Every finding on record at Emerald Trace

Based on observation, interview, review of the facility's documents, and review of the facility's handbook, the facility failed to support and encourage residents to organize and participate consistently in the Resident Council meeting for 2 out of 5 sampled residents, Resident (R) 6 and R38. The findings include: Review of the facility's Resident Handbook - Grievances and Complaints, undated, revealed, Residents may also voice grievances during the Resident Council meetings. Review of the facility's monthly activity calendars, dated from 02/2025 to 07/2025, revealed there were no scheduled Resident Council meetings noted on the calendar. Review of the Resident Council minutes, dated 02/2025 to 06/2025 and provided by the facility, revealed there were no other minutes or meetings during that time frame. Observation of the Resident Council meeting on 08/20/2025 at 1:00 PM revealed the Ombudsman was present, along with five resident participants. During the Resident Council meeting on 08/20/2025 at 1:00 PM R6 expressed a concern for not having consistent Resident Council meetings. Review of R6's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/07/2025 revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 11 out of 15, which indicated moderate cognitive impairment.In addition, during the Resident Council meeting on 08/20/2025 at 1:00 PM, R38 also expressed a concern for not having consistent Resident Council meetings. Review of R38's quarterly MDS, with an ARD of 04/11/2025, revealed the facility assessed the resident to have a BIMS score of 11 out of 15, which indicated moderate cognitive impairment.During an interview with the Ombudsman on 08/20/2025 after the Resident Council meeting at 2:14 PM, she stated she had not been notified of ongoing council meetings and asked for the Social Services Director to convene one for July 2025, and the facility complied. During an interview with the Administrator on 08/20/2025 at 2:30 PM after the council meeting, she stated she knew there had been a lapse in the regularity of the meetings since the Resident Council president transferred to another facility. She stated there were no meetings from 02/2025 through 06/2025. She stated it was her expectation that staff scheduled the Resident Council meetings and to encourage residents to participate.

Based on observation, interview, and review of the facility's policy, the facility failed to store frozen green beans appropriately. Observation on 08/19/2025 of the main kitchen freezer in building B revealed the frozen green beans were taken out of the cases by staff, placed onto the shelf, and not dated according to facility policy.The findings include:Review of the facility's policy titled, Food and Supply Storage, revised 01/2025, revealed all food would be stored in a manner to prevent contamination and to maintain the safety and wholesomeness of the food for human consumption. Per the policy, staff was to use the Daymark labeling system or permanent marker to mark the received date on all items removed from the original shipping box and complete all sections of a food label sticker.Observation in the main kitchen, ground floor in building B, on 08/19/2025 at 2:45 PM revealed in the walk-in freezer, on the top shelf, staff had taken the frozen green beans out of the boxes, discarded the box, and did not date the green beans according to the date found on the box. In an interview with the Senior of Dining Services on 08/21/2025 at 2:48 PM, he stated all food should be dated according to their process, which was to put a date on all food items taken out of the case. In an interview with the Director of Health Services (DHS) on 08/22/2025 at 11:39 AM, she stated her expectation was for all food to be dated according to their process.In an interview with the Administrator on 08/22/2025 at 12:26 PM, she stated all food must be dated.

Based on observation, interview, record review, review of the facility's fall investigation reports, review of a police report, and review of the facility's policies, it was determined the facility failed to ensure it had a system in place for adequate supervision and monitoring to ensure residents at risk for elopement received the necessary supervision to maintain their safety and prevent elopement for two (2) residents (Residents #57 and #115) out of a sample of sixty-nine; and to prevent accidents/falls, to determine the root cause of falls, to evaluate falls, implement individualized interventions, and to monitor the effectiveness of interventions to prevent falls for two (2) residents (Resident #13 and #17) out of a sample of sixty-nine. 1. Resident #57 was admitted on [DATE] at 3:00 PM, with diagnoses of dementia, other amnesia, and a laceration to the head which had staples in place. The facility assessed the resident not to be an elopement risk upon entry to the facility. However, on 07/30/2023 at approximately 10:45 AM, Resident #57 was in the common area and was getting agitated with staff interaction. Resident #57 exited the facility without staff knowledge. Review of the Police Incident Report: 2023-00030066, revealed the police were called at 11:23 AM, and the police returned the resident at 11:57 AM. The facility's failure to have an effective system in place to ensure each resident received adequate supervision and monitoring to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy along with Substandard Quality of Care was identified on 12/03/2023 and was determined to exist on 07/30/2023 under the area of S483.25(d)(2) Free of Accident Hazards/Supervision/Devices, F689 at a Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy (IJ) on 12/03/2023. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 12/12/2023, alleging removal of the IJ on 08/01/2023. The State Survey Agency (SSA) determined the facility had removed the immediacy of the Jeopardy on 08/01/2023, as alleged, before initiation of the survey. However, additional deficient practice was identified at F689 at a scope and severity of a G. 2. Resident #13 had five (5) documented falls with resulting fractures from 06/04/2022 to 10/22/2023. On 06/17/2022 it was documented the resident had fallen out of his/her wheelchair in the doorway to his/her room and fractured his/her left hip. On 11/10/2022, the resident had fallen out of his/her wheelchair and fractured his/her right thumb. On 02/01/2023, the resident attempted to stand and readjust himself/herself in the wheelchair, lost his/her balance and fell , fracturing his/her left clavicle. On 04/26/2023, staff found the resident during rounds lying on his/her back on the floor next to the bathroom. Resident #13 stated it just happened, his/her chair had fallen out from under him/her and he/she hit the floor, resulting in a [NAME] Fracture (a fracture of the bone ring) to his/her Cervical Vertebra number one (C1). Lastly, on 10/21/2023, Resident #13 was observed lying on his/her left side on the bathroom floor which resulted in a repeat [NAME] Fracture to his/her Cervical Vertebra number one (C1). 3. Resident #17 had a fall on 01/08/2023 while being transferred from the toilet to the wheelchair when his/her legs gave out and he/she was lowered to the floor by a nurse aide. Resident #17 was a [NAME] (sit-to-stand) mechanical lift for transfers. However, review of the facility's Mechanical lift policy revealed the facility required all mechanical lifts to have two (2) people in attendance. Resident #17 sustained an acute left ankle fracture requiring surgical intervention from the fall. 4. The facility assessed Resident #115 to be not be at risk for elopement on 11/15/2023. Observation on 12/01/2023 at approximately 1:15 PM, revealed a door alarm sounded, and Resident #115 opened a keypad alarmed door which exited the facility toward the front parking lot. Physical Therapy Assistant (PTA) #1 intervened when the resident was located halfway out the door in his/her wheelchair. PTA #1 stated she was getting off the elevator and heard the alarm sounding and went to find out where it was. The findings include: Review of the facility's policy titled, Elopement, last reviewed 07/30/2023, revealed the facility defined elopement to be when a resident who was cognitively, physically, mentally, emotionally, and/or chemically impaired leaves our facility, without staff knowledge. The policy also revealed a resident who leaves a safe area may be at risk of heat or cold exposure, medical complications or other conditions that threaten their health and safety. Per the policy, to decrease the risk of resident elopement the facility would ensure each resident was assessed for their elopement risk upon admission, quarterly, and as needed. The policy stated all residents were either high risk or low risk, no residents would be assessed as no risk. Both would be documented on the care plan with interventions. The policy noted the facility used an eyes on approach, which meant the resident was visualized regularly and that contact was to be noted on the Medication Administration Record (MAR, during medication administration). Staff would be trained on being vigilant in watching facility exits and identifying residents who were attempting to leave. Review of the facility's policy titled, Accidents and Supervision, implemented 03/24/2023, revealed each resident would receive adequate supervision to prevent accidents and/or hazards, and a fall was considered an accident or a hazard. Staff members were to identify hazards and risks, evaluate and analyze hazards, implement interventions, and monitor for effectiveness and make changes as needed. The policy defined adequate supervision as an intervention and means of mitigating the risk of an accident. Review of the supervision portion of the policy revealed the facility would provide adequate supervision to prevent accidents, and adequacy of supervision was defined by type and frequency and would be based on the individual resident's assessed needs and identified hazards in the resident's environment. Review of the facility's policy titled, Fall Management, undated, revealed care and assistance would be provided to maintain the resident's highest practicable level of well-being, which included minimizing the risk of falls. Individual resident needs for staff assistance and equipment during toileting, transfer, ambulation, and all activities of daily living would be assessed and addressed as appropriate via the Resident Assessment Instrument (RAI) process to determine if residents were at risk (for falls) and implement interventions to minimize the risk of falls. Per the policy, the Fall Committee would review each resident who had fallen as well as the interventions that were in place to minimize the risk of falls. This committee would look at and try to determine the root cause of the fall. 1. Review of Resident #57's medical record revealed the facility admitted the resident on 07/28/2023 at 3:00 PM, with diagnoses of dementia, other amnesia, and a laceration to the head which had staples in place. The facility assessed the resident not to be an elopement risk upon entry to the facility. Review of Resident #57's Progress Note completed by Licensed Practical Nurse (LPN) #7 on 07/28/2023 at 3:00 PM, revealed the resident arrived at the facility via wheelchair van and transferred independently from the wheelchair to the bedside chair. Review of Resident #57's Progress Note completed by LPN #7 on 07/28/2023 at 4:09 PM revealed, per the Medical Director, to add the diagnosis of dementia with behavioral disturbances. Review of Resident #57's Admission Assessment Part 1 completed by LPN #7 on 07/28/2023 at 4:12 PM, revealed the resident was noted as alert with confusion. The assessment revealed the resident walked independently without the use of any assistive devices. Review of Resident #57's Admission Assessment Part 2 completed by LPN #7 on 07/28/2023 at 4:13 PM, revealed a risk factor for the resident was cognitive impairment which was noted as difficulty making decisions in new situations, decisions were poor, required cues or supervision, or did not make decisions at all. The resident was noted with diagnoses of dementia and psychiatric diagnosis. The facility identified the resident not to be an elopement risk. Review of Resident #57's Brief Interview for Mental Status (BIMS) completed by the Minimum Data Set (MDS) Coordinator on 07/30/2023, revealed Resident #57 had a BIMS' score of nine (9) of fifteen (15), which indicated moderate cognitive impairment. Review of Resident #57's Baseline Care Plan revealed it was created by Social Worker #1 on 07/29/2023. Interventions included: discharge planning two (2) days prior to discharge and reach out to family to ensure arrangements were made; encourage participation in activities; encourage the resident with non-pharmaceutical interventions; call the resident by his/her first name as preferred; meet with the resident and his/her family regularly about care plans and progress; introduce the resident to others; watch for signs and symptoms of traumatic experiences and document, as needed; allow the resident the opportunity to express himself/herself; and, treat the resident as an adult. Resident #57's Baseline Care plan was completed on 07/30/2023 at 1:36 PM, after the elopement. Record review revealed on 07/30/2023 at approximately 10:45 AM, Resident #57 was in the common area and was getting agitated with staff interaction, telling staff not to touch him/her. In interview, Licensed Practical Nurse (LPN) #4 stated she observed the resident getting agitated and decided it was best for staff to give the resident some space. She explained she went on to check a blood sugar, and the aides left the area. LPN #4 explained when she returned a few minutes later, Resident #57 was no longer in the common area. Staff searched for the resident and did not locate him/her, and a Code Yellow (Missing Person) alert was called. Staff searched inside and outside the facility and did not locate the resident. Review of the Police Incident Report: 2023-00030066, revealed the police were called at 11:23 AM, and the police returned the resident at 11:57 AM. Review of Resident #57's Hospital Discharge Summary completed by the Attending Physician on 07/28/2023, Inpatient Psychiatry Progress Note, revealed, The patient was seen for the follow-up from the psychiatric standpoint regarding change in mental status, confusion, disorientation, capacity to make informed decisions. The patient was somewhat angry, irritable, [he/she] did not sleep very well last night. [He/she] was oriented to person, place, but not time. The patient may need disposition, [he/she] had word-finding difficulty, [he/she] had element of anger and irritability. [He/she] will be placed on Seroquel 25 mg at bedtime (an antipsychotic which can be used to aid sleep). [He/she] did not seem to have capacity to make informed decisions, [he/she] does not seem to have ability to be independent anymore. Continued review of the Hospital Discharge Summary completed on 07/28/2023, revealed a provisional diagnosis of major neurocognitive disorder, probably Alzheimer's type, late onset, with behavioral disturbances, rule out delirium, due to multiple etiologies. The discharge summary noted the resident's Active Hospital Problems/Diagnosis: syncope and collapse, major neurocognitive disorder due to Alzheimer's disease, without behavioral disturbance, scalp laceration, initial encounter, atrial fibrillation with rapid ventricular response (new onset), skin rash, impaired memory, hyponatremia, type 2 diabetes mellitus without complication, without long-term current use of insulin. Review of Resident #57's Continuity of Care from the hospital, dated 07/28/2023, revealed the resident lacked safety awareness and required 25% input and direction from staff. Further, it was noted the resident was not safe for independent transfers, not safe to ambulate alone, and required supervision to sit and stand, transfer bed to chair and contact guard to ambulate 101 to 150 feet with the least restrictive device. During interview on 11/28/2023 at 11:00 AM, the Administrator entered the conference room and made a statement. She stated the hospital doctor did not make the proper diagnosis for Resident #57, and the facility did not agree with the assessment of the resident. She stated the resident did not need to be in the facility. She also stated it was okay the resident left the facility because he/she discharged home the next day. In an interview with the Administrator on 12/03/2023 at 4:00 PM, she stated the Interdisciplinary Team (IDT) spent a significant amount of time discussing Resident #57, and he/she did not match what the hospital reported in the discharge summary. She explained the facility determined Resident #57 left the facility without asking the aides because the resident looked for the aides but could not find them. The Administrator stated the aides tried to give the resident a bath, and he/she got mad because he/she did not need the help. She again stated the resident looked for staff but could not find anyone so the resident went home. She stated by time she arrived at the facility the resident had already been returned. During the interview, she stated she was a little concerned about heat exhaustion because of the heat on 07/30/2023. The Administrator reported the family and resident declined a trip to the hospital but wanted the resident to discharge home as soon as possible. She stated the night shift supervisor on 07/29/2023 documented or reported to other staff that Resident #57 was wandering. However, she stated the night shift supervisor gave the resident the benefit of the doubt and that was why she did not put an elopement monitor on the resident. Review of the Primary Care Physician Progress Note dated 07/30/2023, revealed [Resident #57] eloped yesterday and was found by the police and brought back. The Resident was seen by the psychiatrist, and it was determined the resident did not have the capacity to make decisions. In an interview with Resident #57's Primary Care Physician (PCP) on 12/01/2023 at 11:00 AM, she stated she was not aware the resident exhibited exit seeking behaviors. She stated the resident arrived shortly before the incident in which he/she left the faciity on [DATE]. She stated she met with the resident on 07/31/2023 to do his/her History and Physical which was after the incident. The PCP stated she was concerned about the resident's ability to return home and provide care for himself/herself. She stated the facility put a good discharge plan in place. Review of the Police Incident Report: 2023-00030066, dated 07/30/2023, revealed the police were called at 11:23 AM and the police returned the resident at 11:57 AM. The police report only gave a timeline of events; no other details were provided. Review of the Facility's Investigation Final Report, undated, revealed a new BIMS' score of ten (10) of fifteen (15), which indicated moderate cognitive impairment. Per the report, the facility's findings indicated the resident was informed by the hospital he/she could leave this facility and come and go as he/she wanted. The report stated the facility determined the resident exercised his/her right to leave the facility on 07/30/2023, based on the fact the resident was his/her own responsible party, no harm occurred to the resident, and the resident discharged home the next day. Review of wunderground.com weather for the facility's area, on 07/30/2023 at 10:52 AM, was 81 eighty-one (81) degrees Fahrenheit (F) and at 12:52 PM it was eighty-four (84) degrees F. Review of the google.com map provided in the facility's investigation, revealed they tracked the resident and determined he/she walked one and seven-tenths (1.7) miles in the time he/she was gone from the facility. Observation on 11/27/2023 at 8:00 AM of the facility's premises, revealed the facility was at the top of a large hill and at the bottom of the hill was a busy main road with five (5) lanes of traffic with a sidewalk. Review of Quality Assurance (QA) meeting minutes dated 07/31/2023 at 11:50 AM, which the facility provided as part of their investigation, revealed the resident left the facility without alerting staff and the resident packed a small bag before leaving. The facility performed a Root Cause Analysis (RCA) and determined: the resident lived independently at home prior to the hospital visit and planned to return home after a brief stay at a short term facility; the resident did not initially want to go to a post-acute care facility, but reluctantly agreed to try it; the hospital informed the resident he/she could leave the facility whenever he/she wanted to, which made the resident believe he/she could just leave; and the resident provided his/her own care at home and did not want the level of care provided by strangers. Per the minutes, the resident stated he/she was used to coming and going as he/she pleased at home. Further review of the QA meeting minutes dated 07/31/2023 at 11:50 AM, revealed the QA Committee did not find the resident eloped from the facility, because had he/she informed the facility of the desire to return home, a discharge plan would have been completed and the resident would have been discharged home. Further review of the Facility's Investigation Final Report, undated, contained the written statement provided by Social Worker #1, dated 08/01/2023, which revealed she did not believe the resident had the mental capacity to return home alone and provide the care the resident required. She noted she was informed via the granddaughter that the resident's neighbor informed her the resident needed more help than what the neighbor could provide. SW#1 also noted the granddaughter reported she noticed a decline in the resident's health in the last month, and she believed the resident needed more assistance at home. In an interview with State Trained Nurse Aide (STNA) #25 on 12/02/2023 at 9:08 AM, she recalled on 07/30/2023 she worked the shift when the elopement occurred, she was informed Resident #57 was gone, and the police returned the resident to the facility. She stated she recalled seeing Resident #57, and he/she looked more like a visitor than a resident. The STNA stated she redirected the resident several times as he/she tried to exit the facility with other families. She stated the resident was steady on his/her feet and walked around without a walker. STNA #25 stated the morning of 07/30/2023, the resident had an incontinence episode, and staff had to find other clothes to change him/her because the resident did not have any clothes. She stated she reported her concerns of the resident trying to follow people out of the facility to the nurse on duty and to the aides. STNA #25 stated she did not know what the nurse did to follow up. In an interview with STNA #26 on 12/02/2023 at 2:09 PM, she stated Resident #57 seemed like he/she was a family member, not a resident, and appeared to be very with it. She explained Resident #57 wanted to put his/her belongings in the common area because the resident said someone was picking me up in the morning. She stated the resident was guided to put personal items back in his/her room. STNA #26 stated the resident went into other residents' rooms and had to be redirected several times. She explained Resident #57 had an incontinence episode. During the interview, she stated she and another aide tried to get the resident cleaned up, and that was when he/she became agitated and told staff not to touch him/her. STNA #26 stated it was reported to her the resident tried to follow another family out the front door but was redirected. She stated she was not sure if the resident was reassessed or not, but she recalled being told to keep an extra eye on the resident until he/she fell asleep. She said it was reported at shift change for staff to keep an extra eye on the resident because she was not sure if he/she was really supposed to be leaving or not. In an interview with Agency LPN #4 on 11/30/2023 at 10:00 AM, she explained on 07/30/2023 when she arrived at her shift at 7:00 AM, Registered Nurse (RN) #4 told her Resident #57 was an elopement risk. However, she stated RN #4 did not put a Roam Alert on the resident because she wanted to give him/her a chance to get used to the facility. LPN #4 stated the morning of 07/30/2023, Resident #57 was seated at the table in the common area near the fireplace with a cup of coffee. LPN #4 stated the resident became upset when staff tried to get him/her to change clothes after an incontinence episode, and the resident yelled out leave me alone. She said at this time the resident started to get more agitated, and she thought it was best if staff gave the resident some space. She explained she went to do a blood sugar check, and when she returned to the common area the resident was not there. LPN #4 stated the staff did a head count, looked around the immediate area for the resident, and she called a Code Yellow, Missing Person alert. LPN #4 stated she tried to announce the code over the intercom, but it did not work. She stated she had to run upstairs and inform the staff up there. She explained she and another staff looked outside the facility on foot and in the car. LPN #4 stated by the time she got back to the facility the resident had been found and was back at the facility. In continued interview with Agency LPN #4 on 11/30/2023 at 10:00 AM, she stated on 07/30/2023 she did not know where to find the Roam Alert bracelets. She stated she later found out they were locked up, and the nurse on the second floor had the keys. LPN #4 stated when Resident #57 got back to the facility, he/she stated, I watched until you were gone and then I booked it down the hill. Review of the Police Incident Report, number 2023-000300066, dated 07/30/2023, revealed the police were called at 11:23 AM and informed there was a missing person from the facility. The report revealed the police officer contacted the facility at 11:44 AM to inform the facility the resident had been located. The police noted the resident was returned to the facility at 11:57 AM. In an interview with LPN #7 on 12/01/2023 at 4:03 PM, she explained Resident #57 was pleasantly confused upon admission on 07/28/2023, and aware he/she left the hospital and was at a rehabilitation center but could not recall the name of the facility. LPN #7 stated Resident #57 did not show exit seeking behaviors while she was present. The LPN stated the resident walked independently around the facility with the use of a walker. She explained every new resident was assessed for elopement risk. She stated based on Resident #57's assessment, the resident was not determined to be an elopement risk. However, she stated the resident showed poor short-term memory recall as evidenced by his/her inability to recall the nurse's name, the year, the president, and the name of the facility. She stated when the resident was up and ambulating, staff cued him/her to sit more often to avoid falls. During the interview, she stated the resident would sit down for a minute and then would be up again walking through the halls, in his/her room, and back to the common area/dining room. LPN #7 stated she completed Resident #57's Admission Assessment Part 1 and Part 2 on 07/28/2023 at 4:12 PM. She stated she believed the resident showed clear signs of dementia because of his/her inability to recall short term information. LPN #7 stated she assessed the resident as high risk for falls and needing assistance with toileting. In an interview with Registered Nurse (RN) #4 on 12/02/2023 at 11:25 AM, she stated she was the night shift supervisor on 07/29/2023. She stated the facility did have wanderers but that was usually caught on the Admission Assessment. RN #4 stated she was given report on 07/29/2023 of a new resident but she did not recall being informed of the resident being an elopement concern. She stated a resident's behavior could differ greatly from daytime to evening because many residents had Sundowners (condition when dementia residents become more confused at night) which increased their wandering and confusion at nighttime. She stated during day shift those same residents could appear very normal. The RN stated if Resident #57 showed exit seeking behaviors, she would have put a wander guard on him/her. She stated, We were all aware [he/she]e was confused and needed to keep an eye on [him/her]. RN #4 stated she did recall informing the day shift nurse that Resident #57 wandered, and she might want to keep an eye on him/her for a couple of days. However, RN #4 stated she thought the resident's behavior was typical of a new resident getting used to being at the facility. The RN stated she thinks the aides came to her and said the resident wandered a lot. She also stated she did not recall the resident to be exit seeking, but the resident's behavior that night should have been documented. RN #4 also stated if she worked as the floor nurse during medication administration, she could not possibly keep her eyes on all the residents all the time. In an interview with Social Worker (SW) #1 on 12/01/2023 at 8:30 AM, she stated she was responsible for all discharge plans, getting people home safely, and completion of psychosocial assessments. She explained she did not meet Resident #57 until the day he/she discharged home 07/31/2023. The SW stated when she met with the resident she was still concerned about his/her return home, about the resident's impairments, and about the care the resident needed and would get at home. SW #1 said the resident had safety awareness concerns and did not understand about going home alone. She said she felt the resident lacked insight into these concerns that were discussed. SW #1 stated she called in an Adult Protective Services (APS) report because she was concerned the resident could not care for himself/herself. She said she always reported to APS if she was concerned the resident would be unable to care for himself/herself. The SW stated the only family the resident had lived out of state and was only here for a couple days, and the neighbors only helped occasionally. SW#1 stated she did not set up aftercare services. However, she stated she provided information for the family to set up the services after discharge. 46651 2. Review of Resident #13's medical record revealed the facility admitted the resident on 12/03/2021 with diagnoses of Parkinson's disease with dyskinesia (involuntary, erratic writhing movements of the face, arms, legs, or trunk), epilepsy, spondylosis (age related wear and tear of the spinal disks), and history of multiple fractures of the pelvis with unstable disruption of the pelvic ring. Review of Resident #13's Admission Minimum Data Set (MDS) Assessment, Section C, Brief Interview for Mental Status (BIMS), dated 12/10/2021, revealed a score of fourteen (14) of fifteen (15), which indicated no cognitive impairment. Review of Resident #13's Fall Risk Assessment, dated 12/03/2021, revealed the facility assessed Resident #13 as having poor vision, balance problems while standing and walking, decreased muscular coordination, was jerking/instable when making turns, and required the use of an assistive device (a walker or wheelchair). Further review of the assessment revealed Resident #13 had a history of three (3) or more falls in the last three (3) months and had neuromuscular and orthopedic limitations. Resident #13's fall risk score was documented as twenty-two (22) where a score of ten (10) or more indicated a high risk for falls. Review of #13's Admission Comprehensive Care Plan (CCP), dated 12/03/2021, revealed the facility assessed the resident as at risk for falls related to weakness, limited mobility, tremors, medication use, a history of falls, and diagnoses of Parkinson's disease (a neurological disorder with involuntary tremors/jerking movements, epilepsy (a seizure disorder), and osteoporosis (brittle/fragile bones). Further review revealed goals that included fall prevention approaches to help minimize fall risk. Interventions or approaches, dated 12/03/2021, included to make sure the call light was accessible in the bed or in the chair in the room, check regularly to assure resident safety and needs were met, and be aware that some medications increased the risk of falls. Interventions/approaches added on 12/16/2021 included the bed was to be kept in the lowest position to minimize the risk of injury if a fall occurred while trying to get out of bed, care items were to be kept in the same place and within reach, reminders to ask for help rather than try getting up alone, and to call for assistance before attempting to transfer, ambulate, or go to the bathroom were to be implemented. Review of Resident #13's Fall Risk Assessment, dated 05/23/2022, revealed the resident had been assessed as having balance problems while standing and walking, decreased muscular coordination, a change in gait pattern when going through a doorway, was jerking/instable when making turns, and required the use of an assistive device (a walker or wheelchair). Further review of the assessment revealed Resident #13 had a history of one (1) or two (2) falls in the last three (3) months and had neuromuscular, psychiatric, or cognitive and orthopedic limitations. Resident #13's fall risk score was documented as eighteen (18) where a score of ten (10) or more indicated a high risk for falls. Review of Resident #13's Quarterly Minimum Data Set (MDS) Assessment, Section C, Brief Interview for Mental Status (BIMS), dated 04/29/2022, revealed a score of fourteen (14) of fifteen (15), which indicated no cognitive impairment. Review of section GG of the same assessment revealed the facility assessed Resident #13 as requiring partial to moderate assistance with one (1) staff person for toileting and supervision assistance with one (1) staff person for transfers. a) Review of Resident #13's Progress Note dated 06/17/2022 at 3:49 PM by LPN #20, revealed she heard screaming from Resident #13's room and found the resident lying in the doorway of her room. LPN #20 documented Resident #13 had stated he/she was fixing his/her wheelchair and fell and was screaming that he/she had broken his/her hip. LPN #20 documented she placed a pillow under Resident #13's head, assessed him/her, called 911, notified the physician, called report to the hospital, and notified Resident #13's daughter he/she was being sent to the emergency room (ER). Review of Resident #13's Post Fall Risk Observation dated 06/17/2022 at 3:39 PM, revealed LPN #20 had documented she heard screaming from Resident #13's room, and upon entering Resident #13's room, she found Resident #13 lying in the inside doorway of his/her room, screaming he/she had broken his/her hip and the pain was terrible. LPN #20 further documented she placed a pillow under Resident #13's head and assessed his/her vitals, while the resident remained in place on the floor. LPN #20 documented Resident #13 stated he/she was standing up fixing the seat of his/her wheelchair when he/she fell . LPN #20 documented she called aides to the room to sit with Resident #13, notified the physician, called 911, called report to the ER, and notified Resident #13's daughter. Further review revealed LPN #20 documented after Emergency Medical Technicians (EMTs) arrived, she and the two (2) EMTs picked Resident #13 up from the floor and transferred him/her to a stretcher, paperwork for Resident #13 was provided, and Resident #13 was sent to the ER. Continued review revealed Resident #13 was assessed to have had a history of falls both prior to and since admission to the facility

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to develop and implement a person-centered care plan for falls for two (2) residents (Residents #13 and #17). The facility also failed to develop and/or implement a person-centered care plan to ensure adequate supervision was provided for one (1) resident (Resident #115). Additionally, the facility failed to develop/implement a person-centered care plan to ensure exit seeking behaviors were identified and adequate interventions were put in place for Residents #114 and #113. The number of sampled residents was sixty-nine (69). 1. Resident #13 had documented falls on 06/04/2022 (no injury), 06/17/2022 (left hip fracture), 08/22/2022 (no injury), 11/10/2022 (right thumb fracture), and 11/28/2022 (small abrasion to left elbow, minor swelling to the left forehead and redness to the lower back) and no fall interventions had been added to the fall care plan for any of the falls. 2. On 01/08/2023, a State Trained Nurse Aide (STNA) transferred Resident #17, while using a stand-pivot lift. The facility reported the resident lost strength in his/her legs, and the STNA lowered the resident to the floor. On 01/10/2023 the resident was sent to the Emergency Department (ED) after a mobile x-ray showed the resident had a fracture to the left ankle. The resident was care planned for an extensive assistance of two (2) staff for transfers and toileting assistance. 3. Observation on 12/01/2023 at 1:22 PM, revealed Resident #115 opened a keypad alarmed door triggering the alarm. Staff interviews revealed they had concerns about Resident #115 getting out of the facility prior to that, so they watched him/her more. Staff stated they reported to management their concerns about Resident #115. However, the resident was not identified as an elopement risk, and the facility did not care plan the resident as a risk until after the 12/01/2023 incident. Review of Resident #115's Comprehensive Care Plan (CCP), initiated 11/28/2023, revealed the facility failed to care plan the resident for his/her desire to smoke and therefore did not have interventions in place to assist the resident. Additionally, the resident was not care planned for his/her ability to ambulate independently in the wheelchair and the ability to open doors and exit the facility. 4. Observation of Resident #114's room on two (2) different dates revealed the resident had several bags by his/her doorway. Interview with staff revealed the resident packed his/her bags every time staff tried to unpack his/her property. Staff stated the resident talked daily about wanting to leave to be with his/her spouse, about being picked up, and about not wanting to be at the facility. Additional interview with staff revealed staff believed the resident had the ability and the desire to leave the facility. Review of Resident #114's Comprehensive Care Plan (CCP), initiated on 11/09/2023, revealed the facility failed to identify the resident's behaviors of packing up his/her property and constantly talking about leaving the facility. 5. Observation of Resident #113 on 11/30/2023 at 11:00 AM in Building #1, revealed the resident moved quickly about the facility with the use of a walker for balance. The resident carried a small bag around with his/her hands at the walker. The resident sat down at the common area table, unpacked and repacked the bag, and then got up and moved around the facility. In an interview with Resident #113's son on 11/30/2023 at 1:00 PM, he stated mobility was not a concern for Resident #113. He explained the resident was very mobile with the walker, and he believed the resident would be able to leave the facility on his/her own accord. Review of Resident #113's CCP, initiated 11/22/2023, revealed the resident required the assistance of one (1) staff member for ambulation. The facility failed to properly develop the care plan to show the resident's ability to ambulate independently with the use of a walker. The findings include: Review of the facility's policy titled, Comprehensive Care Plan (CCP), revised 05/01/2022, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. Additional review of the policy revealed the CCP would be reviewed and revised by the Interdisciplinary Team (IDT) after each comprehensive and quarterly Minimum Data Set (MDS) assessment. It stated the identified objectives would be utilized to monitor the resident's progress and that alternate interventions would be documented as needed. Per the policy, the facility would attempt to alternate methods of refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. Review of the facility's policy titled, Fall Management, undated, revealed care and assistance would be provided to maintain the resident's highest practicable level of well-being, which included minimizing the risk of falls. Individual resident needs for staff assistance and equipment during toileting, transfer, ambulation, and all activities of daily living would be assessed and addressed as appropriate via the Resident Assessment Instrument (RAI) process to determine if the resident was at risk (for falls) and implement interventions to minimize the risk of falls. The plan of care would be reviewed and revised to include new interventions, if appropriate, in order to minimize the risk of falls. Per the policy, the Fall Committee would review each resident who had fallen as well as the interventions that were in place to minimize the risk of falls. Further review revealed this committee would look at and try to determine the root cause of the fall. 1. a. Review of Resident #13's medical record revealed the facility admitted the resident on 12/03/2021 with diagnoses of Parkinson's disease with dyskinesia (involuntary, erratic writhing movements of the face, arms, legs, or trunk), epilepsy, spondylosis (age related wear and tear of the spinal disks), and history of multiple fractures of the pelvis with unstable disruption of the pelvic ring. Review of Resident #13's Quarterly Minimum Data Set (MDS) Assessment, Section C, Brief Interview for Mental Status (BIMS), dated 04/29/2022, revealed a BIMS' score of fourteen (14) of fifteen (15), indicating no cognitive impairment. Review of Resident #13's Progress Note dated 06/04/2022 at 2:00 PM by Licensed Practical Nurse (LPN) #19, revealed Resident #13 had been found on the bathroom floor sitting in an upright position. Per the note, Resident #13 stated he/she was trying to get on the toilet, but the wheelchair had rolled out from underneath him/her. LPN #19 documented she had observed the wheelchair wheels were not in the locked position. Further, Resident #13 stated he/she his/her head on the floor, and his/her right arm was hurting. LPN #19 documented she performed neurological checks on Resident #13, and the resident was able to make his/her needs known, with no signs of acute distress. Per the note, LPN #19 educated Resident #13 to use the call light to call for assistance, but Resident #13 refused. Review of Resident #13's Post Fall Observation Report, dated 06/04/2022 at 10:02 PM, revealed LPN #19 had documented Resident #13 was found in the restroom sitting in an upright position after attempting to self-transfer from the wheelchair in response to bladder/bowel urgency (needing to use the restroom). Resident #13 was documented as having no history of falls but also as having one (1) or two (2) falls within the last three (3) months. The facility assessed Resident #13 to be alert and oriented to person, place, and time and had been educated to use the call light for assistance and to make sure the wheelchair was locked. Resident #13's gait and balance were assessed as normal. Continued review revealed the facility assessed Resident #13 to be continent of bowel and bladder but needed assistance with toileting. Resident #13's factors contributing to falls were identified as Neuromuscular/Functional to include a decline in functional status, Parkinson's Disease, and seizure disorder. Resident #13's Fall Risk Score was determined to be a ten (10), which indicated average risk for falls. Review of Resident #13's Comprehensive Care Plan (CCP), started on 12/03/2021, revealed Resident #13 was documented as being at risk for falls related to weakness, limited mobility, tremors, medication use, impulsiveness, history of falls, and diagnoses of Parkinson's and Epilepsy. Resident #13's documented goal specified fall prevention approaches would help minimize the fall risk. Resident #13's documented interventions included to remind Resident #13 to ask for help rather than trying to get up alone; to call for assistance before attempting to transfer, ambulate, or going to the bathroom; for staff to be aware that some of Resident #13's medications might increase the risk of falls; and to check on Resident #13 regularly to assure safety and that his/her needs were met. However, review of Resident #13's CCP started on 12/03/2021 and reviewed on 12/02/2023, revealed no intervention had been added to the Fall care plan for the 06/04/2022 fall. Attempts were made to interview LPN #19 on 11/29/2023 at 2:30 PM and 11/30/2023 at 8:30 AM with no answer or return call. b. Review of Resident #13's Progress Note dated 06/17/2022 at 3:49 PM by LPN #20, revealed she heard screaming from Resident #13's room and found the resident lying in the doorway of his/her room. LPN #20 documented Resident #13 stated he/she tried to fix his/her wheelchair, fell , and screamed my hip is broken. LPN #20 documented she placed a pillow under Resident #13's head, assessed him/her, called 911, notified the physician, called report to the hospital, and notified Resident #13's daughter he/she was sent to the emergency room (ER). Review of Resident #13's Post Fall Risk Observation Report, dated 06/17/2022 at 3:39 PM, revealed LPN #20 documented she heard screaming from Resident #13's room, and upon entering Resident #13's room, she found the resident lying in the inside doorway of his/her room and screaming he/she had broken his/her hip and the pain was terrible. LPN #20 documented Resident #13 stated he/she was standing up fixing the seat of his/her wheelchair when he/she fell . The LPN documented the resident was sent to the emergency room (ER). Per the report, the resident was assessed with a history of falls both prior to and since admission to the facility and to have had three (3) or more falls within the last three (3) months. Resident #13's contributing factors were assessed as Neuromuscular/Functional to include Parkinson's. Resident #13's Fall Risk Score was determined to be ten (10), with any score between zero and ten (0-10) indicating an average fall risk. Review of the evaluation notes section revealed Resident #13 was standing in his/her room fixing the wheelchair cushion, lost his/her balance, and fell to the floor. Review of Resident #13's CCP dated as started on 12/03/2021, revealed no intervention had been added to the Fall Care Plan for the 06/17/2022 fall. In a phone interview on 12/02/2023 at 7:01 PM with LPN #20, she stated that not all floor staff had access to update residents' care plans and in that case, the Unit Manager (UM) or the Director of Nursing (DON) would update the resident's care plan and add an intervention after a fall. She further stated care plans were reviewed in daily IDT meetings and the IDT members included the UM, DON, Social Services, Activities, MDS, Dietary, and Therapy. She further stated it was important for the resident's care plan to be up to date so each staff member knew the proper protocol for caring for the resident as each resident was different, and the care plan guided staff. LPN #20 further stated the care plan outlined State Trained Nurse Aide (STNA) resident care tasks which were reflected on the STNA Kardex. The STNA Kardex was visible on the tablets the STNA's charted on, and a printed copy was kept in a binder at the nurse's station for reference. Review of Resident #13's Quarterly MDS Assessment, Section C, Brief Interview for Mental Status (BIMS) dated 08/16/2022 revealed a BIMS' score of thirteen (13) of fifteen (15), which indicated no cognitive impairment. c. Review of Resident #13's Progress Note dated 08/22/2022 at 12:15 PM by LPN #20, revealed she had been called to Resident #13's room by a STNA, and the resident was lying on the floor beside the bed on the bathroom side. She further documented Resident #13 had been sitting on the side of the bed on a draw sheet eating lunch, and his/her Parkinson movements of shaking had increased that day causing him/her to slide off the side of the bed. The note stated the resident denied pain or injury. Review of Resident #13's Post Fall Observation Report, dated 08/22/2022 at 12:49 PM, revealed LPN #20 had documented Resident #13 was eating lunch in bed and had been having extreme movements related to his/her Parkinson's diagnosis. Resident #13 had been sitting on a draw pad and slid off the side of the bed and landed on the floor closest to the bathroom. The report stated no injury or complaints of pain had been reported. Resident #13 had been assessed to have a history of falls both prior to and since admission to the facility and to have had three (3) or more falls within the last three (3) months. Resident #13's contributing factors were assessed as Neuromuscular/Functional to include Parkinson's, Psychiatric/Cognitive, and Orthopedic. Resident #13's Fall Risk Score was determined to be eighteen (18), with any score greater than ten (10) indicating a high fall risk. Review of Resident #13's CCP revealed no intervention had been added to the Fall Care Plan for the 08/22/2022 fall. d. Review of Resident #13's Progress Note dated 11/10/2022 at 1:22 PM by LPN #18, revealed she was called to Resident #13's room by staff, and the resident was noted to be lying parallel to the left side of the bed on the floor closest to the window. Resident #13 stated he/she was trying to make the bed on his/her own while sitting up in the wheelchair, the front wheel of the wheelchair got caught on something, and he/she fell out of the wheelchair. The facility assessed Resident #13 for pain and injury at that time and neither were found. Then, at approximately 3:00 PM, swelling and bruising were noted at the right side of Resident #13's hand near the thumb. The note stated the physician had been notified, and an X-ray had been ordered. Review of Resident #13's Progress Note dated 11/10/2022 at 7:48 PM by LPN #22, revealed she had received the X-ray results which showed a fracture of Resident #13's right thumb. LPN #22 documented Resident #13's daughter stated her parent was stubborn and did what he/she wanted to do. Review of Resident #13's Medical Record revealed a Post Fall Observation Report had not been completed. Review of Resident #13's CCP revealed no intervention had been added to the Fall Care Plan for the 11/10/2022 fall. In a phone interview on 12/02/2023 at 2:16 PM with LPN #18, she stated she worked at the facility on an as needed basis and had not been trained on doing care plans. She further stated she did not know how interventions for a resident's care plan were decided upon and thought there was a binder available with resident care information in it, but she received most of the resident information in nurse-to-nurse report. Review of Resident #13's Quarterly MDS Assessment Section C, Brief Interview for Mental Status (BIMS), dated 11/14/2022, revealed a BIMS' score of thirteen (13) of fifteen (15), which indicated no cognitive impairment. e. Review of Resident #13's Progress Note dated 11/28/2022 at 4:50 PM by Registered Nurse (RN) #6, revealed Resident #13 had been heard by staff yelling for help. RN #6 documented she observed the resident on his/her back on the shower stall floor directly across from the toilet in the resident's bathroom. The RN stated Resident #13 stated he/she fell while attempting to self-transfer from the toilet to the wheelchair. Per the note, a small abrasion to the left elbow, minor swelling to the left forehead, and redness to the lower back were noted. Review of Resident #13's Post Fall Observation Report, dated 11/28/2022 at 4:50 PM, revealed RN #6 observed Resident #13 on the bathroom floor on his/her back in the shower stall directly across from the toilet. Per the report, Resident #13 stated he/she had transferred himself/herself onto the toilet from the wheelchair and was transferring back to the wheelchair when he/she fell . Per the report, the facility assessed Resident #13 to have a history of falls since admission and in the last thirty (30) days. Resident #13's contributing factors were assessed as Neuromuscular/Functional to include Parkinson's, and Orthopedic. Resident #13's Fall Risk Score was determined to be fifteen (15), with any score greater than ten (10) indicating a high fall risk. Review of Resident #13's CCP revealed no intervention had been added to the Fall care plan for the 11/28/2022 fall. Attempts were made to interview RN #6 on 11/29/2023 at 12:30 PM and 11/30/2023 at 9:30 AM with no answer or return call. In an interview on 12/01/2023 at 9:30 AM with Licensed Practical Nurse (LPN) #9, he stated he was currently filling in as the Unit Manager. LPN #9 stated Resident #13 was very impulsive and did not have great safety judgment/awareness. He further stated Resident #13 also had obsessive compulsive disorder and was constantly picking things off the floor like lint and tissue. He stated even though staff encouraged Resident #13 to call for assist, he/she did not always listen. LPN #9 stated it was his expectation that all falls would have an accompanying fall observation sheet and care plan interventions would be placed immediately based on what happened with the resident at the time. LPN #9 further stated some floor nurses updated care plans and some did not. He stated Unit Managers and the DON also put interventions in and would be responsible for making sure an intervention was placed during IDT review. In an interview with the Director of Nursing (DON) on 12/04/2023 at 9:26 AM, she stated she was not employed at the facility during the time of Resident #13's falls, but interventions for each fall should have been on the care plan. The State Survey Agency (SSA) Surveyor, on 12/14/2023 at 2:40 PM via email to the DON, requested a description of the Falls Committee duties, members, frequency of meetings, and any dates Resident #13's falls were reviewed. However, this was not provided. In a phone interview on 12/05/2023 at 10:20 AM with the MDS Coordinator #1 (MDS #1), she stated for Resident #13, the UM or DON would have updated the care plan. MDS #1 stated if she had noted any absence of interventions during her review she would have reached out to leadership. In an interview on 12/05/2023 at 10:35 AM with MDS #2, she stated, when asked about Resident #13 and the lack of documented interventions from 12/16/2021 to 02/02/2023, MDS #2 stated she was not sure why. In a phone interview on 12/13/2023 at 12:56 PM with Nurse Manager #1/Quality Program/Improvement Manager, she stated she had been at the facility for three (3) years, but she was not reviewing falls from 06/01/2022 to 11/28/2022, the time Resident #13 was missing fall interventions. She stated another UM who no longer worked at the facility was reviewing falls at that time. In an interview on 12/13/2023 at 10:31 AM with the Administrator, she stated, regarding Resident #13, the only thing she could speak about was the DON said there was an intervention on the resident's care plan for every fall. She stated she did not question this, but it was possible that she had misunderstood. 49050 2. Review of Resident #17's medical record revealed the facility admitted the resident on 04/08/2022, with diagnoses of dementia unspecified severity, with other behavioral disturbance; anxiety disorder, and morbid obesity. Review of Resident #17's Quarterly Minimum Data Set (MDS) Assessment, dated 11/30/2022, revealed the facility assessed Resident #17 to have a Brief Interview of Mental Status (BIMS) score of one (1) of fifteen (15), which indicated severe cognitive impairment. Another assessment, dated 12/29/2022, revealed the facility assessed Resident #17's Activities for Daily Living (ADL) status as requiring assist of two (2) with bed to chair/chair to bed transfers with mechanical lift, and assist of two (2) without mechanical lift to transfer to/from toilet. Review of Resident #17's Comprehensive Care Plan (CCP) dated 04/11/2022, revealed the facility identified the resident as a fall risk due to decreased mobility, episodes of incontinence, cognitive deficits, and medication use with potential for adverse effects and diagnoses. The CCP was amended on 12/29/2022 to assist of two (2) without mechanical lift when transferring from toilet to wheelchair. Review of the facility's care plan transfer status dated 12/29/2022 for Resident #17, revealed the resident required the assistance of two (2) with bed to chair/chair to bed transfers with mechanical lift, assist of two (2) without mechanical lift to transfer to/from toilet. Review of Section GG Tool (Functional Abilities and Goals) of Resident #17's Quarterly MDS Assessment, dated 01/04/2023, revealed the facility assessed the resident was dependent and required the assistance of two (2) or more helpers to complete a toilet transfer (the ability to get on and off a toilet or commode). Review of the facility's Post Fall Observation with Fall Risk Observation Report, dated 01/08/2023 at 2:00 PM, revealed Resident #17 was being transferred from the toilet to the wheelchair when his/her legs gave out, and he/she was lowered to the floor. Additional staff and the nurse were called to the room to help get the resident off the floor to the wheelchair. Per the report, the resident was a [NAME] (sit-to-stand) lift for transfers other than toilet transfers. Continued review revealed the resident required assist of two (2) + with/without device for the resident's usual ambulatory status. The report stated the resident was stabilized for toilet use with the assistance of two (2) staff. Continued review revealed the Root Cause Analysis (RCA) dated 01/08/2023, revealed Resident #17 was transferred assisted by one (1) staff member. Internal risk factors identified included decreased range of motion, unsteady gait, forgetful, displayed poor safety awareness, behavior issues, poor judgement, bowel or bladder incontinence, recent decline in ADL functional status. Per the report, the resident's fall history included falls prior to admission and falls since admission; his/her mental state was intermittent confusion, poor recall-judgment-safety awareness. Per the report, the resident's fall risk score was seventeen (17), where greater than ten (10) indicated a high fall risk. Review of Resident #17's Progress Note dated 01/08/2023 at 7:43 PM by LPN #20, revealed the resident presented with a 2.5 centimeter (cm) by 5 cm dark purple bruise to the left ankle. The note stated the left ankle had edema, redness, warmth to the area, and was painful to touch. Per the note, the resident was unable to recall any injuries and was usually mildly confused and anxious. Review of Resident #17's medical record revealed radiology results from a mobile left ankle X-ray taken on 01/09/2023 at 5:36 PM, revealed acute bimalleolar ankle fracture (where tibia and fibula join at the ankle) with medial ankle mortise widening. Review of Resident #17's Progress Note dated 01/10/2023 at 11:00 AM completed by LPN #20, revealed the resident was transported to the ER (emergency room ) related to a fracture in the left ankle. Review of the Hospital Discharge Summary dated 01/10/2023, revealed Resident #17 was admitted for left ankle fracture. Continued review of the summary revealed the resident underwent surgery for the left ankle fracture (required a plate and screws to stabilize both leg bones and ankle) on 01/11/2023. Further review revealed Resident #17 was discharged and returned to the facility on [DATE]. In a telephone interview on 12/02/2023 at 1:16 PM, STNA #35 stated she responded to a call from STNA #38 on 01/08/2023 at 1:27 PM. STNA #35 stated she found Resident #17 on the floor with STNA #38 next to him/her. STNA #35 stated she along with a nurse (STNA #35 could not recall nurse's name since she was no longer employed at facility) assisted Resident #17 to sit in the wheelchair. STNA stated Resident #17 was in pain when he/she was assisted into the wheelchair. 43694 3. Observation on 12/01/2023 at 1:22 PM, revealed an alarm sounded and upon further observation there was a staff member and Resident #115 in his/her wheelchair halfway in the door. The staff member pulled the resident back into the facility. The staff member was identified as Physical Therapy Assistant (PTA) #1. PTA #1 made the statement, I do not even know how the resident got the door open. Further observation revealed, at the same time, another staff member, identified as State Trained Nurse Aide (STNA) #13, arrived and explained the door opened if you pulled on it for fifteen (15) seconds, and the door unlocked. STNA #13 asked what happened, and PTA #1 said the resident got out the door. PTA #1 pulled the door for fifteen (15) seconds, and the door let off a beep, beep, beep sound. Once it got to fifteen (15) seconds the door sounded a solid beep until the door was closed and the keypad was reset. Observation of Resident #115 on 12/01/2023 at 1:30 PM, revealed he/she explained to PTA #1, he/she wanted to go out to smoke. A few minutes later the resident was at the table in the common area and observed to be crying. Further observation revealed staff talked with the resident and explained he/she was not in any trouble, and one (1) staff hugged the resident to comfort him/her, and the resident smiled. Observation on 12/01/2023 at 1:45 PM, revealed PTA #1 demonstrated exactly what she saw with Resident #115. She placed an empty wheelchair through the door, halfway through the door opening, and it was centered perfectly in the door frame. She showed how she held the door with her back, and then she pushed the resident all the way outside and allowed the door to close behind her. She turned off the alarm. Review of Resident #115's Face Sheet revealed the facility admitted the resident for short-term rehabilitation on 11/15/2023 with diagnoses of surgical amputation on 11/15/2023, dementia, nicotine dependence, and transient ischemic attack (TIA) history. Review of Resident #115's Baseline Care Plan Summary completed on 11/15/2023 revealed the resident required the assistance of two (2) staff for all activities of daily living (ADL). Review of Resident #115's Comprehensive Care Plan (CCP) initiated 11/28/2023, revealed the facility failed to care plan the resident for his/her desire to smoke and therefore did not have interventions in place to assist the resident. Additionally, the resident was not care planned for his/her ability to ambulate independently in the wheelchair and ability to open doors and exit the facility. Review of Resident #115's CCP established 11/16/2023 revealed the resident was at risk for falls related to diagnoses and cognitive deficit. Staff were to check on the resident regularly to ensure he/she was safe and his/her needs were met. The facility care planned the resident for cognitive impairment and dementia, on 11/16/2023, with interventions to encourage the resident to make choices by keeping him/her informed and giving the resident options. Also, to cue the resident and give reminders as needed. Further review revealed the facility failed to develop a care plan to address the resident's desire to smoke and his/her ability to elope, until after the incident on 12/01/2023. Review of Resident #115's Hospital Discharge Summary dated 11/15/2023, identified the resident as a current smoker, which was not addressed in the resident's care plan. On 12/01/2023 at 1:45 PM the DON entered Building #1 and informed the State Survey Agency (SSA) Surveyor that Resident #115 was interviewed, and she said the resident did not want to go home, the resident just wanted to go out to smoke. The DON stated the resident told her he/she had not smoked in years. 4. Observation of Resident #114's room, on 11/30/2023 at 10:00 AM; 11/30/2023 at 2:30 PM; and 12/01/2023 at 11:00 AM, revealed all the resident's belongings were packed up in five (5) bags and placed by the door. Review of Resident #114's Electronic Medical Record (EMR), Minimum Data Set (MDS) section, revealed no documented MDS Assessment was present. Review of Resident #114's History and Physical completed on 11/15/2023 by the resident's Primary Care Physician (PCP), revealed the facility admitted the resident on 11/08/2023 with diagnoses of Parkinson's Disease, lumbar spinal stenosis, and bipolar disorder. Review of Resident #114's Hospital Discharge Summary, dated 11/08/2023, revealed the resident had a lot of difficulty turning in the bed, standing up from a chair using the arms for support, moving from bed to chair, and required assistance with wheelchair mobility. The plan was for the resident to increase his/her strength through therapy to be able to perform these tasks with little assistance. Review of Resident #114's Comprehensive Care Plan (CCP) established on 11/09/2023, revealed the facility completed a problem area for cognitive loss/dementia. However, review of the resident's diagnoses list, revealed the resident did not have a dementia diagnosis. Review of Resident #114's CCP initiated on 11/09/2023, revealed the facility failed to identify the resident's behaviors of packing up his/her property and constantly talking about leaving the facility. In an interview with State Trained Nurse Aide (STNA) #18 on 11/30/2023 at 10:00 AM, she explained Resident #114 had a history of packing up his/her belongings after staff unpacked them to get the resident settled. STNA #18 stated the resident would state he/she was not staying at the facility and was leaving the next day. However, at this time, there was no discharge plan set up. STNA #18 said this type of behavior should have been care planned to ensure all staff was alert and aware and had interventions to try to help change the resident's behavior. STNA #18 said the care plan should always be followed to ensure residents got the best care possible. NURSE INTERVIEW? 5. Observation on 11/30/2023 at 1:00 PM, revealed Resident #113 moving around the common area with his/her walker. The resident was very quick and moved around unassisted by staff. The resident sat at the common area table and unpacked a small bag he/she carried around, packed the bag back up, and moved about the facility again. Observation of Resident #113 and the resident's son on 12/01/2023 at 10:50 AM, revealed they were seated side by side, holding on to each other. The man said he was the resident's son. The State Survey Agency (SSA) Surveyor tried to talk with the son, but every time a question was directed to him the resident would say, don't talk to her, don't tell her anything, just listen to what she is saying and don't tell her anything, it will just cause all kinds of problems, remember what I told you. Observation on 12/01/2023 at 2:00 PM, revealed Resident #113 had on a yellow coat and moved about the facility in the common area. The resident moved quickly about unassisted by staff but used a walker, more for balance then for mobility. [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure opened and in-use medications were labeled with the opened date and were not expired on one (1) of four (4) medication carts and in one (1) of four (4) medication rooms. The findings include: Review of the facility's policy titled, Storage of Medications, undated, revealed medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Further review revealed outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were immediately removed from stock and disposed of according to procedures for medication disposal. Additional review revealed medication storage conditions were monitored on a monthly basis and corrective action taken if problems were identified. Review of audits performed by Pharmacy Technician #2, dated 09/21/2023, 10/19/2023, and 11/16/2023, revealed no out-of-date medications were found. Review of the facility's medication cart and medication room audits, undated, on 12/15/2023 at 10:45 AM revealed audit areas were assessed with marking Satisfactory, Needs Improvement, Not Applicable, or Not Observed. Further review revealed documentation of one (1) instance of the presence of an expired medication and one (1) instance of an undated insulin vial. Observation of the 400 Unit Medication Storage Room refrigerator on 11/29/2023 at 8:13 AM, revealed one (1) bottle of UTIStat Oral Supplement (used to prevent and manage urinary tract infections), opened but not labeled, for an individual resident, with an expiration date of 2022. Observation of the 400 Unit Medication Cart on 11/29/2023 at 8:32 AM, revealed one (1) bottle of ProStat Liquid Protein supplement, opened and labeled for Resident #24, with an opened date of 09/13/2023 and an expiration date of 09/23/2023. Continued observation revealed Ipratropium Bromide 0.5 milligrams (mg)/Albuterol 3.0 mg nebulizer medication in an opened packaging with no date and not in a package labeled for the specific resident; Albuterol Sulfate, 0.083%, nebulizer medication, twenty (20) packages, loose in the cart with no label; and Xiidra PF 5%, single use only, for topical application to the eye, labeled for Resident #20, in packaging that was torn open. During interview with Licensed Practical Nurse (LPN) #1 on 11/29/2023 at 8:35 AM, he stated the Unit Manager (UM) was typically responsible for the medication cart and storage audits, but the unit currently did not have a UM. He stated he did not know who was now responsible for UM duties. LPN #1 stated the Pharmacy also conducted medication cart audits but he did not know the frequency or schedule. He stated medications should be discarded by the expiration date because those drugs might not be effective and even be harmful. During interview with LPN #7 on 12/01/2023 at 3:50 PM, she stated nurses and KMAs were all responsible to audit their own medication carts and medication rooms for expired medications. She stated Pharmacy did audits on the carts sometimes but she was not sure of the frequency. She also stated expiration dates were important as the medication might be ineffective or possibly lead to medication errors. She stated if a staff member found an expired medication, he/she should remove it from the cart, notify the physician, and order a replacement. During interview with the Quality Program Manager on 12/03/2023 at 1:27 PM, she stated KMAs and nurses audited the carts, and Pharmacy also audited the carts and storage rooms monthly. She stated it was important because for the rehabilitation units, there could be multiple medication changes. She stated the staff needed to keep up with that to prevent medication errors and overall for patient safety as well as to reduce clutter. She stated audits also served to remove out of date medications and this was important because expired medications might be less effective. During interview with Pharmacy Technician #1 on 12/04/2023 at 9:03 AM, she stated the Pharmacy sent somebody monthly to conduct audits, and the most recent audit at the facility was on 11/16/2023. She also stated she thought the audit was for all the medication carts and medication rooms. During interview with Pharmacy Technician #1 on 12/04/2023 at 9:15 AM, she stated the Pharmacist audited all the medication carts and rooms monthly, and the treatment carts every three to four (3-4) months. She stated the Pharmacist reported to the facility anything found that was expired or out of compliance. She further stated the Pharmacist sent a report to the Pharmacy of any medication that was out of date or out of compliance so that it could be replenished. During interview with the Director of Nursing (DON) on 12/04/2023 at 9:58 AM, she stated it was a night shift responsibility to check the medication carts and medication rooms. She stated all nurses knew if they opened a medication, they were responsible to date it and not to use a medication that was expired. She stated it was really all the nurses' responsibility to audit carts, a collaborative effort. She also stated if there was an expired medication, someone just failed to see and remove it. During interview with the Administrator on 12/13/2023 at 10:50 AM, she stated Pharmacy did audits in the facility monthly. She further stated the staff did audits at least monthly, per the annual Quality Assurance (QA) plan. She stated management staff conducted audits as well by the night shift supervisor. The Administrator stated nurses should also look when administering medications for expired medications and biologicals. She stated it was important to do this because medications past the expiration date could lose potency and not be as effective.

Based on observation, interview, record review, facility policy review and review of the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) guidelines, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for eleven (11) of sixty-nine (69) sampled residents (Residents #3, #16, #41, #44, #47, #48, #109, #111, #118, #119 and #560). The eleven (11) residents had either wounds and/or indwelling devices. However, neither resident had been placed in Enhanced Barrier Precautions (EBP) as recommended by the CDC, CMS and the facility's policy. The findings include: Review of the CDC National Center for Emerging and Zoonotic Infection Diseases presentation, titled Implementation of Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug Resistant Organisms, dated 07/12/2022, revealed EBP were indicated for nursing home residents with any of the following: - Infection or colonization with an MDRO when Contact Precautions do not otherwise apply - Wounds and/or indwelling medical devices. Review of the facility's policy titled, Enhanced Barrier Precautions, last revised 07/05/2022, revealed it was the policy of the facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms (MDRO). Continued review revealed EBP were defined as the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms. Further review revealed clear signage was to be posted on the door or wall outside of the resident's room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that required the use of gown and gloves. Additional review revealed nursing staff might place residents with certain conditions or devices on EBPs empirically while awaiting physician orders, and an order for EBP was to be obtained for residents with wounds and/or indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy) regardless of MDRO colonization status. During an entrance interview with the Administrator on 11/27/2023 at 10:30 AM, she stated they had no residents or staff with COVID infections currently. During initial screenings on 11/27/2023 at 10:50 AM, no residents were observed on the 100, 200, 300 and 400 units with any Transmission Based Precautions (TBP). Review of the facility's Roster Matrix on 11/27/2023 at 4:00 PM, revealed no documentation of residents with infections requiring TBP. 1. Medical record review revealed the facility readmitted Resident #3 on 11/24/2023, with diagnoses that included Benign Prostatic Hyperplasia (BPH) and retention of urine. Further record review revealed Resident #3 was noted to have an indwelling catheter in place. 2. Medical record review revealed the facility admitted Resident #16 on 04/28/2021, with diagnoses that included Neurocognitive disorder with Lewy bodies, and other specified disorders of the skin and subcutaneous tissue. Continued record review revealed Resident #16 had a mid-lower back wound for which he/she was currently receiving treatment. 3. Medical record review revealed the facility admitted Resident #41 on 11/21/2023 with diagnoses that included fracture of the right proximal femur, BPH with urinary retention and nutritional deficiency. Further record review revealed Resident #41 had a wound to the coccyx and an indwelling urinary catheter in place. 4. Medical record review revealed the facility admitted Resident #44 on 10/31/2023, with diagnoses that included Osteomyelitis of the left hip, status post (s/p) surgical placement of an antibiotic spacer; and obstructive and reflux uropathy with retention of urine. Continued record review revealed Resident #44 had an indwelling urinary catheter in place which had been in place at the time of admission. 5. Medical record review revealed the facility admitted Resident #47 on 11/06/2023, with diagnoses which included dysphagia following cerebral infarction and neuromuscular dysfunction of the bladder. Further review revealed Resident #47 had orders for palliative care; an indwelling urinary catheter; as well as a gastrostomy tube (GT) for feeding. 6. Medical record review revealed the facility admitted Resident #48 on 10/13/2023, with diagnoses that included obstructive and reflux uropathy, dysuria and acute anal fissure. Further record review revealed Resident #48 had an indwelling urinary catheter in place and a surgical wound to his/her right hip, and bilateral heel/midfoot ulcerations. 7. Medical record review revealed the facility admitted Resident #109 on 11/20/2023, with diagnoses that included Unspecified intestinal obstruction, encounter for surgical aftercare following surgery on the digestive system, and colostomy status. Further record review revealed Resident #109 had a GT in place. 8. Medical record review revealed the facility admitted Resident #111 on 11/24/2023, with diagnoses that included left proximal femur fracture, and other forms of acute ischemic heart disease. Continued record review revealed Resident #111 had a surgical wound to the left hip. 9. Medical record review revealed the facility admitted Resident #118 on 11/22/2023, with diagnoses that included venous insufficiency and varicose veins of left lower extremity (LLE) with ulcer of unspecified site. Further record review revealed Resident #118 had a wound with edema to the left lower extremity (LLE). 10. Medical record review revealed the facility admitted Resident #119 on 11/27/2023, with diagnoses that included malignant neoplasm of unspecified part of bronchus or lung with secondary malignant neoplasm of brain and bone, unspecified severe protein calorie malnutrition and gastrostomy status. Continued record review revealed Resident #119 had a GT in place. 11. Medical record review revealed the facility admitted Resident #560 on 11/30/2023, with diagnoses that included displaced fracture of right proximal humerus, BPH and neuromuscular dysfunction of bladder. Further record review revealed Resident #560 had an indwelling urinary catheter in place. During interview with the DON on 11/30/23 9:47 AM, she stated they (the facility) followed guidelines for Enhanced Barrier Precautions. When asked about the residents observed to have indwelling catheters, Percutaneous Endoscopic Gastrostomy (PEG) tubes or wounds with no EBPs in place, the DON stated she would follow up with the Infection Preventionist (IP) nurse. Observation on 11/30/2023 at 4:15 PM, of Unit 200 revealed Resident #44's room door had no EBP signage posted despite his/her having an indwelling catheter. Continued observation of Resident #47's room/door revealed no EBP signage posted, despite his/her having an indwelling catheter and a PEG tube. Further observation on 11/30/2023 at 4:15 PM, of Resident #119's room/door revealed no EBP signage posted despite him/her having a wound. Observation on all units on 12/01/2023 beginning at 10:15 AM, revealed residents on all units continued to have no TBP in place, as evidenced by absence of any signage or supplies located by their rooms. Observation across the 100, 200, 300 and 400 units on 12/02/2023 beginning at 8:30 AM, revealed EBP signage and supplies for Resident #119, Resident #109, Resident #48, Resident #111, Resident #47, Resident #44, Resident #560, Resident #118, Resident #3, Resident #41 and Resident #16. During interview with the Administrator, who was also the secondary IP, on 12/01/2023 at 2:07 PM, she stated the facility should have been using Enhanced Barrier Precautions for residents with an indwelling device. She stated she did not know why those precautions were not currently in place for residents with indwelling devices. The Administrator stated they reviewed the Infection Control policies in Quality Assurance meetings. She further stated the QA Committee typically documented policy reviews once a year during a QA meeting. During interview with LPN #7 on 12/01/2023 at 3:50 PM, she stated she was not aware of the criteria for EBP. During interview with the Quality Improvement (QI) Manager on 12/03/2023 at 1:27 PM, she stated she was aware of EBP, however, the facility was only using EBPs currently to protect residents when there was a resident with an MDRO requiring contact precautions in the facility. She stated staff had received education on EBPs in August and then again on 12/01/2023. The QI Manager stated any infection reportable to the health department would have triggered using EBP. She stated the facility did not have a good answer why there was no EBP in place. The QI Manager stated, after she pulled the policy and procedure and reviewed it, they placed Resident #119, Resident #109, Resident #48, Resident #111, Resident #47, Resident #44, Resident #560, Resident #118, Resident #3, Resident #41 and Resident #16 in EBP. In continued interview, she stated the facility had conducted face to face inservices with staff who have worked since implementing EBP. The QI Manager stated they then had a Care Feed (electronic system for disseminating information widely via cell phone text) communication that there was Relias Education and face to face training pending for those who had not worked. During interview with State Trained Nurse Aide (STNA) #29 on 12/01/2023 3:37 PM, she stated she had no problem with needed supplies, as housekeeping restocked supplies for all the units. She stated there was a cart and signage at the door if a resident was on any kind of TBP, and the nurse was to give information about the type of precautions to other staff. Interview with STNA #13 on 12/01/2023 at 3:44 PM, she stated if a resident was on TBP, usually the nurse would say what type of precautions were in place, and there would be signage on the door. During interview with STNA #2 on 12/03/2023 at 1:50 PM, she stated she was trained on Saturday (12/02/2023) She stated training was completed via text message because she was not at the facility and that was often how they communicated. STNA #2 stated if she was going to do anything to a patient that had a point of entry use of EBPs, she would put on gown, gloves, and a mask if something like a Foley (catheter) were present. STNA #2 stated if a resident had a Foley, needed a bath and bed change, she would use PPE. She further stated she did not recall prior EBP training at the facility. In interview with STNA #3 on 12/03/2023 at 3:45 PM, she stated she had seen the EBP signage before, and the nurse had told her to gown and glove for that precaution, related to something about urine, and that she must gown for any high contact care. She stated that was for residents, such as those who had a catheter. In interview with STNA #16 on 12/03/2023 at 3:52 PM, she stated the nurse gave face-to-face inservices about EBP; however, she did not recall signing an attendance sheet. She stated EBP had something to do with urine but she was not sure. STNA #16 stated she just read the signage and followed it. In additional interview, she stated she knew staff did not have to gown to pass medications, gowning was necessary to help a resident in EBP to the bathroom or when assisting with other personal care. She stated she had not checked Relias lately for trainings, but felt comfortable that she knew what she was expected to do. During interview with STNA #36 on 12/03/2023 at 5:27 PM, she stated she received face to face inservicing about EBP that explained EBPs were used to help prevent transfer of infection, more from staff to the residents. She also stated it was because of catheters and g-tubes. STNA #36 further stated she also received written information about EBP, that she signed to attest she had read. During interview with STNA #37 on 12/03/2023 at 5:34 PM, she stated she had received face to face inservicing and written information to read and sign about EBP. She stated with residents in EBP, she was expected to wear gloves and a gown if entering the room to provide personal care; however, she could answer a call light, bring water to the resident, or other non-contact actions without a gown. In interview with LPN #1 on 12/03/2023 at 1:40 PM, she stated if a resident was on EBP and needed something like their tray setup she would clean her hands, and if they had any type of opening, we must gown and glove for any entry into the body. She stated training took place yesterday (12/02/2023) given by the Administrator. LPN #1 stated that it was possible that prior training was completed at the facility regarding EBP. In continued interview, she stated during the training provided by the Administrator (on 12/02/2023) they went through several scenarios and examples and she felt comfortable with the content provided to do her work safely. In interview with LPN #16 on 12/03/2023 1:30 PM, she stated education on the facility's EBPs took place yesterday in a face to face setting. She stated the education provided was related to the signage, and that residents with catheters, tubes, or other points of entry required EBP. In continued interview, she stated multi drug-resistant organisms (MDROs) required EBP. LPN #16 stated any type of contact care would require PPE use. She stated that as an LPN, she was comfortable with the content in order to continue her work at the facility at that time. She further stated did not recall any specific prior training at the facility related to EBPs. During interview with LPN #15 on 12/03/2023 at 1:35 PM, she stated she had worked at the facility for a few months. She stated she was educated on EBPs last night. She stated the education included specific patients (residents) that were on EBP now, and how to do EBP as an LPN. LPN #15 stated they educated as to the specific types of personal protective equipment to use. She further stated the facility provided EBP training prior to the current survey. LPN #15 further stated she felt comfortable with the content in order to do her work here at the facility. During interview with LPN #21 on 12/03/2023 at 3:58 PM, she stated EBP was for residents with wounds, catheter, ostomies or g-tubes. LPN #21 stated EBP was applied for residents in those circumstances because the wounds and devices were an entry for an infection. She further stated she had to sign the sheet with information about EBP that she had read it and felt comfortable with what she was taught and expected to do. During interview with the DON on 12/04/2023 at 9:54 AM, she stated they had provided a mass education on EBP in August and then again in December. She stated she expected nurses to initiate needed precautions on admission. The DON further stated the facility had folders on each unit with resources and guidance for actions to take, which was broken down by disease. During interview with the State Regional Infection Prevention Program Coordinator on 12/04/2023 at 10:06 AM, she stated the CDC expanded EBP to those without a history of infection or colonization. She stated it did not matter if no other residents had an MDRO, those residents with wounds or indwelling devices should have been on EBP. She further stated when the CDC made recommendations, CMS expected facilities to implement them.

Based on interview, record review, review of the facility's Investigation Report, and review of the facility's policy, it was determined the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (1) of sixty-nine (69) sampled residents (Resident #21). The facility reported that when State Trained Nurse Aide (STNA) #32 was providing care for Resident #21, she was rough, became frustrated, and cursed in front of him/her. Resident #21 reported to STNA #33 that STNA #32's behavior was mean and hurt his/her feelings. The findings include: Review of the facility's policy titled, Resident Rights, dated 02/02/2022, revealed residents had the right to be treated with respect and dignity. The policy also stated the facility must care for each resident in a way that promoted enhancement of his or her quality of life, recognizing each resident's individuality. Review of Resident #21's medical record revealed the facility admitted the resident on 09/16/2022 with diagnoses of unspecified dementia, Alzheimer's; psychotic disturbance; mood disturbance; and anxiety. Review of Resident #21's Admissions Minimum Data Set (MDS) Assessment, Section C, Brief Interview for Mental Status (BIMS), dated 11/14/2022, revealed a BIMS' score of six (6) of fifteen (15), which indicated severe cognitive impairment. Review of Resident #21's Comprehensive Care Plan, dated 08/04/2022, revealed he/she had difficulty with memory and decision making. Interventions included: providing resident cues and reminders as needed and offering him/her options. Further review revealed Resident #21's care plan was updated on 11/30/2022 to include mood and behavior concerns. Interventions implemented included: observation of Resident #21 for signs of declining mood and psychosocial strengths; assessment for causes in declining mood and psychosocial strengths; and assistance and support as appropriate. Review of the facility's Investigative Report, dated 12/08/2022, revealed, on 12/02/2023, STNA #11 reported to Licensed Practical Nurse (LPN) #14 that STNA #32 was rough with Resident #21's care and when unable to complete the attempted task, became frustrated and cursed in front of the resident. Per the report, STNA #32 was suspended pending an investigation. The report stated LPN #14 performed a head-to-toe assessment which included a skin assessment on Resident #21 that revealed no signs of injury. Statements were obtained from on duty staff at the time of the incident, and Resident #21's physician and family were notified. Per the report, after review of the information obtained during the investigation, the facility concluded although the behavior of STNA #32 was inappropriate, it did not rise to the level of abuse. The report stated STNA #32's behavior did not meet the facility's minimum expectations; and therefore, she was terminated on 12/08/2022. Review of the facility's Investigative Report, dated 12/08/2022 revealed STNA #24's witness statement documented she was on duty the day of the alleged incident, she was in Resident #21's room, and witnessed the actions of STNA #32. Per the statement, STNA #24 documented STNA #32's language was inappropriate in front of the resident, and STNA #24 asked STNA #32 to leave the room. The statement documented STNA #24 then reported STNA #32's language to the nurse on duty and called another STNA to assist her with the resident. The witness statement documented Resident #21 was clearly troubled. Review of STNA #33's witness statement, dated 12/03/2022, revealed Resident #21 voiced to STNA #33 that his/her feelings were hurt by the behavior of STNA #32. Review of Resident #21's skin assessment, dated 12/03/2022, revealed no skin changes or new skin concerns. During an interview with Resident #21's spouse on 11/30/2023 at 1:14 PM, he/she stated the care at the facility was great. He/she said because of his/her spouse's Alzheimer's and dementia, the resident did not like to be touched and yelled out even if someone barely touched him/her. The spouse stated Resident #21 did not walk by himself/herself but was mobile around the unit in his/her wheelchair. Resident #21's spouse stated the staff was very good with the resident. Resident #21's spouse stated that he/she could not remember for sure that the facility called him/her regarding the incident with STNA #32. During an interview with STNA #11 on 11/29/2023 at 8:39 PM, she stated she had worked at the facility for a year. She stated her initial orientation included both dementia care and abuse training. She further stated continuing education on both dementia and abuse was provided multiple times throughout the year. STNA #11 stated the morning of the alleged incident, STNA #32 was asleep in the television area and became irritated because she had to get Resident #21 up for his/her daily weight. STNA #11 stated that STNA #32 said, I don't want to deal with [him/her] today. STNA #11 stated when they went to provide care to Resident #21, STNA #32 was rough and tried to rush the resident. The STNA stated when Resident #21 was not able to move quickly enough, STNA #32 became more agitated and said, Fuck it! I don't have time for this shit! STNA #11 stated she reported the behavior to LPN #14. STNA #11 stated STNA #32 was suspended immediately and ultimately terminated. During an interview with STNA #24 on 11/30/2023 at 1:21 PM, she stated she was a staff employee and had worked at the facility for two (2) years. She said she did recall the incident with Resident #21. STNA #24 stated the resident was very easily agitated and just required a soft touch. She further stated it was her opinion the abrasiveness of STNA #32's approach triggered the situation. The State Survey Agency (SSA) Surveyor attempted to reach STNA #23 on 11/30/2023 at 1:19 PM, STNA #32 on 12/01/2023 at 10:47 AM, and STNA #33 on 12/01/2023 at 1:19 PM for interview. Voicemail messages were left for all three (3) STNA's. However, none of the three (3) STNA's responded to the messages. During an interview with the Administrator on 11/30/2023 at 2:13 PM, she stated STNA #32 was with an agency and had been placed on the facility's do not return list. She stated even though the facility did not consider STNA #32's behavior abusive because her language was not directed at Resident #21, her behavior was unacceptable per their facility standards.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to prepare, store, and distribute food in a safe manner. Observation, during the initial kitchen tour, revealed a hanger with a broom and mops on the wall behind the stand mixer which was not covered. Observation, of the lunch meal service in Building A, the 100 Unit, showed Dietary Aide #1 continuously touching her clothes while wearing gloves. The findings include: Review of the facility's policy titled, Safety and Sanitation, dated 02/2018, revealed disposable gloves were used to ensure safe, sanitary conditions in food preparation and service to prevent cross contamination of food products from bacteria and to prevent the possibility of foodborne illness. Per the policy, staff was instructed to remove gloves when touching any part of the body, such as clothes, hair, face, and nose. In addition, staff was instructed to remove gloves after handling of non-food items, such as chemicals. Observation, during the initial tour of the kitchen, on 09/28/2021 at 11:46 AM, revealed a wall hanger with a broom, a mop, and a dust pan hanging on the wall behind the large stand mixer which was uncovered. Observation, on 09/28/2021 at 12:25 PM, Building A, during the lunch service, revealed Diet Aide #1 touching her clothing while wearing gloves for meal service. The State Survey Agency (SSA) Surveyor then pointed out to Dietary Aide (DA) #1 that she touched her clothes while wearing gloves. Interview with DA #1, on 09/28/2021 at 12:28 PM, revealed she had been trained on proper hand washing and glove wearing. Continued observation of DA #1, on 09/28/2021 at 12:28 PM to 12:55 PM, revealed she took off her gloves, washed her hands, and donned another pair of gloves. However, she continued to touch her clothing with gloved hands and to wipe down the counter after meal service. Interview with the Dietary Manager (DM), on 09/29/2021 at 3:45 PM, revealed the location of the brooms and mops behind the uncovered stand mixer could be a potential for cross contamination. Also, she stated DA #1 touching her clothing with her gloves created the potential for cross contamination. The DM stated staff was instructed on proper hand washing and wearing/changing of gloves. Additional interview with DA #1, on 09/30/2021 at 1:31 PM, revealed she should wash her hands and change gloves every time she changed tasks, gloves were soiled, or she touched her clothing. DA #1 stated touching clothing could pass germs to the resident and cross contaminate food. She further revealed she had a bad habit of touching her clothes with her gloves on. Interview with the Administrator and the Director of Nursing (DON), on 10/01/2021 at 2:10 PM, revealed the broom and mop hanging on the wall behind the uncovered stand mixer was an infection control issue. In addition, they both stated staff should not touch their uniforms without hand hygiene and changing of gloves afterwards to prevent the potential of cross contamination and concern for infection control.

Based on observation, interview, and review of the Centers for Disease Control and Prevention Mantoux [MEDICATION NAME] Skin Test Facilitator Guide, dated (MONTH) 2003, it was determined the facility failed to ensure proper storage and labeling of drugs. Observation on [DATE], revealed two (2) bottles of [MEDICATION NAME] Purified Protein Derivative (Mantoux [MEDICATION NAME]) were opened, but not marked with the open date on the vial. The findings include: Review of the facility Policy titled, Vials and [MEDICATION NAME] of Injectable Medications, undated, revealed vials and [MEDICATION NAME] sent from the provider pharmacy in a box or container with the label on the outside are kept in that box or container. The date opened and the initials of the first person to use the vial are recorded on multidose vials on the vial label or an accessory label affixed for that purpose. Review of the Centers for Disease and Prevention, Mantoux [MEDICATION NAME] Skin Test Facilitator Guide, dated (MONTH) 2003, revealed the vial label on [MEDICATION NAME] Purified Protein Derivative (Mantoux [MEDICATION NAME]) should indicate the expiration date. If it has been opened more than thirty (30) days or the expiration date has passed, the vial should be discarded and a new vial used. Further review revealed when a new vial is opened, the date and initials of the person opening the vial should be indicated on the label. Observation on [DATE] at 2:00 PM, of the First Floor Medication Room, in the Short-Term Rehabilitation Unit, revealed a vial of [MEDICATION NAME] in a box with the box labeled with an open date of [DATE] and an expiration date of [DATE]. However, there was no date on the vial to indicate when the vial was opened. Observation of the Second Floor Medication Room, in the Short-Term Rehabilitation Unit on [DATE] at 2:23 PM, revealed a vial of [MEDICATION NAME] in a box with the box labeled with an open date of [DATE] and an expiration date of [DATE]. However, there was no date on the vial to indicate when the vial was opened. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 2:02 PM, revealed if she opened a vial of [MEDICATION NAME], she would label the vial as well as the box with the open date. Per interview, if the vial was to become separated from the box, staff would be able to tell by checking the date on the vial if the [MEDICATION NAME] was still good for use. Further interview revealed if [MEDICATION NAME] was used which had not been dated, or the date the vial was opened was unknown, the [MEDICATION NAME] could be less effective and provide the wrong results. Interview with LPN #3, on [DATE] at 2:23 PM, revealed she was aware [MEDICATION NAME] vials needed to be dated when opened, as the vial could become separated from the box. Further interview revealed if the [MEDICATION NAME] vial was not in the box and there was no date marked on the vial to indicate the date the vial was opened, the vial would need to be discarded. Continued interview revealed if a nurse used a [MEDICATION NAME] vial without a date and the contents of the vial was expired, the skin test could give a false result or a positive result. Interview with the Consulting Pharmacist, on [DATE] at 3:45 PM, revealed pharmacy placed a small label on the box and the date opened sticker on the box for [MEDICATION NAME] vials. Per interview, staff were instructed to keep the vial with the box, and this training was provided to facility staff from pharmacy. Further interview revealed once a [MEDICATION NAME] box was opened, it was good for thirty (30) days, but if the vial was by itself and not in the box, the vial should be discarded. Further review revealed the Consulting Pharmacist was not certain if the vial had to be marked with the open date as long as the box was labeled with the open date. However, per interview, there was a place on the vial for the nurse or medical person to date the vial. Continued interview revealed the reason staff was instructed to date the box when [MEDICATION NAME] was opened was to ensure consistent labeling and storage of [MEDICATION NAME]. The Consulting Pharmacist stated, after thinking about the situation, the nurses should be instructed to label the [MEDICATION NAME] vial with the date the [MEDICATION NAME] was opened. Interview with the Director of Nursing (DON), on [DATE] at 5:08 PM, revealed she had always been trained to date the label on the vial with the open date, but the policy states the accessory label could be dated. Per interview, staff was trained to put the open date for vials on the box. However, further interview revealed the Consulting Pharmacist discussed with management prior to leaving for the day, that staff would need to date [MEDICATION NAME] or [MEDICATION NAME] on the vials when opened. Interview with the Administrator, on [DATE] at 5:18 PM, revealed the facility did not have a separate policy for [MEDICATION NAME] or [MEDICATION NAME], but he felt the present policy encompassed all injectables. Further interview revealed staff was following the policy for labeling and storage of medications as it should be followed. He stated the number on the vial matched the number on the box and per policy, the vial or the box containing the vial should be labeled with the open date.

Based on interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure resident assessments accurately reflected the resident's status for one (1) of thirteen (13) sampled residents. Resident #4's Quarterly Minimum Data Set (MDS) Assessments, dated 02/16/19, and 02/23/19, revealed information in Section C, Cognitive Patterns, was not coded. The findings include: Review of the facility Policy, titled Resident Assessment Instrument (MDS 3.0), undated, revealed the Resident Assessment Instrument will be completed as per regulatory standards. This assessment includes the Minimum Data Set (MDS) and Care Area Assessment (CAA) as specified by federal and state law. Continued review of the Policy, revealed procedures, which documented the MDS and CAAs are completed using information obtained by the assessment team through observation, examination, interview, and collaboration with other health care professionals, along with inspection of the resident's medical record. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), Version 3.0 Manual, Chapter 2: Assessments for the RAI, Page 2-38, revealed the use of the dash -, is appropriate when the staff are unable to determine the response to an item, including the interview items. Review of Resident #4's medical record revealed the facility admitted the resident on 08/21/18 and readmitted the resident on 02/16/19, with [DIAGNOSES REDACTED]. Review of Resident #4's medical record revealed a Discharge Assessment-Return not Anticipated MDS Assessment, dated 02/08/19. Continued review revealed the resident did not have an Admission MDS Assessment completed upon return to the facility on [DATE], but had a Quarterly assessment dated [DATE] in which dashes were recorded in Section C, Cognitive Patterns. Further record review revealed the most recent MDS Assessment for Resident #4 was a Quarterly assessment, dated 02/23/19, in which dashes were recorded in Section C, Cognitive Patterns. A copy of the MDS assessment dated [DATE] was requested by the Surveyor, and when received the following day, on 05/30/19, the MDS Assessment received had been corrected; and the resident was now assessed as having a BIMS score of fifteen (15). Interview on 05/30/19 at 9:48 AM, with the MDS Coordinator, revealed the Discharge Assessment-Return not Anticipated MDS Assessment, dated 02/08/19, should have been coded Discharge Return Anticipated. Per interview, this should have been done to allow for the ongoing OBRA (Omnibus Budget Reconciliation Act) schedule, and the Quarterly assessment dated [DATE]. The MDS Coordinator further stated she just made an entry error which would need to be corrected immediately. Continued interview with the MDS Coordinator, revealed the Quarterly MDS Assessment was completed on 02/16/19, the day the resident returned to the facility from the hospital. Per interview, this MDS Assessment was not an accurate picture of Resident #4's status so she scheduled another Quarterly MDS Assessment to be completed in a week. Continued interview with the MDS Coordinator, revealed the Quarterly MDS assessment dated [DATE] was corrected the date of interview, 05/30/19, as she had the Social Worker enter the information related to Section C, Cognitive Patterns. The MDS Coordinator stated the MDS assessment dated [DATE] was not completed for Section C, Cognitive Patterns and the original MDS assessment dated [DATE], was not completed for Section C, Cognitive Patterns, prior to 05/30/19. Subsequent interview with the MDS Coordinator, on 05/30/19 at 5:40 PM, revealed the Resident Assessment Instrument (RAI) Manual addressed the use of dashes, and dashes were to be used only if staff were unable to determine information. Continued interview revealed Social Service Staff #2 was assigned to do Section C, Cognitive Patterns, and should have entered this information on the MDS Assessments. Continued interview revealed staff covering for the facility MDS Coordinator while she was on leave, dashed the MDS Assessments because Social Service Staff #2 hadn't entered the information. Interview with Social Services Staff #1, on 05/30/19 at 5:09 PM, revealed typically social services staff complete Section D, Mood, and section Q, Participation in Assessment and Goal Setting, and other disciplines and nursing completed the rest of the MDS Assessments. Per interview, social service staff did not typically Complete Section C, Cognitive Patterns, but social service staff was supposed to complete Section C if the MDS Coordinator was on leave, and the MDS Coordinator was on vacation in (MONTH) 2019. Interview with Social Service Staff #2, on 05/30/19 at 5:16 PM, revealed she usually completed section D, Mood, and section Q, Participation in Assessment and Goal Setting. She further stated the facility MDS Coordinator was on vacation so she had to complete Section C, Cognitive Patterns and BIMS (Brief Interview of Mental Status) as well as the pain portion of Section J of the MDS Assessments which were due. Continued interview revealed she was at the facility on 02/16/19, and 02/23/19 and interviewed Resident #4, and made a note saying she completed his/her interviews. Per interview, she normally went into the MDS Assessment and recorded the information, and was unaware she had not recorded this information on the MDS Assessments until this date. Further interview with Social Service Staff #2, revealed the staff covering for the MDS Coordinator that transmitted the MDS Assessment dashed out Section C, Cognitive Patterns for Resident #4's MDS Assessments, dated 02/16/19 and 02/23/19, and did not contact her for the information needed before the Assessments were transmitted. Per interview, the staff that transmitted these MDS Assessments worked at a sister facility. Interview with the Director of Nursing (DON), on 05/30/19 at 5:31 PM, revealed when the MDS Coordinator was on leave/off duty, the assignments were divided up between the team of about six (6) additional staff and there was an MDS Coordinator at the sister facility that assisted them with MDS Assessments. Subsequent interview with the DON, on 05/30/19 at 5:49 PM, revealed it was her understanding Social Service Staff #2 did the interviews with Resident #4 in order to complete Section C, Cognitive Patterns, and had the interviews on a Note, but failed to record them on the MDS Assessments. Per interview, the staff covering for the MDS Coordinator didn't contact Social Service Staff #2 to obtain the needed information for the MDS Assessments, and just placed dashes under that Section C. Further interview revealed Resident #4's MDS Assessments could have had more information and painted a better picture if Section C had been completely filled out. Per interview, it was her expectation staff follow the RAI Manual and have effective communication; as good communication was what was needed to complete the MDS Assessments accurately. Interview with the Administrator, on 05/30/19 at 6:07 PM, revealed it was his expectation staff follow the RAI Manual as it was spelled out. Further interview revealed its was his understanding, per the Manual, that if the staff completing the MDS Assessment did not have the information, it did not need to be recorded on the MDS Assessment at that time. Further interview revealed the main goal was to make sure the MDS Assessments were modified in the time frame, and the MDS Assessments were an accurate assessment of the resident.

Based on observation, interview, and review of the facility's Policy, it was determined the facility failed to ensure staff followed food safety requirements. Observation of the lunch meal service on 05/01/18 and the breakfast meal service on 05/02/18 in the Building (A) 2nd floor Dining Room Satellite kitchen, revealed staff did not have their hair completely covered with a hairnet. The findings include: Review of the facility Infection Control Policy, revised 12/06/17, revealed all staff will be required to have their hair (head and facial) covered while working in the food preparation area. Per Policy, upon arrival to household or main kitchen, staff will put on hairnet or hair restraint. Observation of the lunch meal service, 2nd floor Dining Room Building (A), on 05/01/18 from 12:20 PM to 12:45 PM, revealed State Registered Nursing Assistant (SRNA) #1 donned a hairnet prior to entering the Satellite kitchen area; however, her bangs and the front of her hair were exposed. Additional observation revealed while SRNA #1 was in the Satellite kitchen, she opened the refrigerator to retrieve milk and other beverages for residents. Further observation of the lunch meal service, 2nd floor Dining Room Building (A), on 05/01/18 from 12:20 PM to 12:45 PM, revealed Cook #1 was preparing food in the Satellite kitchen with a ball cap on her head; leaving her ponytail hanging down her back without a hairnet. Observation of the lunch meal service 2nd floor Dining Room Building (A), on 05/03/18 at 8:45 AM, revealed SRNA #1 was working in the Satellite kitchen during the breakfast meal. She was wearing a hairnet; however her bangs were not contained in the hairnet. On 05/03/18 at 8:50 AM, the Director of Nursing (DON) was observed to be speaking with SRNA #1, and SRNA#1 then adjusted her hairnet to cover her bangs area. Interview on 05/03/18 at 10:08 AM, with Cook #1, revealed when she entered the kitchen area she always washed her hands, then donned her hairnet. Further interview revealed Cook #1 acknowledged wearing a ball cap with her ponytail hanging on 05/01/18 at the lunch meal, and stated she should have ensured all of her hair was covered while in the kitchen. Interview on 05/03/18 at 10:18 AM, with the Dietary Manager, revealed all staff were to wear hairnets which covered all the hair while in the Satellite kitchen. Further interview revealed all staff were in-serviced related to this one (1) month ago. Interview on 05/03/18 at 10:28 AM, with the Director of Dining Services, revealed she expected all staff to completely cover all hair and beards when working in the satellite kitchen. Interview with the DON, on 05/03/18 at 10:36 AM, revealed it was her expectation for all staff handling food in the Satellite kitchen to wear hairnets and to ensure all their hair was covered including facial hair. Further interview revealed all SRNAs who assisted in the kitchen area were to have all their hair covered, not just dietary staff. Interview with the Administrator, on 05/03/18 at 10:54 AM, revealed it was his expectation for all staff to utilize safe food handling practices. Per interview, all staff were to wear a hairnet in such a manner to keep their hair contained properly according to the dietary regulations when in the kitchen.