Interventions included, report any skin concerns to nurse, initiated on 6/2/2023; conduct body audit weekly, initiated on 6/16/2020. A review of the Incidents by Incident Type dated 7/9/2023 through 1/9/2024, did not document any incident for Resident #29. A review of the Body Audits dated 1/3/2024 and 1/10/2024 documented skin condition clear. A review of the Monthly Nursing Summary dated 1/6/2024 did not document any skin issues. A review of Resident #29's Progress Notes dated 12/31/2023 through 1/10/2024, did not document any skin issues for Resident #29. A review of Resident #29's Certified Nursing Assistant (CNA) Task, Skin Observation, dated 12/13/2023 through 1/11/2024, revealed no scratches, no red areas, no discolorations, no skin tears, and no open areas documented. A review of a policy titled, Abuse, Neglect, and Maltreatment Investigation & Reporting Policy indicated, The facility will endeavor to protect Resident/Elders from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of Resident/Elder property. All incidents of alleged or suspected Resident/Elder maltreatment, including neglect, or abuse, and misappropriation of Resident/Elder property must be reported immediately to the Administrator or the Administrator's Designees by a facility staff member or their immediate supervisor. On 1/08/2024 at 10:51 AM, Resident #29 was in the dining room sitting in a wheelchair. A large purple, reddened area, approximately 6 centimeters (cm) in diameter was observed on Resident #29's right forearm. On 1/08/2024 at 12:50 PM, Resident #29 was sitting in a wheelchair in the dining room on the secure unit. A large purple, reddened area, approximately 6 cm in diameter was observed on Resident #29's right forearm. On 1/11/2024 at 9:03 AM, Certified Nursing Assistant (CNA) #9 was asked what do you do if a resident receives a skin tear or a bruised area? CNA #9 stated, Notify the nurse and the wound nurse. CNA #9 was asked what is an injury of unknown source? CNA #9 stated, Skin tear or a bruise, or discoloration of skin. CNA #9 was asked what are you supposed to do if you find an injury of unknown source? CNA #9 stated, Report to the charge nurse immediately. On 1/11/2024 at 9:09 AM, CNA #8 was asked what is an injury of unknown source? CNA #8 stated, Broke leg or arm, skin tear, or bruise. CNA #8 was asked what are you supposed to do if you find an injury of unknown source? CNA #8 stated, Report to the nurse. CNA #8 was asked to raise Resident #29's right shirt sleeve and identify the reddened/purple area to the right forearm. On 1/11/2024 at 9:14 AM, Resident #29 was sitting in a wheelchair in the dining room on the secure unit. A large, fading, reddened, purple area, approximately 6 cm in diameter was observed on Resident #29's right forearm. CNA #8 was asked how did Resident #29 obtain the reddened/purple area to the right forearm? CNA #8 stated, I haven't seen it. I don't know how it happened and don't know how long it's been there. On 1/11/2024 at 9:18 AM, Licensed Practical Nurse (LPN) #1 was asked what is an injury of unknown source? LPN #1 stated, A bruise or skin tear, where we don't know how it happened or occurred. LPN #1 was asked what are you supposed to do if you find an injury of unknown origin? LPN #1 stated, The CNAs will usually find it nine out of ten times and report it to the treatment nurse and if the treatment nurse isn't available, they will notify the floor nurse. We go and assess, report it to the Physician, the Director of Nursing (DON), and the family and do an I & A (Incident and Accident Report). LPN #1 was asked has anyone reported any new skin issues with Resident #29. LPN #1 stated, No, there is a place on the face, but nothing else has been reported to me. On 1/11/2024 at 9:25 AM, LPN #2 was asked what is an injury of unknown source? LPN #2 stated, An injury that the team can't figure out how it happened. LPN #2 was asked what staff do if a resident receives a skin tear or a bruise. LPN #2 stated, Alert the supervisor or me. LPN #2 was asked who does the resident body audits? LPN #2 stated, I do. LPN #2 was asked did you perform the body audit dated 1/10/2024 on Resident #29? LPN #2 stated, I did, there were no skin issues. There is a place on the cheek, and sometimes Resident #29 will pick at it, and we'll have to do a treatment, but we aren't doing anything to it right now. LPN #2 was asked when you do the body audits, what do you look at? LPN #2 stated, I look at what is documented on the body audit. LPN #2 was asked do you look at the residents' arms and legs? LPN #2 stated, Yes. LPN #2 was asked how Resident #29 received the reddened/purple area to the right forearm. LPN #2 stated, I don't know. LPN #2 was asked did you report this to anyone. LPN #2 stated, If it's been there, we don't report it, and that's been there. I saw it yesterday when I did the body audit. On 1/11/2024 at 9:46 AM, the Infection Control Preventionist (ICP) was asked what staff are supposed to do if a resident receives a skin tear or a bruise. The ICP stated, Notify the charge nurse. The ICP was asked what is an injury of unknown source? The ICP stated, Any injury where we don't know how it happened. The ICP was asked how did Resident #29 receive the reddened/purple area to the right forearm, and has anyone reported it to you? The ICP stated, I don't know, and it has not been reported. On 1/11/2024 at 9:55 AM, the Director of Nursing (DON) was asked what are staff supposed to do if a resident receives a skin tear or a bruise? The DON stated, Report to the charge nurse and the treatment nurse, do an I & A. The DON was asked what is an injury of unknown source? The DON stated, A bruise or skin tear that we are not aware of how it happened. The DON was asked were you aware of the reddened/purple area to Resident #29's right forearm? The DON stated, I am not aware. The Immediate Jeopardy was removed on 01/12/24 at 09:50 AM when the following Plan of Removal was implemented: Plan of Removal F610 On 1/1l/2024 at 10:00am it was reported to the administrator that an elder on 500 hall had discolored areas of unknown origin on her right forearm and 2 small areas on her left forearm. On 1/11/2024 at 10:30am the administrator immediately began a reportable investigation for an injury of unknown origin to the Office of Long-Term Care. The report was completed on 1/11/2024 at 11:59am. On 1/11/2024 at 10:20am the ADON [Assistant Director of Nursing] started body audits on att residents on the 500 [NAME]. This was completed on 1/11/2024 at 10:40am. No injuries of unknown origin were noted. on 1111/2024 at 10:00am the DON [Director of Nursing] conducted staff interviews on staff on duty on the 500 hall. This was completed on 1/11/2024 at 10:03am. On 1/11/2024 at 10:30 am the nurse consultant in serviced the treatment nurse on completing a body audit to include head to toe assessment and reporting injuries of unknown origin. This was completed on 1/11/2024 at 10:40am. On 1/11/2024 at 10:45am the nurse consultant in serviced all staff on reporting abuse/neglect with focus on reporting injuries of unknown origin. This was Completed on 1/11/2024 at 11:30am. On 1/11/2024 at 12:28pm the HR [Human Resources] and BOM [Business Office Manager] began interview of all staff on duty for any potential unreported abuse. This was completed on 1/11/2024 at 3:00pm with no abnormal findings. On 1/11/2024 at 12:28pm the ADON, floor nurses, and MDS [Minimum Data Set] nurse began body audits including head to toe of all residents. This was completed on 1/11/2024 at 3:20pm. No injuries of unknown origin were noted. On 1/11/2024 at 1:30pm all residents with a BIMS [Brief Interview for Mental Status] score of 12-15 were interviewed by Medical Records to ensure they have not been abused, witnessed another resident being abused, and that they feel safe reporting any abuse. This was completed on 1/11/2024 at 3:25pm. With no abnormal findings. 2 The failed practice had the potential to affect 66 residents that reside within the facility. 3. To prevent re-occurrence: The DON/designee will 5 days a week interview 6 staff members for any potential unreported abuse. The DON/designee will 5 days a week interview 6 residents for being abused or witnessing abuse. The DON/designee will 5 days a week audit 6 body audits done by the treatment nurse for accuracy and reporting of injuries of unknown origin. 4. Completion: 1/11/2024 3:30pm

Based on observation, record review, and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) were able to demonstrate competency in safely conducting manual transfers to prevent potential serious injury, serious harm, and or death for 1 (Resident #33) of 1 sampled resident who required assistance with transfers. The failed practice had the potential to affect 19 residents who required assistance with transfers using a mechanical/manual lift according to a list provided by the Director of Nursing (DON) on 1/12/2024 at 10:37 a.m. This failed practice resulted in non-compliance at the level of Immediate Jeopardy. The Administrator was notified of the Immediate Jeopardy on 1/10/2024 at 3:36 PM. The State Office accepted the Plan of Removal on 1/11/2024 at 1:46 PM. The findings are: A review of an Admission Record indicated the facility admitted Resident #33 with a diagnosis of dementia. The Annual Minimum Data Set (MDS), dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The resident was dependent for all activities of daily living (ADLs). Review of Resident #33's Care Plan, revised on 10/26/2023, revealed the resident had an ADL self-care performance deficit related to dementia with behaviors. Interventions included transfers, requires total assistance x 2 staff with transfers, medium/purple sling. A review of Certified Nursing Assistant (CNA) #6, Certified Nurse Assistant Orientation Checklist, dated 4/29/2016, which included Use of Mechanical Lift, contained no signature from CNA #6 was on the form, only the Director of Nursing's (DON) signature at the time. A review of a facility in-service titled, Lift in-service, dated 10/19/2022 indicated CNA #6 was present during the in-service. A review of a facility in-service titled, Equipment, dated 12/06/2023, indicated CNA #6 was present during the in-service. A review of a facility in-service titled, Attendance, Weekend Option, Secure Units, Vital Signs, dated 11/7/2023, indicated CNA #6 was present during the in-service. The secure units must be covered at all times. Always have someone come to the unit to relieve you for any reason. A review of the manufacturer's guidelines for the mechanical lifts 450 and 600 models indicated, .When using an adjustable base lift, the legs must be in the maximum opened/locked position before lifting the patient. Wheelchair wheel locks must be in a locked position before lowering the patient into the wheelchair for transport . On 01/08/2024 at 02:34 PM, Certified Nursing Assistant (CNA) #6 and Nursing Assistant (NA) #1 assisted Resident #33 to the resident's room in specialized chair. Observed CNA #6 place her right hand under Resident #33's left elbow and her left hand under the resident's left thigh. Observed CNA #7 place her left hand under Resident #33's right elbow, and her right hand under Resident #33's right thigh. CNA #6 and CNA #7 lifted Resident #33 up using a 4 point system, assisting Resident #33 to a sitting position in the specialized chair. CNA #6 and CNA #7 did not use a lift pad or a gait belt to lift Resident #33 up in the specialized chair. On 01/09/2024 at 10:00 AM CNA #6 left the legs apart on the mechanical lift and did not lock the wheels on the specialized chair. CNA #6 placed the lift under Resident #33's specialized chair and assisted Resident #33 up from the specialized chair using the lift and lift pad. The specialized chair brakes were not locked. CNA #6 lowered Resident #33 back into the specialized chair using the lift and lift pad. On 01/09/2024 at 10:08 AM, CNA #6 moved the mechanical lift under Resident #33's specialized chair. CNA #6 did not lock the brakes of the specialized chair. CNA #6 and NA #1 hooked the lift pad to the hooks on the mechanical lift. On 01/09/2024 at 10:09 AM, CNA #6 lifted Resident #33 up from the specialized chair using the mechanical lift. The legs of the lift were open and the brakes were not locked on the specialized chair. CNA #6 attempted to turn the mechanical lift toward Resident #33's bed. The spreader bar on the lift would not lock and the mechanical lift legs kept closing while CNA #6 attempted to turn the lift. The spreader bar on the lift was loose and would not stay in a position. CNA #6 continued to use the lift with Resident #33 in the lift pad and in the air. CNA #6 maneuvered the lift with Resident #33 in the lift pad and in the air and positioned the lift under Resident #33 bed with Resident #33 positioned over the bed. On 01/09/2024 at 10:10 AM, Resident #33 was lowered onto the bed. The spreader bar on the mechanical lift was loose and not secure and keeps moving and closing the legs to the lift. CNA #6 continued to use the lift. On 01/09/2024 at 10:20 AM, CNA #6 hooked the lift pad to the hooks on the lift. The lift legs were closed, and the brakes were not locked on Resident #33's specialized chair. On 01/09/2024 at 10:21 AM, CNA #6 lifted Resident #33 off the bed using the mechanical lift and lowered Resident #33 into the specialized chair, the brakes were not locked on the specialized chair. The lift legs were not open and the brakes were not locked on the specialized chair. CNA #6 continued to use the lift. On 01/0920/24 at 10:25 AM, CNA #6 was asked what was wrong with the mechanical lift, the spreader bar that keeps the legs closed or open is loose. CNA #6 stated, It's broke, when I put it in stationary position, the brakes are supposed to be locked CNA #6 was asked are you supposed to lock the mechanical lift brakes/or brakes on the wheelchair, specialized chair, or geriatric chair, at any time when using/transferring residents. CNA #6 stated, I guess when I lift them up, I don't know. CNA #6 was asked have you been trained on using the mechanical lifts? CNA #6 stated, I've had training, but I don't know when. On 1/10/2024 at 9:18 AM, upon entering the Secure Unit on the 500 Hall. Resident #22 was sitting in a wheelchair in his/her room with a call light attached to the blanket covering the lap and yelling out. Resident #33 was in the specialized chair in the dining room. Another resident was in his/her room. Resident #29 was alone, and Resident #25 was alone in the dining room. Resident #17 was ambulating with a walker down the hall toward his/her room. The mechanical lift was on the hall. The spreader bar was loose. This was the only mechanical lift on the hall. There was a sit to stand lift in the hall. There were no staff present on the 500 Hall. The residents were left alone on the hall. On 01/10/2024 at 09:21 AM, Maintenance #1 entered the 500 Hall through the patio door looking for an Aid, he was going in and out of resident's rooms. The Surveyor stated there were no staff on the hall. Maintenance #1 left the hall through the coded fire doors. On 1/10/2024 at 9:21 AM, CNA #6 entered the 500 Hall from the coded fire doors. CNA #6 was asked how many staff members were on the hall. CNA #6 stated CNA #8 is supposed to be on here but was doing showers. I left for just a minute. On 1/10/2024 at 9:22 AM, CNA #2 entered the 500 Hall. On 1/10/2024 at 9:23 AM, the Director of Nursing (DON) entered the 500 Hall. On 1/10/2024 at 9:28 AM, CNA #6 was asked if there should always be staff on the secure unit. CNA #6 stated, Yes. On 1/10/2024 at 10:14 AM, the DON was asked how many staff are supposed to be on the secure unit at all times? The DON stated, At least one. The DON was asked why there should be at least one staff member on the secure unit at all times. The DON stated, To make sure they don't exit, get hurt, or to assist with any needs. The DON was asked to explain what happened on the secure unit earlier. The DON stated, I was told, CNA #6 told LPN #1, that CNA #6 was going to leave and get a resident some tea. When the nurse finished passing medications, the nurse thought one of the aides was in a room. We had an aid and a float (doing showers). The DON was asked who was responsible for ensuring a staff member was on the secure unit at all times. The DON stated, Ultimately I am, the staff knows that someone should be on the hall before they exit that hall. The DON was asked how the staff know that there is to be a staff member on the secure unit at all times. The DON stated, We do in-services and I'm doing one now. On 1/10/2024 at 10:20 AM, Licensed Practical Nurse (LPN) #1 was asked how many staff are to be on the secure unit at all times? LPN #1 stated, At least one staff. LPN #1 was asked why should there be at least one staff on the secure unit at all times? LPN #1 stated, Because everybody down there are confused, need assistance, or have behaviors, or elopement risks. LPN #1 was asked when did you become aware there was no staff on the hall? LPN #1 stated, The maintenance man ran out and stated we can't find any aides. LPN #1 stated, It was a miscommunication between me and CNA #6, I thought the float was still on the hall. I was in a room giving a resident medicine. CNA #6 asked if she could run to the kitchen and get someone a drink. I told CNA #6 to be quick and go right there and get right back. I thought the float was in/on the hall, but the float wasn't. On 1/10/2024 at 9:29 AM, CNA #9 was asked why there should be staff on the secure unit at all times? CNA #9 stated, Residents could fall or get into anything. On 1/10/2024 at 10:46 AM, CNA #10 was asked when something is broken what are you supposed to do. CNA #10 stated, Write it in the maintenance book. CNA #10 was asked when using a mechanical lift, are the lift legs open or closed when lifting/lowering a resident? CNA #10 stated, Opened. CNA #10 was asked when using a mechanical lift, are the wheelchair, geriatric chair, or the specialized chair brakes locked or unlocked? CNA #10 stated, Locked. CNA #10 was asked about the mechanical lift with the loose spread bar and was asked, why is the spreader bar loose? CNA #10 stated, I don't know. CNA #10 was asked how long the spreader bar had been loose and if it had been reported. CNA #10 stated, I don't know. CNA #10 was asked why was the mechanical lift with a loose spreader bar still in service? CNA #10 stated, I don't know. CNA #10 was asked who was responsible for ensuring broken equipment and lifts that need to be fixed were reported and to whom? CNA #10 stated, Anybody and it goes to maintenance. CNA #10 was asked how long the mechanical lift had been used on the secure unit and who does the maintenance on the lifts. CNA #10 stated, I don't know, but a company named [Durable Medical Equipment Company]. On 1/10/2024 between 11:00 AM, and 11:08 AM, a total of 4 mechanical lifts 600s were assessed throughout the building with no negative findings. A total of 2 mechanical lifts 450s were assessed throughout the building with no negative findings. On 01/10/2024 at 11:08 AM, observed a mechanical 450 lift in the hall outside of the 600 Secure Unit with a sign taped on it that read: Out of order, Do Not Use. On 01/10/2024 at 11:11 AM, the Director of Nursing (DON) was asked when something is broken what are you supposed to do. The DON stated, Put it in the maintenance book, report it to us, and if it's a lift, we put a sign on it to not use it and we call [Durable Medical Equipment Company]. The DON was asked when using a hoyer lift, are the lift legs open or closed when lifting/lowering a resident? The DON stated, open. The DON was asked, when using a mechanical lift, are the wheelchair, geriatric chair, and the specialized chair brakes locked or unlocked? The DON stated, Locked. The DON was asked about the mechanical lift with the loose spread bar and was asked, why is the spreader bar loose? The DON stated, I don't know. The DON was asked how long the spreader bar had been loose and if it had been reported. The DON stated, It just got reported. The DON was asked why was the mechanical lift with a loose spreader bar still in service? The DON stated, I don't know why it was still in use. Because it wasn't reported. The DON was asked who was responsible for ensuring broken equipment and lifts that need to be fixed are reported and to whom? The DON stated, Whoever sees it or uses it. The DON was asked how long the mechanical lift has been used on the secure unit and who does the maintenance on the lifts. The DON stated, [Durable Medical Equipment Company] services the lifts and we are waiting on the email from when they were here the last time. On 01/10/2024 at 1:23 PM, Maintenance #1 was asked when the lifts need to be fixed, what are the staff supposed to do? Maintenance #1 stated, They put an out of order sign on it. bring it to my office or park in a hall, and we call [Durable Medical Equipment Company]. Maintenance #1 was asked what is the bar called on the lift? Maintenance #1 stated, I don't know what the bar is called, but it opens and closes the legs, it goes up, and latches to keep the legs open or closed. Maintenance #1 was asked why the spreader bar is loose on the hoyer lift that was on the 500 Hall. Maintenance #1 stated, It should be secured and locked into place. Maintenance #1 was asked when were you aware of the loose spreader bar of the hoyer lift. Maintenance #1 stated, I wasn't aware. On 1/11/2024 at 3:15 PM, the Infection Control Preventionist (ICP) was asked why staff should not pull a resident up in a geriatric, specialized chair, or wheelchair, using the resident elbows and legs? The ICP stated, It could cause injury. The Immediate Jeopardy was removed on 1/11/2024 at 1:46 PM when the following Plan of Removal was implemented: Plan of Removal F726 1. On 1/10/24 the DON [Director of Nursing] and ADON [Assistant Director of Nursing] immediately in serviced CNAs [Certified Nursing Assistants] and Nurses on duty by verbal review, written material, check off with the return demonstration completed by 1/10/2024 4:40pm. On 1/10/2024 at 3:40pm the DON assessed residents that require the use of a mechanical lift for transfers. No negative findings were noted. On 1/10/2024 at 4:25pm the Administrator in serviced HR [Human Resources] manager that all licensed employees will have a competency check off on all mechanical lift use and transfer. On 1/10/2024 The Administrator will validate by employee roster that all licensed employees will receive Inservice training, skills check off with return demonstration. Completed on 1/11/2024 at 11:30am. 2. This failed practice had the potential to affect 18 residents that require the use of a mechanical lift. 3. To prevent reoccurrence: The DON/Designee will perform skills check off, training, and ensure competency by observation and return demonstration before they are assigned the halls. The HR manager will ensure that all new licensed employees have signed a competency once their training is completed, to be filed in their employee training file. The Administrator will verify through record review that all new hire licensed employees have received their skills check off with return demonstration for mechanical lift use for transfers. The DON/Designee will perform quarterly Inservice training, skills check off with return demonstration for all licensed employees. The Administrator will verify that all licensed employees have received quarterly training, skills check off with return demonstration. 4. Monitoring: The DON/Designee [NAME] [will] monitor 2 mechanical lift transfers q [every] shift until in compliance. The Administrator will monitor all employees files to ensure competency training and skill check offs are complete for all new employees. The Administrator will monitor quarterly training compliance q 3 months and as needed to ensure compliance is maintained. 5. Completion date: 1/11/2024 at 11:52 am.

Based on observation, record review and interview, the facility failed to ensure staff correctly and safely used a mechanical lift to transfer a resident; and failed to ensure staff secured a specialized chair while assisting the resident when using a mechanical lift according to the manufacturer's instructions for 1 (Resident #33) of 1 sampled resident observed during a lift transfer using a mechanical lift to prevent potential serious injury, serious harm, and possible death. This failed practice resulted in Immediate Jeopardy, which caused or was likely to cause serious harm, injury, or death to Resident #33, who was transferred using a malfunctioned mechanical lift and was transferred into a specialized chair that was not secured during immobility. This failed practice had the potential to cause more than minimal harm to 19 residents who required a mechanical lift for transfers according to a list provided by the Director of Nursing (DON) on 1/12/2024 at 10:37 AM. This failed practice resulted in non-compliance at the level of Immediate Jeopardy. The Administrator was informed of the Immediate Jeopardy condition on 1/10/2024 at 3:36 PM. The Administrator was notified the Plan of Removal was accepted on 1/11/2024 at 1:46 PM; the clothes dryers remained free of excessive lint build-up to decrease the potential for fire in the laundry room; and supervision and fall interventions were provided for 1 (Resident #3) of 1 sampled resident to prevent repeated falls and possible injury. The findings are: 1. A review of an Admission Record indicated the facility admitted Resident #33 with a diagnosis of dementia. The Annual Minimum Data Set (MDS), dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The resident was dependent for all activities of daily living (ADLs). Review of Resident #33's Care Plan, revised on 10/26/2023, revealed the resident had an ADL self-care performance deficit related to dementia with behaviors. Interventions included transfers requires total assistance x 2 staff with transfers, medium/purple sling. A review of Certified Nursing Assistant (CNA) #6, Certified Nurse Assistant Orientation Checklist, dated 4/29/2016, revealed no signature from CNA #6 only the DON at the time. A review of a facility in-service, Lift in-service, dated 10/19/2022, indicated CNA #6 was present during the in-service. A review of a facility in-service, Equipment, dated 12/06/2023, indicated CNA #6 was present during the in-service. A review of the manufacturer's guidelines for the mechanical lifts 450 and 600 models, battery powered patient lifts indicated, .When using an adjustable base lift, the legs must be in the maximum opened/locked position before lifting the patient. Wheelchair wheel locks must be in a locked position before lowering the patient into the wheelchair for transport . On 01/08/2024 at 02:34 PM, Certified Nursing Assistant (CNA) #6 and Nursing Assistant (NA) #1 assisted Resident #33 to the resident's room in a specialized chair. CNA #6 placed her right hand under Resident #33's left elbow and her left hand under Resident #33's left thigh. CNA #7 placed her left hand under Resident #33's right elbow, and her right hand under Resident #33's right thigh. CNA #6 and CNA #7 lifted Resident #33 up using a 4 point system, assisting Resident #33 to a sitting position in the specialized chair. CNA #6 and CNA #7 did not use a lift pad or a gait belt to lift Resident #33 up in the specialized chair. On 01/09/2024 at 10:00 AM, CNA #6 left the legs apart on the mechanical lift and did not lock the wheels on the specialized chair. CNA #6 placed the lift under Resident #33's specialized chair and assisted Resident #33 up from the specialized chair using the lift and lift pad. The specialized chair brakes were not locked. CNA #6 lowered Resident #33 back into the specialized chair using the lift and lift pad. On 01/09/2024 at 10:08 AM, CNA #6 moved the mechanical lift under Resident #33's specialized chair. CNA #6 did lock the brakes of the specialized chair. CNA #6 and NA #1 hooked the lift pad to the hooks on the hoyer lift. On 01/09/2024 at 10:09 AM, CNA #6 lifted Resident #33 up from the specialized chair using the mechanical lift. The legs of the mechanical lift were open and the brakes were not locked on the specialized chair. CNA #6 attempted to turn the mechanical lift toward Resident #33's bed. The spreader bar on the lift would not lock and the mechanical lift legs kept closing while CNA #6 attempted to turn the lift. The spreader bar on the lift was loose and would not stay in a position. CNA #6 continued to use the lift with Resident #33 in the lift pad and in the air. CNA #6 maneuvered the lift with Resident #33 in the lift pad and in the air and positioned the lift under Resident #33's bed with Resident #33 positioned over the bed. On 01/09/2024 at 10:10 AM, Resident #33 was lowered to the bed. The spreader bar on the mechanical lift was loose and not secure and kept moving and closing the legs to the lift. CNA #6 continued to use the lift. On 01/09/2024 at 10:20 AM, CNA #6 hooked the lift pad to the hooks on the mechanical lift. The lift legs were closed, and the brakes were not locked on Resident #33's specialized chair. On 01/0920/24 at 10:21 AM, CNA #6 lifted Resident #33 off the bed using the mechanical lift and lowered Resident #33 into the specialized chair, the brakes were not locked on the specialized chair. The mechanical lift legs were not open and the brakes were not locked on the specialized chair. CNA #6 continued to use the lift. On 01/0920/24 at 10:25 AM, CNA #6 was asked what was wrong with the mechanical lift, the spreader bar that keeps the legs closed or open is loose. CNA #6 stated, It's broke. When I put it in stationary position, the brakes are supposed to be locked CNA #6 was asked are you supposed to lock the mechanical brakes/or brakes on the wheelchair, specialized chair, or geriatric chair, at any time when using/transferring residents. CNA #6 stated, I guess when I lift them up. I don't know. CNA #6 was asked have you been trained on using the mechanical lifts. CNA #6 stated, I've had training, but I don't know when. On 1/10/2024 at 9:18 AM, upon entering the Secure Unit on the 500 Hall. Resident #22 was sitting in a wheelchair in his/her room with a call light attached to the blanket covering the lap and yelling out. Resident #33 was in the specialized chair in the dining room. Another resident was in his/her room. Resident #29 was alone, and Resident #25 was alone in the dining room. Resident #17 was ambulating with a walker down the hall toward his/her room. The mechanical lift was on the hall. The spreader bar was loose. This was the only mechanical lift on the hall. There was a sit to stand lift in the hall. There were no staff present on the 500 Hall. The residents were left alone on the hall. On 1/10/2024 at 10:46 AM, CNA #10 was asked when something is broken what are you supposed to do. CNA #10 stated, Write it in the maintenance book. CNA #10 was asked when using a mechanical lift, are the lift legs open or closed when lifting/lowering a resident? CNA #10 stated, Opened. CNA #10 was asked when using a mechanical lift, are the wheelchair, geriatric chair, or the specialized chair brakes locked or unlocked? CNA #10 stated, Locked. CNA #10 was asked about the mechanical lift with the loose spread bar and was asked, why is the spreader bar loose? CNA #10 stated, I don't know. CNA #10 was asked how long the spreader bar had been loose and if it had been reported. CNA #10 stated, I don't know. CNA #10 was asked why was the mechanical lift with a loose spreader bar still in service? CNA #10 stated, I don't know. CNA #10 was asked who was responsible for ensuring broken equipment and lifts that need to be fixed were reported and to whom? CNA #10 stated, Anybody and it goes to maintenance. CNA #10 was asked how long the mechanical lift had been used on the secure unit and who does the maintenance on the lifts. CNA #10 stated, I don't know, but a company named [Durable Medical Equipment Company]. On 1/10/2024 between 11:00 AM, and 11:08 AM, a total of 4 mechanical lifts 600s were assessed throughout the building with no negative findings. A total of 2 mechanical 450 lifts were assessed throughout the building with no negative findings. On 01/10/2024 at 11:08 AM, observed a mechanical 450 lift in the hall outside of the 600 Secure Unit with a sign taped on it that read: Out of order, Do Not Use. On 01/10/2024 at 11:11 AM, the Director of Nursing (DON) was asked when something is broken what are you supposed to do. The DON stated, Put it in the maintenance book, report it to us, and if it's a lift, we put a sign on it to not use it and we call [Durable Medical Equipment Company]. The DON was asked when using a hoyer lift, are the lift legs open or closed when lifting/lowering a resident? The DON stated, open. The DON was asked, when using a mechanical lift, are the wheelchair, geriatric chair, and the specialized chair brakes locked or unlocked? The DON stated, Locked. The DON was asked about the mechanical lift with the loose spread bar and was asked, why is the spreader bar loose? The DON stated, I don't know. The DON was asked how long the spreader bar had been loose and if it had been reported. The DON stated, It just got reported. The DON was asked why was the mechanical lift with a loose spreader bar still in service? The DON stated, I don't know why it was still in use. Because it wasn't reported. The DON was asked who was responsible for ensuring broken equipment and lifts that need to be fixed are reported and to whom? The DON stated, Whoever sees it or uses it. The DON was asked how long the mechanical lift has been used on the secure unit and who does the maintenance on the lifts. The DON stated, [Durable Medical Equipment Company] services the lifts and we are waiting on the email from when they were here the last time. On 01/10/2024 at 1:23 PM, Maintenance #1 was asked when the lifts need to be fixed, what are the staff supposed to do? Maintenance #1 stated, They put an out of order sign on it. bring it to my office or park in a hall, and we call [Durable Medical Equipment Company]. Maintenance #1 was asked what is the bar called on the lift? Maintenance #1 stated, I don't know what the bar is called, but it opens and closes the legs, it goes up, and latches to keep the legs open or closed. Maintenance #1 was asked why the spreader bar is loose on the hoyer lift that was on the 500 Hall. Maintenance #1 stated, It should be secured and locked into place. Maintenance #1 was asked when were you aware of the loose spreader bar of the hoyer lift. Maintenance #1 stated, I wasn't aware. On 1/11/2024 at 3:15 PM, the Infection Control Preventionist (ICP) was asked why staff should not pull a resident up in a geriatric, specialized chair, or wheelchair, using the resident elbows and legs? The ICP stated, It could cause injury. The Immediate Jeopardy was removed on 1/11/2024 at 1:46 PM when the following Plan of Removal was implemented: Plan of Removal F 689 1. On 1/10/2024 at 3:45 pm 1. Administrator verified that the mechanical lift in need of repair was removed from service at 1/10/2024 at 11:00 am and the Medical Records staff contacted the DME [Durable Medical Equipment] Service for scheduling repair and service of the mechanical lift on 1/10/2024 at 11:09 am completed 1/10/2024 3:45 pm. 2. The DON [Director of Nursing] and ADON [Assistant Director of Nursing] began Inservice training for licensed staff on duty 1/10/2024 for the 3-11 shift including skills check off competency with return demonstration completed 1/10/2024 at 4:45 pm. 3. On 01/10/2024 4:15 pm The Administrator notified Social Service employee to apply labels to the lifts instructing staff to STOP and assure equipment is in proper working condition and all parts are operating correctly prior to use! Please notify Administrator immediately if equipment is defective and remove from service Completed 1/10/2024 4:40 pm 4. On 01/10/2024 at 3:40 pm DON assessed all residents that require the use of a mechanical lift for transfers and lifts. No negative findings were noted. Completed 1/10/2024 5 pm 5. On 01/10/2024 4:25 pm the Administrator in serviced HR [Human Resources] manager that all licensed employees will have a competency check off on all mechanical lift use and transfer. Completed 01/10/2024 4:45 pm 6. On 01/10/2024 The Administrator will validate by employee roster that all licensed employees will receive Inservice training, skills check off with return demonstration by 01/11/2024 @ [at] 11:30 am. 2. This failed practice had the potential to affect 18 residents that require the use of a mechanical lift. 3. To prevent reoccurrence: The DON will Inservice all staff to check the mechanical lift to ensure it is in good repair and functioning properly and if not, remove the equipment form service and notify the Administrator. The DON/Designee will perform skills check off, training, and ensure competency by observation and return demonstration before they are assigned to the halls. The HR manager will ensure that all new licensed employees have a signed competency once their training is completed, to be filed in their employee training file. The Administrator [NAME] [will] verify through record review that all new hire licensed employees have received their skills check off with return demonstration for mechanical lift use for transfers. The DON/Designee will perform quarterly Inservice training, skills check off with return demonstration for all licensed employees. The Administrator will verify that all licensed employees have received quarterly training, skills check off with return demonstration. 4. Monitoring: The Administrator/ Designee will monitor mechanical lifts to ensure the lifts are in good repair and working properly 5 x week x 2 weeks then 3 x a week for 4 weeks, then weekly x 6 weeks or until compliance is maintained. The DON/Designee will monitor 2 mechanical lift transfers q [every] shift until in compliance. The Administrator will monitor all new employee files to ensure competency training and skills check offs are complete for all new employees. The Administrator will monitor quarterly training compliance q 3 months and as needed to ensure compliance is maintained. 5. Completion date: 01/11/2024 @11:52 am 2. On 01/08/2024 at 11:55 AM, Dryer #1 and Dryer #2 lint traps were assessed with staff members House Keeping (HK) #2 and HK #3 present. Dryer #1's lint trap contained lint 1 inch thick by 12 inches by 12 inches. Dryer #2's lint trap contained lint particles and the lint trap was free of excessive lint buildup. The Lint Trap Cleaning Log for Dryer #1 was checked off as cleaned at 10:00 AM on 01/08/24 see picture. On 1/11/2024 at 3:35 PM, Housekeeping (HK) #2 was asked why should the dryers be free of excessive lint? HK #2 stated, Because of the thickness of the lint could cause fires on the electrical wires. 46724 3. Resident #3 had a diagnosis of dementia. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/21/2023 documented the resident had not had any falls prior to admission. The Significant Change MDS with an ARD of 12/21/2023 documented Resident #3 had had 2 or more falls since admission. Resident #3's Care Plan with a revision date of 09/29/2023 documented, .is at risk for falls . has had an actual fall .10/4/23 minor injury, 10/30/23 no injury, 12/8/23 no injury, 12/23/23 minor injury .10/4/23 Neuro-checks per facility protocol .10/30/23 Encourage use of call light for standby assistance during toilet transfers .12/23/23 Staff assist with transfers .12/8/23: refer to therapy for wheelchair positioning .Check Vital signs post fall and PRN [as needed], report abnormalities to MD [Medical Doctor] . Resident #3's Physician Orders did not document an order for a physical therapy evaluation. On 01/12/2024 at 11:15 AM, the Director of Nursing (DON) was asked what interventions are put into place when a resident is considered at high risk for falls? The DON listed: a low bed, a fall mat at times, nonskid socks, call light reeducation, and restorative. The Surveyor asked if reeducation was an effective fall prevention measure for a cognitively impaired resident. The DON answered no. The Surveyor asked if Resident #3 was on restorative services. She answered I don't think so, but he is being evaluated by physical therapy. On 01/12/2024 at 11:25 AM, Registered Nurse (RN) #1 was asked what interventions are implemented when a resident is evaluated to be at risk for falls. She stated, It depends on what happened, we could use a fall mat, nonskid socks, a low bed, educate them on the call light. The Surveyor asked if education was an appropriate intervention for cognitively impaired residents. She said it would not. Physical Therapy received a request for an evaluation for strengthening on 12/14/2023 but it has not been completed yet. The Facility Fall Guidelines obtained from the Administrator on 01/12/2024 documented the charge nurse will, .implement intervention to prevent further injury .in-service staff on new interventions .update the Care Plan with new interventions .The Director of Nursing [DON] will .review for appropriate intervention change as needed .

Based on observation, interview and record review, the facility failed to ensure food items were labeled, dated, stored properly in sealed packaging, and the dishes were properly cleaned and sanitized, to prevent growth of bacteria, for residents who receive meals from 1 of 1 kitchen. This failed practice had the potential to affect 66 residents who receive meals from the kitchen, according to list provided by the Dietary Manager on 1/11/2024 at 3:30 p.m. The findings are: A review of the facility policy, Receiving and Storage, dated 2010, indicated all foods should be covered, labeled and dated. On 1/8/2024 at 9:55 AM, aluminum foil was observed covering the bottom shelf of the steam table. The aluminum foil was stained and had hard dried substances on it and was not clean. On 1/8/2024 at 9:57 AM, a pan of dumplings, a pan of green beans, and a pan of polish sausage was on the stove and was not covered. On 1/8/2024 at 10:00 AM, a metal cart holding clean dishes was observed in the kitchen. A metal pan with a metal rack was observed on the bottom shelf of the metal cart. The metal pan had a dried white substance in it and was not clean. On 1/8/2024 at 10:01 AM, a blue plastic rack on the bottom shelf of a metal rack containing clean dishes was observed containing bowls. The blue plastic rack had a brown dried substance and was not clean. On 01/08/24 at 10:00 AM, Dietary Employee (DE) #2 was asked what the pan on the bottom shelf of the metal rack was. DE #2 stated, It's a bread pan, it's waiting to be run through the wash. DE #2 was asked do you usually store dirty dishes with the clean dishes? DE #2 stated, Not usually, I had dirty dishes in the sink, so I stored them there. On 1/8/2024 at 10:04 AM, a package of tortilla shells with an opened date of 12/25/23 in a plastic resealable bag was not sealed. A 1/2 package of opened cream cheese in a plastic resealable bag was not sealed and did not have a date. A package of shredded cheese with an open date of 12/28/23 and a use by date of 12/26 was in a plastic resealable bag and was not sealed. A package of bologna with a date of 12/20/23 was in a plastic resealable bag that was not sealed. A package of Swiss/ American cheese with a use by date of 1/2/23 was in a plastic resealable bag was not sealed. On 01/08/2024 at 10:16 AM, there was dust and dirt observed on the ceiling and the wiring of the main refrigerator in the kitchen. The dust and dirt were easily removed by wiping it with fingers and falling onto the food. On 01/08/24 at 10:22 AM, a refrigerator in the kitchen with a sign labeled special drinks was observed with DE #2. There were 6 - 240 cc (cubic centimeters) of plastic cups with lids. The cups were not labeled with date, contents, or names.

Based on observation, interview, and record review, the facility failed to provide skin treatment for 1 (Resident #18) sampled resident who had a dry red rash to the face and neck. The findings are: Resident #18 had a diagnosis of dementia with agitation. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/2023 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had no skin issues. On 01/08/24 at 10:28 PM, 01/09/2024 at 9:00 AM, 01/09/2024 at 2:00 PM and 01/11/2023 at 3:00 PM, the skin on Resident #18's face was red and splotchy with white dry scaly patches noted on the right side of nose, his forehead, and chin. Resident #18's January 2024 Physician's Orders did not document any orders to treat the rash and scaly areas to the face. Resident #18's task sheet did not document a refusal of care in the past 30 days. Resident #18's Body Audit Report completed on 01/10/2024 noted no negative findings with clear skin. Resident #18's Care Plan with an initiated date of 03/08/2018 documented, .I have an ADL [activities of daily living] self-care performance deficit related to decreased mobility and dementia progression .I am dependent on staff for bathing .I require dependent assistance with personal hygiene .Report s/s [signs and/or symptoms] of hypothyroidism such as fatigue, dry skin, constipation to MD [Medical Doctor]/Practitioner .Observe/report PRN [as needed] any changes in skin status . On 01/12/2024 at 11:22 AM, the Director of Nursing (DON) was asked how often body audits are done. The DON stated, Weekly. The DON then accompanied the Surveyor to Resident #18's room to observe Resident #18's skin. The Surveyor asked if the resident was getting any treatment for the dry scaly red skin. The DON responded that she thought the resident had a treatment previously which may have been completed.

Based on observation, record review, and interview, the facility failed to ensure staff sat at eye level while assisting residents with meals for 2 (Residents #22 and #33) of 2 sampled residents who required assistance with meals; and failed to provide privacy during care for 1 (Resident #33) of 1 sampled resident who required assistance with activities of daily living. The findings are: 1. A review of an Admission Record, indicated the facility admitted Resident #22 with a diagnosis of stage 5 chronic kidney disease. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #22 had a Staff Assessment for Mental Status (SAMS) score of 2, which indicated the resident had moderate cognitive impairment. The resident required maximum assistance for eating. Review of Resident #22's Care Plan, revised on 10/25/2021, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to seizures, fibromyalgia, type 2 diabetes mellitus, lack of coordination, cerebral vascular accident (CVA) with right sided deficits. Interventions included, requires substantial/maximum assistance with meals/eating, revised on 1/3/2024. A review of the facility's undated policy titled, Summary of Residents' [NAME] of Rights, indicated, The facility must ensure and protect the human right of every individual in residence and to that end will provide a clean healthy attractive environment wherein the resident will receive treatment without discrimination as to race, color, religion, sex, national origin, disability or source of payment. Every resident has the right to considerate and respectful care. Every resident will be treated with consideration, respect and full recognition of his/her dignity and individuality. Privacy during treatment and care of personal needs. On 01/08/2024 at 12:55 PM, the Director of Nursing (DON) was observed standing next to Resident #22 while assisting the resident with eating. On 01/08/2024 at 12:58 PM, the DON was observed to give Resident #22 a drink while standing over the resident. 2. A review of an Admission Record indicated the facility admitted Resident #33 with a diagnosis of dementia. The Annual MDS, dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The resident was dependent for all activities of daily living (ADLs). Review of Resident #33's Care Plan, revised on 10/26/2023, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to dementia with behaviors. Interventions included the resident was dependent upon staff for feeding, initiated on 6/16/2021. The resident was dependent on staff for all activities of daily living (ADLs). On 01/08/2024 at 12:56 PM, Certified Nursing Assistant (CNA) #6 was observed standing next to Resident #33 while assisting Resident #33 with eating. CNA #6 gave Resident #33 a drink while standing over the resident. CNA #6 gave Resident #33 a bite of food while standing over the resident. CNA #6 gave Resident #33 another bite of green beans while standing over the resident. On 01/08/2024 at 12:58 PM, CNA #6 gave Resident #33 another bite of food while standing over the resident. On 01/08/2024 at 1:21 PM, CNA #6 was asked why did you stand while assisting Resident #33 with meal service? CNA #6 stated, Because I was going to sit there, but I was trying to help Resident #33 eat. CNA #6 was asked why should staff sit at eye level while assisting residents with meals? CNA #6 stated, Not to hover over them. On 01/08/2024 at 2:08 PM, the DON was why did you stand while assisting Resident #22 during meal service? The DON stated, Because I thought the CNA had the chair. We were short a chair. The DON was asked why should staff sit at eye level while assisting residents with meals? The DON stated, It's less intimidating. The DON was asked why were the residents meals left on the meal trays during meal service? The DON stated, I'm not sure. The DON was asked how do you ensure residents are served meals in a non-institutionalized manner and their dignity is maintained during meals? The DON stated, Make sure their meals are individualized, let them make choices, don't stand over them, sit at eye level. 3. Review of Resident #33's Care Plan, revised on 6/16/2021, revealed the resident had incontinence related to (r/t) dementia with behaviors and psychosis. Interventions included uses disposable briefs initiated on 6/16/2021; and an intervention initiated on 6/16/2021 to clean peri-area with each incontinence episode. On 01/08/2024 at 02:34 PM, CNA #6 assisted Resident #33 to the residents' room in a specialized chair. Resident #33's roommate was in bed. Resident #33 was laying back in the specialized chair. CNA #6 moved to the left side of Resident #33 specialized chair. CNA #7 moved to the right side of Resident #33's specialized chair. Observed CNA #6 and CNA #7 lift Resident #33 up in the specialized chair to a sitting position. Staff did not pull the privacy curtain. The CNAs did not use a gait belt or a lift. On 01/08/2024 at 2:36 PM, the Surveyor asked CNA #6 and CNA #7 why they didn't pull the privacy curtain when assisting Resident #33. CNA #7 stated, We didn't think, we just did it. The Surveyor asked how do you normally pull Resident #33 up in the chair? CNA #7 stated, If we are just pulling up in the chair, one on each side and pull up, but if chair to bed, or bed to chair, we use a lift. [Resident #33] is a total lift.

Based on observation and interview, the facility failed to ensure 1 (Resident #222) of 1 sampled resident received lunch choices ordered the morning of 1/8/2024. The findings are: a. On 01/08/24 at 12:53 PM, observed Resident #222 sitting up in a motorized wheelchair in the dining room. Lunch was served to Resident #222 by Licensed Practical Nurse (LPN) #2. Resident #222 stated, I ordered sausage, and they brought me chicken and dumplings. The Surveyor observed chicken and dumplings, green beans, cornbread, strawberry ice cream, iced tea, and water on Resident #222's tray. b. On 01/08/24 at 12:55 PM, sausage and corn were delivered to Resident #222 by LPN #2. Resident #222 asked for a slice of bread and mustard at 12:56 PM. Resident #222 stated, I didn't get any cobbler either. c. On 01/08/24 at 12:58 PM, a Certified Nursing Assistant (CNA) brought Resident #222 mustard and bread as requested and told Resident #222 they had run out of cobbler. d. On 01/09/24 at 02:30 PM, Resident #222 was sitting up in a specialized wheelchair in the resident's room watching TV. Dietary Employee (DE) #3 came in to get Resident #222's order for dinner, a choice between pork chops, or breakfast food. Resident #222 ordered breakfast food with no tomato juice. DE #3 wrote Resident #222's preferences on a clipboard she was carrying. e. On 01/11/24 at 09:38 AM, the Surveyor asked DE #1 who was responsible for making sure residents got their food choices daily. DE #1 stated, I have someone that goes around and asks the residents what they want for their meal, if they want an alternative, or if they want soup and a sandwich. The Surveyor asked what time does staff usually make rounds? DE #1 stated, Usually at nine am and again at three pm. The Surveyor asked how is it ensured that the process is followed for the residents to get their food choices. DE #1 stated, I've been here for fifteen years and have good communication with my helpers. The Certified Nurse Assistants usually come and tell me if there is a problem and I get it for them. Sometimes residents themselves will come and tell me. The Surveyor asked what the breakdown in the process was with what had happened with Resident #222's lunch on Monday? DE stated, To be honest with you, I didn't hear nothing about it. Sometimes people will order something, and they will look at someone else's plate and decide that they want that instead. It happens all the time. f. On 1/10/24 at 09:00 AM, the Administrator provided a document titled, Summary of Residents' [NAME] of Rights, which documented, . ACTIVITIES AS A RESIDENT, YOU HAVE THE RIGHT TO: . Individual preferences regarding such things as food, clothing, religious activities, friendships, activity programs and entertainment. Such preferences shall be elicited and respected by nursing home staff .

Based on observations, interview and record review, the facility failed to ensure a safe, clean, comfortable homelike environment was maintained by failing to ensure resident bathrooms were cleaned, foul odors were addressed on the Secure Unit, vinyl furniture was repaired, tiles and bedside tables were maintained and repaired, dead insects were cleaned from window seals, empty urine bottles were stored appropriately, burnt out lightbulbs were changed, and baseboards, walls, and floors were repaired throughout the facility. This failed practice had the potential to affect 66 residents residing in the facility, based on a Midnight Census Report dated 1/7/2024 provided by the Business Office Manager on 01/8/24 at 10:30 AM. The findings are: On 01/08/24 at 12:10 PM, a strong odor of ammonia and urine was noted upon entrance into the 600 Hall Secure Unit. The Dayroom on the 600 Hall Secure Unit contained two vinyl brown couches with torn vinyl on the arms and seams; a nightstand with the top peeling; a brown chair with peeling vinyl exposing the foam; and a plastic over the bed table that was ripped six inches and exposing a hard plastic pointed area. Thirty six inches of baseboard was pulled away from the wall exposing the drywall, rocks, and possible bricks between the bathroom door and the area under the TV. Another baseboard, 36 inches in length, was pulled away from the wall behind a brown chair in the dayroom exposing drywall and bricks. The window seal in the dayroom had dead bugs and/or moths. A broken tile was noted outside of room [ROOM NUMBER], the corners of 4 tiles were 12 centimeters in diameter, and 0.5 centimeters deep. A review of the facility's undated policy titled, Summary of Residents' [NAME] of Rights, indicated, The facility must ensure and protect the human right of every individual in residence and to that end will provide a clean healthy attractive environment wherein the resident will receive treatment without discrimination as to race, color, religion, sex, national origin, disability or source of payment . A review of an Admission Record indicated the facility admitted Resident #33 with a diagnosis of dementia. The Annual Minimum Data Set (MDS), dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The resident was dependent for all activities of daily living (ADLs). Review of Resident #33's Care Plan, revised on 10/26/2023, revealed the resident had an activity of daily living self-care performance deficit related to dementia with behaviors, anxiety. Interventions with a revision date of 9/16/2022, included, requires total assistance x 2 staff with transfer medium/purple sling. Resident had limited physical mobility due to dementia with behaviors and psychosis, revised on 10/26/2023. Interventions revised on 10/26/2023, included, resident is non-ambulatory and uses a geri-chair for mobility. On 01/08/24 at 10:47 AM, Resident #33 in a specialized chair, with the chair leaned back and Resident #33 kicking outward and restless. The specialized chair cushion was stained with a black wet substance. The strap at the foot of the specialized chair was loose. On 01/08/24 at 12:26 PM, in room [ROOM NUMBER], observed a cloth recliner with a brown rust stain on the seat and a yellow stain on the floor near the recliner. The room had a strong odor of ammonia and urine. On 01/08/24 at 12:29 PM, in room [ROOM NUMBER], there was a cloth recliner. The room had a strong odor of ammonia and urine. On 01/08/24 at 12:35 PM, observed Resident #33 leaned back in a specialized chair in the Dining Room on the 500 Women's Secure Unit. The strap at the foot of the specialized chair was loose. On 01/08/24 at 02:27 PM, observed Resident #33 leaned back in a specialized chair in the Dining Room of the Women's Secure Unit. The strap at the foot of the specialized chair was loose. The pillow was torn at the left side of resident's head with foam exposed. On 01/09/24 at 10:50 AM, upon entry onto the Men's Unit, a strong odor of ammonia and urine was noted. Certified Nursing Assistant (CNA) #11 was asked what the smell was on the unit. CNA #11 said a resident just had a BM [bowel movement]. CNA #11 was asked what is the ammonia/urine smell? CNA #11 said well they just cleaned down here, so it maybe the cleaner they are using. The smell was stronger in the dayroom than at the end of the hall. CNA #11 stated, They think it's the furniture, they ordered new furniture, and it was supposed to be here last week, but now it's supposed to be here this week. On 01/10/24 at 09:03 AM, the Maintenance Logs dated 12/26/23 to 01/10/24 were reviewed with no documentation noted for the odors on the 500 or 600 secure units or the concerns observed on the 500 Hall secure unit. 47912 On 01/09/24 at 08:44 AM, observed the bathroom shared by room [ROOM NUMBER] and 403. There was a black and brown substance built up around the base of both faucets and the chrome hardware spigot. There was a white residue built up on the chrome soap dispenser above the sink, and multiple smears and spots of an opaque substance up and down the chrome hardware on the sink. There was light brown, yellow and orange colored particles visible on the surface of both sides of the white sink. There was an empty white toilet paper holder resting on the left side of the sink that had a brown colored spot on it, and a blue sticky substance was smeared on the front left corner of the sink. There were dried opaque spots on the mirror above the sink. The floor around the base of the toilet was brown colored and there were packages of briefs lying on the floor next to the toilet, and there were brown colored streaks visible in the toilet bowl. The bathroom smelled of old urine. On 01/10/24 at 08:48 AM, room [ROOM NUMBER] and room [ROOM NUMBER]'s bathroom sink remained the same with a black substance around the bases of both faucets. The blue sticky substance remained on the lower left corner of the sink. On 01/10/24 at 02:15 PM, room [ROOM NUMBER]and 403's bathroom sink remained the same. There was also a chrome piece observed lying on the floor next to the toilet. The floor around the base of the toilet was stained dark brown and there were small black specks of debris accumulated and scattered on the base of the white toilet. There was another chrome piece attached to the wall. There was a metal square with sharp edges on the wall where the chrome piece that was lying on the floor had been attached. There were specks of an unidentified substance on the mirror, and brown streaks in the toilet bowl. On 01/09/24 at 09:18 AM, the resident in room [ROOM NUMBER]-A was lying in bed asleep. There were 2 empty urine bottles hanging over the side of trashcan in the room to the left of the resident's bed. There was an empty urine bottle with a dried drop of light brown substance on the outside surface sitting on top of the bookshelf to the right as the Surveyor walked into the room. The empty opened urine bottle on the bookshelf was sitting directly under the hand sanitizer dispenser on the wall. There were snacks and vitamin C tablets sitting next to the open urine bottle on the bookshelf. On 01/08/24 at 11:27 AM, the exit door at the end of the 300 Hall had a draft, and the hinge mechanism at the top of the door was missing 2 out of 3 bolts. On 01/09/24 at 12:28 PM, the exit door at the end of the 300 Hall remained the same with 2 out of 3 bolts missing from the hinge mechanism at the top of the door. On 01/10/24 at 08:52 AM, in room [ROOM NUMBER]-A, the open empty urine bottle remained on the bookshelf under the hand sanitizer on the wall. The 2 empty open urine bottles were still hanging on the edge of the trashcan in the room between the wall and the bed. On 01/10/24 at 12:10 PM, observed CNA #5 sitting in room [ROOM NUMBER]. The resident was in the bathroom. The open, empty urine bottle remained on the bookshelf, and the 2 open empty urine bottles remained hanging over the edge of the trash can as before. On 01/10/24 at 02:21 PM, in room [ROOM NUMBER]-A, the urine container had been removed from the bookshelf. The 2 empty urine bottles remained hanging on the trashcan between the wall and the resident's bed. On 01/10/24 at 02:41 PM, the Surveyor asked Housekeeping (HK) #1 what rooms she was assigned to clean. HK #1 answered, Today I have 300 and 400 halls. I've already done 400 Hall. The Surveyor asked HK #1 to talk through the process of cleaning the resident rooms. HK #1 answered, I get one rag and clean everything off like the side table, the countertop and I pull stuff out and clean behind it. In the bathroom, I use one rag for the commode and another rag for the sink and another rag for the paper towel and another rag for the soap thing. The Surveyor asked what the rags were made of. HK #1 answered, Cloth from the laundry. I also use peroxide in the commode for three seconds to kill the odor. Well, I pull the bed out, clean the bed off. Then I mop the bathroom. Come out. Rinse the mop out and then mop the room. I put out a yellow caution sign. before I start. On 01/10/24 at 02:43 PM, the Surveyor accompanied HK #1 to the bathroom shared by room [ROOM NUMBER] and 403. HK #1 took her bare hand and scraped the black substance from around the right faucet on the sink. The Surveyor observed a black colored liquid substance on the index finger of HK #1's right hand, and under the index fingernail as she proceeded to push the paper towel dispenser to get a towel to wipe her hand. The Surveyor asked if there were any issues with touching the paper towel dispenser with dirty hands. HK #1 replied, Oh, I guess I shouldn't have done that. The Surveyor asked if she knew about the toilet paper dispenser chrome pieces being broken and the sharp metal piece left on the wall, and if she saw any issue with it being that way. HK #1 answered, No I didn't know about that, but I'll pick it up and clean the floor. HK #1 then left the room without sanitizing, or washing hands stating she would come back right away and wipe the sink and clean the toilet which had brown streaks visible on the inside of the toilet bowl. On 01/10/24 at 03:10 PM, the Surveyor accompanied the Maintenance Supervisor to room [ROOM NUMBER] and 403's bathroom where HK #2 was cleaning the sink, and HK #1 was mopping the floor. The Surveyor asked the Maintenance Supervisor if he knew about the toilet paper holder needing repair. He answered, I didn't know about the toilet paper holder, but I've been planning on replacing that toilet since there have been problems with it leaking and staining the floor. The Surveyor asked if he thought there were any issues with the chrome pieces left on the wall. The Maintenance Supervisor answered, Well it looks like it might need to be moved back so they don't have to reach as far to get to it. The chrome piece was no longer lying on the floor next to the toilet. The Surveyor asked HK #1 what had happened to the chrome piece. HK #1 answered, I put it on my cart out in the hallway. On 01/10/24 at 03:21 PM, HK #2 (Housekeeping Supervisor) stopped the Surveyor in hall 400 and asked the Surveyor to accompany him to look at the bathroom in room [ROOM NUMBER] and 403. The Surveyor accompanied HK #2 to the bathroom where HK #1 was finishing cleaning the bathroom. The sink was clean, the toilet was cleaner, the chrome fixtures were clean, and the mirror had been cleaned. The Surveyor asked HK #2 what had been done differently that hadn't been done earlier when it was cleaned. HK #2 answered, She [HK #1] used a stone cleaner that she didn't use on it before. The Surveyor asked if gloves were worn when cleaning the resident rooms. HK #2 answered, Yes, we normally do. The Surveyor noticed HK #2 was not wearing gloves. HK #1 was wearing gloves. The Surveyor asked why HK #1 was wearing gloves, and HK #2 was not. HK #2 answered, Well we usually wear them. The Surveyor asked if there were any issues with scraping the black substance from the faucet with a bare hand, wiping it off with a paper towel, and leaving the room without washing or sanitizing, and why washing hands and sanitizing was important? HK #2 answered, Yes, that is a problem, passing germs or mold to residents when you touch paper towel dispensers, anything in the room, doorknobs, other residents, or anything a resident touches. On 01/08/24 at 11:48 AM, observed room [ROOM NUMBER]'s bathroom vanity lights were burned out. The baseboards behind the toilet were peeling from the wall. The metal door frames needed painting and there were deep scrapes in the wooden door. The Surveyor asked the resident in 402-A if it bothered him to have the lighting not working in the bathroom. The resident answered, Yes. The Surveyor asked if he had told anyone. The resident answered, Just the Aide. The Surveyor asked how the Aide responded. The resident answered, They said they would tell someone. The Surveyor asked how long ago he had told the Aide. The resident answered, I don't know. About a year, I think. On 01/10/24 at 02:06 PM, room [ROOM NUMBER]-A's bathroom smelled of old urine. 3 out of 4 round vanity lights above sink were still burned out, and the baseboard behind the toilet was still peeling from the wall. room [ROOM NUMBER] and 404 share the bathroom. On 01/10/24 at 03:14 PM, the Surveyor accompanied the Maintenance Supervisor to room [ROOM NUMBER] and 404 bathroom and asked if he knew about the light bulbs being burned out, and the peeling baseboard behind the toilet. The Maintenance Supervisor answered, No I didn't know about the lights being out or the baseboard peeling, but it is an easy fix, and I will take care of it right away. The Surveyor asked the Maintenance Supervisor how he knew when facility repairs needed to be done. The Maintenance Supervisor answered, The CNAs are supposed to write it down in a book for me so I can keep up with it, but they don't always do that. On 01/10/24 at 03:40 PM, the Surveyor accompanied the Maintenance Supervisor to the end of the 300 hallway where he stated he had replaced the 2 screws on the top door hinge that were missing. The Surveyor asked how long it had been that way. The Maintenance Supervisor answered, I don't really know, I've been battling with that door for a long time. We replaced the hinge, put on a new alarm, and I've replaced these screws before. I think it might have just happened. Housekeeping told me about it, and I just got it fixed today. On 01/10/24 at 08:58 AM, the Assistant Director of Nursing (ADON) provided a document titled, Record of In-Service dated 8/17/23 that documented on Page 1 under Section 1: Introduction, .Hazards in the Workplace .Recognize potential hazards in residential, home, and community settings . and on page 8, Section 3: Conclusion, second paragraph, under Work Place Safety: The Basics, .Employees at all levels of the organization have responsibility for the safety and well being of the individuals they serve and themselves . On 01/11/24 at 07:59 AM, the Administrator provided a cleaning schedule document that documented, .No Food, Drinks, Dangerous Object on HK Cart . and under required Supplies/Tools: .Gloves . and under 7-step (washroom Cleaning), .Clean Commode/Base, Clean Sink/Pipes, Sweep, Damp Mop . On 01/11/24 at 07:50 AM, Admin informed the Surveyor that there was no facility policy on Maintenance, and stated, We follow the Life Safety Book.

Based on observation, record review and interview, the facility failed to ensure nail care was regularly provided for 1 (Resident #221) of 1 sampled resident who was dependent for nail care and oral care was regularly provided for 1 (Resident #223) of 1 sampled resident who was dependent for oral care to maintain good hygiene, promote a sense of wellbeing, and prevent potential injuries or infections. The findings are: 1. Resident #221 had a diagnosis of aftercare following joint replacement surgery and unspecified systolic congestive heart failure. a. A 5-Day Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/23 documented a Brief Interview for Mental Status (BIMS) of 10 (8-12 indicates moderately cognitively impaired) and was dependent on staff for personal hygiene. b. A Care Plan with an initiation date of 12/22/23 documented, .requires assistance with ADLs [activities of daily living] due to left hip fx [fracture] and arthroplasty . Personal Hygiene: requires partial/mod [moderate] assistance with Personal Hygiene . c. A Physicians Order dated 12/25/23 documented, .OT [Occupational Therapy] to treat 5 times/week for 4 weeks to address deficits related to lack of coordination and need for assistance with personal care . d. On 01/08/24 at 12:14 PM, Resident #221 was sitting in a wheelchair in her room at the bedside table. Her fingernails were 1/4 inch past the fingertips with a brown substance under the right and left index fingernails and the right middle fingernail. The fingernails were uneven in length. The Surveyor asked Resident #221 if it was ok to see her hands and fingernails. Resident #221 stated, My nails are dirty., and pointed to the left index finger with the right hand. The Surveyor asked if she had told anyone. She stated, I haven't had time to tell nobody nothing. e. On 01/09/24 at 08:47 AM, Resident #221 was lying in bed awake. Her fingernails remain 1/4 inch past the fingertips in length and uneven, with a brown substance observed under the nails. Her hair was uncombed and disheveled looking. f. On 01/09/24 at 02:50 PM, Resident #221 was lying in bed awake. The Surveyor asked if she had gotten a bath or shower recently. She stated, Yes, I had one yesterday I believe. The Surveyor asked to see her fingernails. Resident #221 stated, They are still dirty and need to be cleaned out. The Surveyor asked if she thought her fingernails needed to be trimmed. Resident #221 stated, They sure do. The Surveyor asked if she liked the way they looked. Resident #221 stated, No they need to be cleaned. Can you clean them for me? Do you have one of those sticks? The Surveyor asked if she had asked staff to help with her nails. Resident #221 stated, No, they are too busy and don't want to do that, I'm sure. g. On 01/09/24 at 02:57 PM, the Surveyor accompanied Certified Nursing Assistant (CNA) #3 to Resident #221's room and asked her to describe Resident #221's fingernails. CNA #3 stated, Well, they are long and dirty. The Surveyor asked if she thought they needed to be cleaned and trimmed. CNA #3 stated, Yes ma'am The Surveyor asked who was responsible for nail care for the residents. CNA #3 stated, It depends on if she's diabetic. If she is, the treatment nurse does them. If not, it would be the CNA on the hall giving the shower. She's a three to eleven shift shower. The Surveyor asked CNA #3 what are Resident #221's shower days. CNA #3 stated, Monday, Wednesday, Friday afternoon. The Surveyor asked how often fingernails should be checked. CNA #3 stated, Frequently. The Surveyor asked why regular nail care was important. CNA #3 stated, Hygiene and infection control. h. On 01/09/24 at 03:03 PM, CNA #1 and CNA #4 entered Resident #221's room. The Surveyor asked CNA #4 to describe Resident #221's fingernails. CNA #4 stated, They are dirty and long. The Surveyor asked CNA #4 if she thought Resident #221's fingernails needed to be trimmed. CNA #4 stated Yeah, they need to be filed, cleaned, and clipped. The Surveyor asked CNA #4 how often nail care should be done for residents. CNA #4 stated, A few times a week. The Surveyor asked CNA #4 who was responsible for providing resident nail care. CNA #4 stated, If diabetic, the nurses. The Surveyor asked why regular nail care was important. CNA #4 stated, It's just part of taking care of them like taking showers. CNA #1 stated, It's part of infection control too. i. On 01/10/24 at 01:31 PM, the Assistant Director of Nursing (ADON) informed the Surveyor that there was no policy or procedure guide for nail care and/or oral care. j. On 01/11/24 at 12:42 PM, the Surveyor asked the Director of Nursing (DON) who was responsible for nail care and oral care for the residents. The DON stated, CNAs. The Surveyor asked what could happen if nail care and oral care was not done on a regular basis. The DON stated, Infection, poor dental hygiene, cavities. The Surveyor asked when or how often nail and oral care should be done. The DON stated, Nailcare should be done when residents do their showers. Oral care is supposed to be done daily. The Surveyor asked for a list of residents who were dependent on staff's assistance with activities of daily living specifically for nail care and oral care. The DON stated, Everyone here is dependent upon staff for nail care. We have a few walkie talkies that do their own. I will get you a list of the one's dependent for oral care. k. On 01/11/24 at 4:05 PM, the DON provided a list of 21 Residents in Facility Dependent upon Oral Care. 2. Resident #223 had diagnoses of type 2 diabetes mellitus, functional quadriplegia, acquired absence of leg above right knee and left knee. a. A Quarterly MDS with an ARD of 12/26/23 documented a BIMS score of 12 (8-12 indicates moderate cognitive impairment) and was dependent on one staff for oral and personal hygiene. b. A Quarterly MDS with an ARD of 9/25/23 documented Resident #223 was dependent on one staff for oral and personal hygiene. c. A Care Plan with an initiation date of 06/20/23 documented, .has an ADL self-care performance deficit . Personal Hygiene/oral care: .is totally dependent on staff for personal hygiene and oral care . d. On 01/08/24 at 02:26 PM, Resident #223 was sitting up in a specialized chair in his room. The Surveyor observed that Resident #223 had several teeth missing and a foul breath odor. The Surveyor asked if he was able to brush his teeth by himself or if he needed assistance. Resident #223 stated, I don't brush my teeth, but I have a toothbrush. The Surveyor asked if the staff had brushed his teeth. Resident #223 stated, No. The Surveyor asked if he had asked staff to help brush his teeth. Resident #223 stated, Yes, but they don't do it. The Surveyor asked what happens when staff are asked to help you with tooth brushing. Resident #223 stated, They say they will get to it, and then don't come back. e. On 01/09/24 at 03:16 PM, Resident #223 was sitting up in a blue specialized chair in his room watching TV. The Surveyor asked if his teeth had been brushed. Resident #223 stated, No. The Surveyor asked if anyone had offered to help brush his teeth today. Resident #223 stated, No. Resident #223's breath had a foul odor. The Surveyor asked if he would like to have his teeth brushed. Resident #223 stated, Yes. The Surveyor asked if he had asked for help brushing teeth. Resident #223 stated, This morning we didn't have time, and I've given up on asking. f. On 01/10/24 at 10:43 AM, Resident #223 was lying in bed awake with his face covered. The Surveyor asked if his teeth had been brushed today. Resident #223 stated, They didn't brush my teeth. I haven't gotten up yet today. The Surveyor asked permission to pull the covers down to see Resident #223's face. Permission was given, and the Surveyor pulled the covers down. Resident #223's breath still had a foul odor. The Surveyor asked if he would like to have his teeth brushed. Resident #223 stated, Yes. The Surveyor asked if he knew where his toothbrush was. Resident #223 stated, Yes it's in the cabinet. The Surveyor asked permission to open the cabinet, which was given. There was a pink basin with toiletries including a toothbrush in a closed case and toothpaste observed. g. On 1/10/24 at 10:58 AM, the Surveyor accompanied CNA #5 into the dining area and asked her to pull up Resident #223's personal hygiene documentation. CNA #5 pulled up Resident #223 in (Facility Computer Software) and stated, She didn't chart it. There is nothing charted for personal hygiene today. The Surveyor asked if she could pull up yesterday's personal hygiene documentation. CNA #5 stated, No I don't know how to do that, you will have to ask [name]. She's the one that shows me how. h. On 01/10/24 at 11:10 AM, the Surveyor asked LPN #1 to pull up specific documentation for Resident #223's oral care. LPN #1 pulled up the screen the CNAs use to document ADL care from 1/9/24 at 14:12 which documented, 1. Personal Hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers and oral hygiene) Helper does ALL the effort or task requires 2 or more helpers. The Surveyor asked how to tell if oral care or brushing teeth had been done or not done. As she pulled up the options on the screen LPN #1 stated, If it wasn't done, they should have selected the boxes marked either Not attempted, Not Available, or Resident Refused. Those should have been selected if it was not done. The Surveyor informed LPN #1 that Resident #223 had foul breath and stated that he hadn't had his teeth brushed in three days. LPN #1 stated, I will have someone down there to take care of that right away. The Surveyor asked why regular oral care was important. LPN #1 stated, A lot of reasons. Pain, Infection, and overall health. The Surveyor asked who was responsible for providing oral care. LPN #1 stated, Generally the Certified Nursing Assistants do it when they get them out of bed or put them back to bed. It depends on the resident's preference. i. On 01/10/24 at 08:58 AM, the Assistant Director of Nursing (ADON) provided an Inservice Education Report dated 4/2/2023 on Oral Care which documented under Best Practices - Oral Care .Should be done at least twice a day . Conclusion, People in residential or continuing care have an equal right to good oral health as people residing in the community . j. On 01/10/24 at 01:01 PM, the Surveyor asked the ADON how to tell if oral care had been done for residents if it is not specifically documented in the Electronic Health Record (EHR). The ADON stated, The best way to tell is to go down and look to make sure there is no food on their face or particles in between their teeth. If they have dentures, look to see if they are soaking. The Surveyor asked who was responsible for resident oral care. The ADON stated, The CNAs. The Surveyor asked why routine oral or dental care was important. The ADON stated, A lot of things. Infection from bacteria building up in the mouth, and dignity as far as looks and smells. k. On 01/10/24 at 01:31 PM, the ADON informed the Surveyor that there was no facility policy for nail care or oral care.

Based on observation, record review, and interview, the facility failed to ensure physician's orders for cleaning the BiPAP (bilevel positive airway pressure) mask and machine were followed for 1 (Resident #16) of 1 sampled resident and an oxygen humidifier bottle was adequately filled with water and deemed safe for administration for 1 (Resident #52) of 1 sampled resident. The findings are: 1. Resident #16 had a diagnosis of Obstructive Sleep Apnea. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/23 documented a Brief Interview Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact) and had a non-invasive mechanical ventilator (CPAP (continuous positive airway pressure)/BiPAP). a. A Physicians Order dated 3/23/23 noted clean BIPAP water tank & Mask with soap and water, wipe down external surface of machine, mask and tubing, allow to air dry not in direct sunlight every day shift and every 24 hours as needed . b. A Care Plan initiated 5/26/23 documented, .Clean bipap as ordered . prefers to keep mask on side table and does not like to keep mask in bag . c. A Care Plan initiated 11/17/21 documented, .has risk for altered respiratory status/difficulty breathing r/t [related to] sleep apnea . Clean bipap as ordered . prefers to keep mask on side table and does not like to keep mask in bag . d. On 01/08/24 at 02:33 PM, Resident #16 was lying in bed awake, a BIPAP mask was at bedside uncontained, resting inside of an open drawer on top of personal items, with no barrier. The Surveyor asked Resident #16 if he put the mask on and off by himself. Resident #16 stated, Yes. e. On 01/09/24 at 11:36 AM, Resident #16 was ambulating from the bathroom back to the bed after filling a water jug in the bathroom. The BIPAP mask remained uncontained and resting in the opened drawer of the nightstand. It was open to air and resting on objects and personal toiletries in the drawer. f. On 01/09/24 at 03:12 PM, Resident #16 was lying awake in bed watching TV. The BIPAP mask remained uncontained sitting on top of items in the opened drawer. The Surveyor asked Resident #16 if there was a bag to put the mask in. Resident #16 stated, They gave me one., as he sat up to find a plastic baggie in the drawer dated 10/26/23. Resident #16 placed the BIPAP mask in the bag and sat it back in the opened drawer. g. On 01/10/24 at 04:20 PM, Resident #16 was lying in bed awake wearing his BIPAP mask. The Surveyor asked Resident #16 if anyone had washed or cleaned the mask and machine today, yesterday, or any time during the week. Resident #16 stated, No. The Surveyor asked how long it had been since anyone had cleaned his BIPAP mask, tubing, and machine. Resident #16 stated, It's been about 2 weeks. h. On 01/11/24 at 09:34 AM, Resident #16 was out of the room. The BIPAP mask was lying on top of personal items in the drawer uncontained. There appeared to be specks of white particles on the clear section of the mask. At 9:57 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 to accompany the Surveyor into Resident #16's room. The Surveyor asked CNA #1 who was responsible for cleaning the BiPAP mask and equipment. CNA #1 stated, I really couldn't tell you. I hate to lie. CNA #2 entered Resident #16's room. The Surveyor asked how often the BiPAP mask and equipment were supposed to be cleaned. CNA #2 stated, I'd have to ask the nurse. The Surveyor asked why it was important to keep the BIPAP mask and machine clean. CNA #2 stated, Infection control, bacteria. The Surveyor asked what could happen if the mask and tubing was not cleaned regularly. CNA #2 stated, It could make them sick, or expose them to bad germs and bacteria. Resident #16 entered the room and sat on the edge of the bed. The Surveyor asked Resident #16 when the last time the mask and machine were cleaned. Resident #16 stated, It's been about two weeks. CNA #2 stated, Sometimes residents clean their own. The Surveyor asked Resident #16 if he cleaned his own BIPAP mask and equipment. Resident #16 stated, No. The Surveyor asked Resident #16 who normally cleans his mask and machine. Resident #16 stated, [Name]. CNA #2 stated, [Name] is the nurse on the three to eleven shift. i. On 01/11/24 at 11:09 AM, the Surveyor accompanied Registered Nurse (RN) #1 to Resident #16's room and asked how often his BIPAP mask and equipment were cleaned. RN #1 stated, His mask is wiped out every shift and air dried with vinegar and water. The Surveyor asked who does the cleaning. RN #1 stated, The day shift nurse does his. The Surveyor asked when was the last time Resident #16's mask and machine were cleaned. RN #1 stated, Yesterday. Resident #16 was standing in the room and added, They cleaned it today. The Surveyor asked who had cleaned it, and when it was cleaned. Resident #16 stated, [Name] the CNA, after you left. The Surveyor asked RN #1 who normally cleans Resident #16's mask and machine, and if CNAs are assigned that task. RN #1 stated, Usually the nurse cleans it. I'm not sure what [Name] wiped it out with this morning, but it's usually us. The Surveyor asked what could happen if the mask and machine were not cleaned on a regular basis. RN #1 stated, He can get a bad infection, bacteria, or mold. The Surveyor asked where the mask should be stored. RN #1 stated, It should be in a bag, but he uses it quite often, so we have a hard time keeping it covered. The Surveyor asked why it was important to keep it contained. RN #1 stated, So nothing can get transmitted on to him that could make him sick. Infection Control. 2. Resident #52 had a Diagnosis of Acute and Chronic Respiratory Failure, Unspecified whether with Hypoxia or Hypercapnia. A 5-Day MDS with an ARD of 12/4/23 documented a BIMS score of 8 (8-12 indicates moderate cognitive impairment) and received oxygen therapy. a. A Physician's Order dated 3/29/23 documented, .May have Oxygen 2 LPM (Liters per Minute) Via N/C (nasal cannula) as needed every shift for Oxygen Therapy . b. A Care Plan initiated 12/14/22 documented, .has altered respiratory status/difficulty breathing r/t COPD [Chronic Obstructive Pulmonary Disease] .Administer medication/treatment as ordered . Observe for s/sx [signs and symptoms] of respiratory distress and report to MD [Medical Doctor]/Nurse PRN [as needed] .O2 via nasal cannula as ordered . c. On 01/08/24 at 11:56 AM, Resident #52 was lying in bed with oxygen at 2 liters via nasal cannula. The humidifier bottle was dated 1/3/24 and was empty and swollen. The tubing was not dated. There was an empty baggie hanging from the tubing dated 1/3/23. d. On 01/09/24 at 08:46 AM, Resident #52 was lying in bed awake with oxygen at 2 liters via nasal cannula. The humidifier bottle remained empty and swollen with a date of 1/3/24. Tubing remained undated, and empty baggie dated 1/3/23 remained hanging from the tubing. e. On 01/09/24 at 02:26 PM, Resident # 52 was lying in bed asleep with oxygen at 2 liters via nasal cannula. The Humidifier bottle remained empty and swollen with a date of 1/3/24. Tubing remained undated, and empty baggie dated 1/3/23 remained hanging from tubing. f. On 01/10/24 at 01:03 PM, the Surveyor asked the Assistant Director of Nursing (ADON) if residents receiving oxygen via nasal cannula should have humidifier bottles with water in them. The ADON stated, They should, and yes, they should have water in them. The Surveyor asked how often humidifier bottles should be checked. The ADON stated, Daily, and every shift. Also, the departmentals when they are doing rounds in the morning The Surveyor asked why it was important to make sure humidifiers were checked and half full of water. The ADON stated, To make sure the nasal passages do not dry out. The Surveyor asked what could happen to residents if humidifiers are not checked or filled with water. The ADON stated, Nosebleeds from dried mucosa. g. On 01/10/24 01:33 PM, the ADON provided a policy titled, Respiratory Care, which documented, Policy .The facility will ensure residents that need respiratory care, including tracheostomy care and suctioning, will be provided consistent with professional standards of care . h. On 01/10/24 at 01:33 PM, the ADON provided documentation titled, Procedure Guidelines 10-12 Administering Oxygen by Nasal Cannula, which documented under section Equipment, .Humidifier filled with sterile water . and under Performance phase, .1. Make sure the humidifier bottle is filled to the appropriate mark .

Complaint # 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 for 1 (Resident #1) of 1 case mix resident who was at risk for elopement. The facility failed to consistently monitor Resident #1 during a period when he was allowed off of the secure unit where he resided; the resident walked out of the secure unit when the doors were propped open, entered the front door security code (which was posted near the door), then exited the facility through the front door and walked down the highway alone, at night. This failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1. This failed practice had the potential to affect only this resident (the only resident in the facility who was assessed as at risk for elopement) according to a list provided by the Administrator on 10/3/17 at 12:00 p.m. The Administrator was informed of the past immediate jeopardy condition on 10/4/17 at 11:15 a.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. a. A Physician order [REDACTED]. b. The Admission Agreement dated 4/5/16 documented, .Responsible Party - to appoint one family member or other person to act as the Resident's responsible party in admission, care and treatment, and discharge decisions, and to designate one other contact person if the responsible party is not available . Please name the responsible party and one alternate: (Family member #1) and (Family member #2). c. A Nurse's Note dated 4/5/16 at 4:51 p.m. documented, Resident admitted to (current facility) from (past facility). Resident admitted to male secure unit per MD (Medical Doctor) orders due to elopement risk . Resident alert and oriented times 3 with mild confusion noted . d. A Nurse's Note dated 9/17/16 at 3:13 p.m. documented, Resident constantly opens the door to the secured unit, resident knew the code for the key pad. Resident would let other residents out of the secured unit, where they would have to be escorted back down to secured unit. Key code is now changed and resident gets visibly upset when no one will tell him the code. Resident constantly punches in numbers to attempt to figure out the code. Aid present on hall for observations. e. A Nurse's Note dated 10/3/16 at 2:59 p.m. documented, Late entry for 9/27 - Quarterly Note: Resident is currently on the male secure unit with no future plans of being removed from the unit. He tends to come off the unit for meals and certain activities. Recently, he has been trying to get outside more and is very difficult to redirect once he is outside. He tends to keep to himself and is soft spoken . f. A Nurse's Note dated 12/20/16 at 9:28 p.m. documented, Late entry for 12/16 - Quarterly Note: Resident is still on the male secure unit . He is able to ambulate with the help of his walker. He attempts to get off the unit from time to time and the code has to be changed . g. The Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/16/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a brief interview for mental status (BIMS); was independent with transfer, walking in room and corridor and locomotion; had active [DIAGNOSES REDACTED]. A Care Area Assessment (CAA) Summary dated 3/16/17 documented, CAT (Care Area Trigger) Worksheet Problem Area: 11. Falls . He is at high risk for falls due to side effects of his psychotropic medications, poor safety awareness, and TBI (Traumatic Brain Injury). Safety interventions in place by staff. He walks with a rolling walker at this time. h. A Care Plan dated 6/12/17 documented, 4/26/16 - Resident is alert and oriented. He is pleasant with others. He enjoys most activities. He also enjoys going out to smoke on his scheduled smoke times. He remains on the male secure unit due to past attempts of elopement at other homes. Since his admission he has not attempted to leave the unit . He is at high risk for falls due to his brain injury and seizure disorder . The care plan did not accurately reflect that the resident had made attempts to exit the secure unit, as per the Nurses' Notes above, dated in September, October and December 2016. i. The Quarterly MDS with an ARD of 8/24/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, had no behaviors and required supervision with locomotion off the unit. j. A Risk of Elopement Review form dated 8/24/17 and completed by Licensed Practical Nurse (LPN) #1 documented, Is the resident cognitively impaired with poor decision making skills (i.e. (such as) intermittent confusion, cognitive deficits or disoriented)? Yes . Confusion noted at times. Does the resident have a pertinent [DIAGNOSES REDACTED].? Yes . Depression, (NAME)D (Obsessive Compulsive Disorder). Does the resident ambulate independently, with or without the use of assistive devices (including a wheelchair)? Yes. Ambulates independently using a rolling walker. Does the resident have any hearing, vision or communication problems? Yes. Mildly hard of hearing. Does the resident have a history of elopement while at home? Yes. 1-3 times . Has the family/responsible party voiced concerns that would indicate the resident may have wandering tendencies or attempt to leave? Yes . Based on review of the above risk factors and resident status, is the resident at risk for elopement at this time? Yes. Due to his prior history of elopement at other nursing facilities and home . On 10/4/17 at 10:08 a.m., LPN #1 was asked what her job consisted of at the facility and stated, I mainly do risk assessments and keep the closet care plans updated. The LPN was asked about the elopement risk assessments that she completed on Resident #1 and stated, Yes, he was considered at risk because he eloped from a prior nursing home and if that happens then they are automatically at risk at our home. He doesn't try to elope from here, but he does try to figure out the codes, and they have to change them frequently. The LPN was asked, based on her assessments of the resident, if she felt he could make rational decisions regarding his safety and stated, No. It's hard to tell sometimes if he's doing something to be ornery, or if it's a mental issue. k. A Social Service Note dated 8/25/17 at 12:59 p.m. documented, Late entry for 8/24/17 - Quarterly Note: Resident is on the male secure unit with no future plans of removal due to trying to get out of the building and difficult to get back in the facility at times. He has family members that come to visit him often and take him out to eat from time to time . l. A Special Care Unit Criteria Review dated 9/1/17 for Resident #1 documented, Criteria Review: Resident has Alzheimer's or related dementia diagnosis - No. Resident habitually wanders or would wander out of the building, and would not be able to find way back - Yes. Resident has significant behavior problem that seriously disrupts the rights of other residents - No . Resident is able to ambulate independently - Yes. At times; mostly uses a walker . Describe resident's special concerns (including behavioral issue): Had prior history at nursing home in (town); walking to the liquor store to get cigarettes. admitted to (current facility) for secure unit for this reason. Resident can be difficult to go back on the secure unit at times when he comes off for smoke breaks and activities. He is usually easy to redirect once this happens. He states he just wants to stay outside but does not attempt to run from staff or leave the facility. m. A Nurse's Note dated 9/4/17 at 10:37 p.m. by LPN #2 documented, 10:10 p.m. - Staff member saw resident on highway by the Prairie County Museum. Resident put his walker into the back of the staff member's truck. Resident states 'why are you taking me back' when staff found him. Resident was returned at 10:13 p.m. No injuries were apparent or reported. I saw him at 7:30 p.m. on unit when I was passing medication to him and his peers . An Addendum dated 9/6/17 at 7:02 p.m. and signed by LPN #2 documented, Amend to elopement risk. 9/4/17 resident alert and oriented x (times) 2, makes poor decision at times with daily activities, resident ambulates with a rolling walker with left sided weakness, resident is able to use left hand at times while eating or using his walker to ambulate . n. A Nurse's Note dated 9/7/17 at 2:32 p.m. documented, Resident has been accepted to (geriatric-psychiatric unit). Resident transported via facility van with two aids for observations . o. A Nurse's Note dated 9/9/17 at 1:14 p.m. documented, Late entry for 9/5/17: Administrator, this nurse, resident, and resident's family had care plan meeting. Administrator informed resident that what he did was very dangerous and this type of behavior is not allowed in this facility. (Family) also expressed concern to resident about how dangerous this was and how upset he was with resident. Resident stated he left facility to go and get a pizza. Resident was asked if he was happy here or if he wanted to live somewhere else and he said 'no I like it here and I just wanted a pizza.' Resident promised he would never do it again. Resident and family member informed that we were still waiting for a bed to come open in geri-psych facility. p. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and (&) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 9/11/17 documented, 9/4/17 at 10:10 p.m. - (LPN #3) saw resident (Resident #1) walking on the side of the road by the Prairie County Museum. (LPN #3) stopped and put resident's walker in back of truck and put resident inside the truck and took him back to the facility and was back by 10:13 p.m. Resident said he punched the code and walked off the unit and out the front door. Resident is a [AGE] year old male resident . ambulates independently with a rolling walker on the secure unit . Resident has a known brain injury from a previous MVA (motor vehicle accident). Resident enjoys coming off the unit for activities such as bingo, happy hour, movies, church activities, and scheduled smoke breaks. Resident returns to secure unit without incident after activities. Resident often plays with the keypad on the secure unit to show staff he is able to figure out the code, but never attempts to exit the secure unit. Maintenance Supervisor has changed the code on the door multiple times due to this. This resident along with other residents on the secure unit enjoy coming off the unit in the evenings after residents have been put to bed to get snacks and visit with staff members. The doors to the secure units are occasionally left open in the evenings during less stimulating times to allow these residents to come and go. Residents willingly return to secure unit without incident . Administrator had care plan meeting with resident and family . Resident stated, 'The door to my hall was open and I walked to the front door and punched the code in and left . I was wanting to go get a pizza and when I saw that the restaurant was closed I was going to walk on into town to another store.' Administrator informed resident that what he did was very dangerous . On 10/4/17 at 10:17 a.m., LPN #3 was asked what happened the evening of 9/4/17 and stated, I was coming out here to the facility to receive a fax and I saw something shiny and as I got closer I realized it was a walker. It was (Resident #1). I rolled down my window and asked him where he was going and he said he was going to get a pizza. He asked me if I was bringing him back and I said yes. Then he picked up his walker and put it in my truck. The LPN was asked why the resident was on the unit and stated, He got out at another nursing home. He's never tried to leave here. When he comes off the unit, he makes his rounds and goes back. Usually someone stands at the door and watches them. I don't know what happened that night. q. A Social Service Addendum Note dated 9/12/17 for 8/25/17 documented, Correction: Resident can be difficult to get back on the male secure unit at times due to not wanting to go back on the unit. He has not attempted to leave the facility or run from staff, he just states that he wants to remain outside or off the unit. He is usually easy to redirect during this time and does not show aggression or violence towards staff members. He appears to just want to sit in the day room, walk the halls or find something to occupy his time and not return to the male unit. On 10/2/17 at 1:50 p.m., the Social Director was asked about her quarterly note addendum dated 9/12/17 and stated, I was asked to clarify that because it wasn't very clear. I thought he had tried to leave this building, but he hadn't, so I wrote the addendum. He comes off the unit for activities and smoking, and they've kind of backed off of that, because he doesn't want to go back on the unit. She was asked why staff would leave the secure unit door open, but not provide supervision for him, knowing the resident was an elopement risk. She stated, I'm not sure how to answer that. I mean, he came from another facility because he was getting out. r. On 10/2/17 at 2:45 p.m., LPN #2 was asked what happened the evening of 9/4/17 and stated, We would leave the doors open, if there was less stimuli, and (Resident #1) would come out of the unit to get a snack. Just so he wouldn't feel so confined. And he was bad about knowing the code. The LPN was asked why he was on the unit and stated, Elopement. I think his history is that he eloped from another facility and someone found him in a ditch. s. On 10/2/17 at 3:56 p.m., Certified Nursing Assistant (CNA) #1 was asked about the events of 9/4/17 and stated, I normally work the units, but that night, I was working the 400 hall. I had no idea until they came in with him that he was gone. At night, when it's quiet, we would leave the door open to the unit so they could come out and get snacks. He's never done this before. He's tricky though. The CNA was asked why the resident was on the unit and stated, From what I have heard, he was an elopement risk at another facility. That's all I know. The CNA was asked if it was okay to prop the door to a secure unit open for an elopement risk resident to come out without supervision and stated, No, I don't think so. Before, when I would do it, I would stay with him. When I first came here, it was strictly locked. But we are trying to de-institutionalize this place, give them more freedom as people. We were trying this out to see if we could give them something. It was working. We have never had any trouble with (Resident #1). t. On 10/2/17 at 3:24 p.m., CNA #2 was asked what happened the evening of 9/4/17 and stated, I was working that night, and to be honest, I didn't see him. I was on the women's unit that night when he left. I didn't even know he had left til they told me to check all the windows and alarms. The CNA was asked if the resident routinely came off the unit at night and stated, Yes, he would come out, walk around the Nurse's station, get a snack and go back. But he's never tried to leave. The CNA was asked why the resident was on the unit and stated, I'm not sure, other than he's at risk for leaving. u. On 10/2/17 at 3:34 p.m., CNA #3 was asked what happened the evening of 9/4/17 and stated, I was on the unit, and there was nothing going on out of the ordinary. He was in his bed watching TV, and I left that room to go help another resident. Everybody was in bed, and I thought he was in bed too. I didn't know he wasn't in bed until he was brought back. The CNA was asked how he got off the unit and stated, We leave the door open for him to do that. The doors have magnets that hold them open. Normally, one of us is out there watching him. The CNA was asked why he was on the unit and stated, I'm not totally sure. He's never tried to escape from this nursing home at all. v. On 10/3/17 at 10:42 a.m., the Director of Nursing (DON) was asked about Resident #1 and stated, I have never known him to try to escape. He teases and thinks it's funny to learn the code. When he comes off the unit at night for a snack, he always goes right back in the unit. I've seen him go out with his cousin to eat, and he will get out of the car and come back in. I think he does stuff to get attention. The DON was asked why the doors to the locked unit were propped open and stated, Isn't that what culture change is all about? To make it more like home? w. On 10/3/17 at 7:30 p.m., the resident's Power of Attorney (Family Member #2) was contacted and asked if she felt it was safe for the resident to leave the nursing home and go where he wanted to go whenever he wanted to go and stated, Well no, it's not safe. The place he was at before, police would call us at 2:30 a.m. because they would find him walking down the street. He was found in a deep ditch one time. The family member was asked why the resident was at the nursing home and stated, Because (former facility) kicked him out due to his elopements. The family member was asked why he was on the secure unit and stated, Because he will leave if he is not. That's why we were so surprised when we got a call telling us he got out. We had no idea the CNA had left the door to the unit open until we went up there. My husband asked for a copy of the incident report, and they wouldn't give it to him. But they did read it to us. That's when we found out about them leaving the door open. The family member was asked if the resident had the capability to make sound decisions regarding his safety and stated, No. Now he is smart. He was an electrician before he had an accident that caused a brain injury. Doctors took out a big part of his brain. We don't know what to do. He has no one left to help him, and that's why we stepped in. We just don't want him to get out and get hurt. He has some left-sided weakness due to a couple of strokes and he loses his balance a lot. The family member was asked if the resident had ever tried to leave this facility before and stated, As far as I know, he has not. But they tell us all the time, 'well he's cracked the code, so we are changing it again.' He tells us all the time that he wants to go home, but he has no home to go to. The resident's Durable Power of Attorney information was reviewed; the form was dated as recorded 7/14/16 and documented, .This Power of Attorney may be revoked only by written revocation entered of record in the office of the County Clerk of in which this instrument is recorded . My attorney has the power to make any health care decision for me. It is my intention that my attorney has a personal obligation to me to make health care decisions to the same extent that I would have if able to make decisions for myself which shall include, but not be limited to, the authority: .To make all necessary arrangements at any hospital, psychiatric hospital or psychiatric treatment facility, hospice, nursing home or similar institution . all as my attorney shall deem necessary for my physical, mental and emotional well-being . x. On 10/4/17 at 9:23 a.m., the Medical Director and his nurse were asked about the resident's cognitive status. The physician stated, We see him at least once a month. He has always answered my questions appropriately, but of course those are basic medical questions, like are you in pain. My nurse converses with the residents here on a more personal level. His nurse was asked if she felt the resident could make sound decisions regarding his safety and stated, I think he has the capability to walk to the gas station and then back. But I can't say he's that way 24/7. y. On 10/4/17 at 10:33 a.m., the MDS Coordinator was asked about Resident #1's cognitive status and stated, I think he's very smart in some things. I think he can make good decisions on some things, but I wouldn't trust him in a car or with a bottle of medicine. I don't think he could make it in assisted living, but I think he knows better than to do things like leave. The MDS Coordinator was asked if she considered the resident an elopement risk and stated, My reason for considering him an elopement risk is because (POA) couldn't keep him at home. (Resident #1) would leave and wind up in a ditch, and he left the other facility. My rationale is that he's done it before, so he'll probably do it again. z. On 10/4/17 at 11:24 a.m., the resident was asked if he could say how he got out of the facility on 9/4/17 and stated, I walked to get me a drink, then walked out the front door. The resident was asked how he got out the front door and stated, I punched the code in. They had it posted. The resident was asked if he knew the code now and stated, No. The resident was asked if he was happy with his POA making decisions for him and stated, Yes, I'm okay with that. The resident was asked when he left that night, did he consider that it could be unsafe for him to be walking down the street after dark and stated, No. I didn't think about it. aa. On 10/4/17 at 11:40 a.m., the Administrator stated the resident had not been declared incompetent by a court, therefore, the resident could come and go from the facility as he pleased. According to the Nurse's Notes, the resident was in a geriatric-psychiatric (geri-psych) facility from 9/7/17 until 9/25/17. On 10/4/17 at 12:50 p.m., the resident's psychiatric physician was asked about the resident's cognition while in the geri-psych facility and stated, When he left here, he was in good shape. He left with a [DIAGNOSES REDACTED]. I don't give that [DIAGNOSES REDACTED]. One example is when he was here, he knew that he had to go to group, but he wanted to lay on his bed instead. When I talked with him and explained why he needed to go to group, he went. I started him on some Ritalin to help with cognition, but all of that can change obviously. It's fluid. I think he's on that slippery slope. Here, he understood and knew, but I also saw signs of where he's going. He was asked if he felt the resident's cognition could fluctuate from day to day and stated, Yes, I think that's likely. You have good days and bad days. Sometimes we want black and white, but there's gray. That's about as honest as I can get. The physician was informed that the resident had left the facility alone, at night, and stated, That's not good. We can't have that. bb. Based on the resident's location at the time he was spotted by LPN #3, as compared with Google satellite images and mileage information, the resident crossed a 4-lane highway after dark and was walking, with his walker, near a museum that was 0.2 miles away from the facility, before being picked up by LPN #3 and returned to the facility. 2. The facility removed the Immediate Jeopardy and corrected the failed practices on 9/8/17, prior to the survey entrance date, as evidenced by the following: a. The facility's written corrective action plan, per the DMS-762 dated 9/11/17, documented, .9/4/17 - the resident was placed 1:1 (one-on-one) until placement was found at a geri-psych facility on 9/7/17. The local police department was notified to make a report of the incident. Staff completed a head count on the unit to ensure all residents were accounted for and there were no negative findings. A body audit was performed by the nurse with no negative findings. The Maintenance Supervisor came to the facility to change the code to the unit. The family of the resident was notified. The resident's physician was notified. The nurse called several geri-psych facilities but could find no available beds on 9/4/17. The nurse started an in-service regarding standing in front of the keypad so residents could not see the code being punched . On 9/5/17, the keypads on both secure units were covered and codes were changed. Maintenance supervisor removed the code that was posted at the front door entrance going out of the facility. A note was placed at the front entrance keypad going out of the facility stating 'The code to exit our home has been changed. Please see any staff member to assist you with leaving.' Staff was in-serviced that the doors to the secure units are no longer allowed to be left open. The CNA who propped the door open was counseled and suspended for 3 days and will no longer be allowed to work on the unit. The Administrator had a care plan meeting with the family . On 9/6/17, the Administrator re-enacted the incident and walked a tenth of a mile to the museum and it took 5.5 minutes. On 9/7/17, the resident was transported to a geri-psych facility. On 9/8/17, the Assistant DON reviewed all elopement risk assessments for residents on the secure unit. The code to the keypad on the unit will be changed every month. Since 9/4/17, department heads and nursing staff were inserviced on new systems put in place to prevent elopement from the facility. Department heads complete rounds at least daily that includes monitoring of new systems put in place in include the following: keypads are covered, keypad code is not posted at the front door exiting the facility, notification sign at the front door regarding code change, and secure unit doors locked and closed at all times. Daily rounds are completed by Department Heads during focus rounds and by shift supervisors to monitor these interventions and reviewed during daily startup. The Maintenance Director will change the secure unit door keypad code monthly, and as needed, for additional security and monitors for continued presence of keypad covers. There have not been any negative findings reported during daily startup, or on the 24 hour nursing report, with all interventions intact with ongoing daily/shift monitoring. b. On 10/2/17 at 5:00 p.m., the surveyor and the Maintenance Manager observed and checked all exit doors and unit doors in the facility for proper functioning. All doors were functioning without any problems, and door codes were not posted in areas that were visible to residents.