Every finding on record at Fifth Avenue Health Care

Based on observations, staff and resident interviews, record review, and review of the facility policies titled Accidents and Incidents - Investigating and Reporting, Elopement, and Dementia Care, the facility failed to maintain an accident-free environment and provide adequate supervision to prevent accidents for one of three sampled residents (R) (R1). This had the potential to affect at least 10 additional residents identified as being at risk for wandering/elopement. Specifically, the facility failed to implement effective interventions to prevent the elopement of R1, creating an ongoing risk for resident elopement and injury. This deficient practice placed residents at risk for serious harm, injury, and death. On 6/16/2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.On 6/16/2026 at 2:53 pm, the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy (IJ) was identified to have existed on 6/7/2026, when R1 eloped from the facility.An Acceptable Removal Plan was received on 6/17/2026. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was confirmed that the corrective plans and the deficient practice were removed on 6/18/2026. The facility remained out of compliance at a lower scope and severity as follows: F689 Scope/Severity: D, while the facility continued management-level staff oversight, as well as continuing to develop and implement a Plan of Correction (PoC). This oversight process includes assessing, monitoring, and supervising residents at risk for wandering/elopement.Finds included:A review of the facility's initial incident summary revealed that on 6/7/2026 at approximately 8:45 pm, staff were unable to locate R1 after a certified nursing assistant (CNA) reported the resident missing. The facility initiated a search of the building and, when unable to locate R1, expanded the search to the parking lots and surrounding area. Law enforcement was notified at 9:09 pm and arrived at 9:12 pm. R1 was located at 9:47 pm, appeared unharmed, and was transported to the emergency department for evaluation before returning to the facility without new orders. Further review revealed that maintenance staff responded to the facility and inspected all exit doors. The code to the door adjacent to the Minimum Data Set (MDS) office was changed after the door was reportedly found slightly ajar during the search for R1. The investigation further revealed that the facility was unable to determine the exact circumstances under which R1 exited the building.During an observation on 6/15/2026 at 10:24 am, it was revealed that the facility had 11 exit doors. Ten doors were equipped with magnetic locks requiring code access; however, only one exit door had an audible alarm. The observation further revealed that five exit doors had delayed closure, including an approximately nine-second delay on the employee breakroom door. The employee breakroom exterior door remained a primary entrance and exit point and could be easily opened from the interior, as it remained unlocked. The observation revealed that only one surveillance camera in the lobby area was operational, while cameras located near most exit doors were nonfunctional.A review of the facility's investigation of the elopement incident dated 6/7/2026 identified that R1, a resident assessed as being at risk for wandering/elopement, exited the facility without staff knowledge after being redirected multiple times for wandering into resident rooms. The investigation revealed surveillance footage that showed R1 traveling through the facility lobby at approximately 7:53 pm and in an adjacent parking lot by approximately 8:00 pm. The facility concluded that R1 most likely exited through the East Wing exit door adjacent to the employee breakroom; however, the investigation was unable to determine the exact circumstances under which R1 exited the building. A review of the facility's Wandering/Elopement Risk List revealed 11 residents identified as being at risk for wandering/elopement.A review of the electronic medical record (EMR) revealed that R1 was admitted to the facility on [DATE] with diagnoses, including but not limited to late-onset Alzheimer's disease, severe dementia with agitation, anxiety disorder, insomnia, Chronic Obstructive Pulmonary Disease (COPD), and a history of breast cancer.A review of R1's annual MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment, and that R1 had no impairments and did not require any assistive devices.A review of the care plan dated 2/25/2026 indicated R1 presented with a problem of cognitive impairment related to dementia and Alzheimer's disease and a history of falling with prior fractures. Goals included, but were not limited to, maintaining safety and preventing injury or complications through the review period. Interventions included, but were not limited to, monitoring the resident for changes in condition, providing appropriate supervision, and implementing safety measures as indicated for the resident's condition and risk factors.A review of R1's Elopement Evaluation dated 4/7/2026 revealed that R1 was assessed as being at risk for wandering/elopement related to severe cognitive impairment and dementia. The evaluation identified interventions, including staff awareness of elopement risk, monitoring whereabouts, frequent observation, redirection, purposeful activities, use of safety devices, and implementation of measures to prevent an unsupervised exit from the facility.A review of the care plan, revised 6/10/2026, revealed that R1 presented with a problem of elopement risk, exit-seeking behaviors, and wandering related to severe cognitive impairment, disorientation, wandering throughout the facility, entering other residents' rooms, and an actual elopement event on 6/7/2026. Goals included, but were not limited to, R1 not leaving the facility unattended through the review period. Interventions included keeping R1 in supervised areas whenever possible, monitoring whereabouts, redirecting as needed, providing structured activities, encouraging participation in activities, and conducting visual safety checks every 15 minutes.A review of nursing documentation dated 4/15/2026 through 6/15/2026 revealed that R1 had a BIMS score of zero, indicating severe cognitive impairment, exhibited chronic confusion, frequent wandering behaviors, entered other residents' rooms, required frequent redirection, and was documented as an elopement risk. Documentation further revealed that R1 eloped from the facility on 6/7/2026 and was subsequently located by law enforcement and transported to the emergency department for evaluation.A review of the emergency department record dated 6/7/2026 through 6/8/2026 revealed that R1 had been missing from the facility for approximately three hours and was found walking along a roadway in the rain before being transported by Emergency Medical Services (EMS) for evaluation.During an interview with R1's family member on 6/15/2026 at 1:13 pm, he was notified on 6/7/2026, after R1 had been located, and was informed that she had left the facility. He stated R1 had resided at the facility for approximately two years, ambulated independently, frequently walked throughout the facility, and was found approximately one block away from the facility. He further stated he did not believe R1 could have independently navigated her way out of the facility and believed someone may have allowed her to exit.During a telephone interview on 6/15/2026 at 3:30 pm, CNA BB revealed that R1 was known to walk throughout the facility, push on exit doors, attempt to open doors, and occasionally attempt to follow others through doorways. CNA BB stated she participated in the search for R1 after staff were unable to locate her on the evening of 6/7/2026.During a telephone interview on 6/15/2026 at 2:50 pm, CNA CC revealed that R1 regularly walked throughout the facility and attempted to exit through the doors. CNA CC stated R1 had been observed wandering on the evening of the incident before being discovered missing.During a telephone interview on 6/15/2026 at 3:43 pm, CNA EE revealed R1 routinely entered other residents' rooms and frequently tested exit doors to determine if they would open. He stated that staff often redirected R1 due to these behaviors. CNA EE stated that staff searched the facility after R1 could not be located.During a telephone interview on 6/15/2026 at 3:11 pm, Registered Nurse (RN) Weekend Unit Supervisor FF revealed that at approximately 8:30 pm on 6/7/2026, staff notified him they were unable to locate R1. He stated that staff conducted a systematic search of resident rooms, bathrooms, closets, and common areas before determining R1 was not in the building. He stated law enforcement was contacted after the facility-wide search was completed. RN FF stated R1 was known to wander throughout the facility and enter resident rooms. He further stated that maintenance immediately secured a door identified during the investigation and acknowledged he was unaware of the existence of one of the exit doors before the incident.During an interview on 6/15/2026 at 4:33 pm, the Social Services Director revealed R1 had been a wanderer since admission and routinely required redirection due to entering resident rooms and wandering throughout the facility. Further stated she responded to assist after being notified of the elopement and observed R1 after she was located by emergency responders.During an interview on 6/15/2026 at 4:40 pm, the MDS Coordinator revealed R1 had been identified by the facility as being at risk for wandering/elopement and exit-seeking behaviors. The MDS Coordinator stated interventions included increased monitoring, redirection, and maintaining a wandering resident tracking book at the nurses' stations.During an interview on 6/15/2026 at 4:03 pm, the Maintenance Director revealed that a review of available surveillance footage showed R1 in the facility lobby at approximately 7:53 pm and in an adjacent parking lot by approximately 8:00 pm. Based on the footage and R1's observed path of travel, he believed R1 most likely exited through the breakroom door or the exterior door leading to the parking lot; however, he could not determine the exact door used by R1. The Maintenance Director stated that only one lobby camera was operational and acknowledged he was unable to review footage from other areas because most facility cameras were not functioning. He further stated that residents or visitors may have obtained door access codes from others, that most exit doors were equipped with magnetic locks but lacked audible alarms, and that door closure delays could be adjusted from approximately 10 seconds to 1 second. Further reported that he inspected all exit doors following the incident and changed the code to the exit door adjacent to the MDS office after concerns were raised that the door had not fully closed during the search for R1. He further stated that city surveillance footage showed R1 crossing multiple roadways before being located.During an interview on 6/15/2026 at 4:38 pm, the DON revealed R1 wandered throughout the facility daily and required frequent observation and redirection. Further stated the facility did not know exactly how R1 exited the building, but believed she likely exited through the area adjacent to the employee breakroom. She further stated that family members commonly entered the facility through the breakroom exterior entrance and acknowledged that staff had provided education regarding not sharing door access codes. The DON further stated that she believed, based on fire safety design, the facility exit doors would open if held for approximately 15-30 seconds; however, observation did not confirm this function at the time of survey.During an observation with the DON and Maintenance Director on 6/15/2026 at 5:08 pm, the exit door across from the conference room was tested. The handle was held for multiple minutes to test whether the delayed egress system would release as described by the DON. This test revealed that the door did not release or alarm. During the same observation, a staff member exited the employee breakroom adjacent to the lobby, and the breakroom door failed to close and latch completely, allowing the surveyor to push the door open. The Maintenance Director confirmed the door delay settings had recently been adjusted from 10 seconds to 1 second. Follow-up interview on 6/15/2026 with the Maintenance Director further clarified that the facility doors do not function in the manner described by the DON, stating the doors would not open if held down for an extended period of time and would only release based on their programmed locking mechanism, not continuous pressure applied to the handle.During a telephone interview on 6/16/2026 at 10:11 am, Licensed Practical Nurse (LPN) KK revealed that she observed R1 wandering on the evening of 6/7/2026, entering resident rooms, and requiring redirection. She stated she last observed R1 shortly after 8:00 pm in a lounge area and later assisted with the facility-wide search when staff were unable to locate her. Further stated staff inspected an exit door near the MDS office during the search after concerns were raised that the door was not closing properly.During an interview on 6/16/2026 at 1:06 pm, LPN GG revealed that staff maintained wandering and elopement books identifying residents at risk and that interventions for residents identified as wanderers included redirection, close monitoring, and 15-minute safety checks following an elopement incident.During an interview on 6/16/2026 at 1:16 pm, CNA HH revealed R1 was well known by staff to wander throughout the facility, enter other residents' rooms, take belongings, push on exit doors, and require frequent redirection. Further, these behaviors had been ongoing and were known to facility staff before the elopement incident.During an observation on 6/16/2026 at 12:42 pm, R1 ambulated independently throughout the East Wing hallway while awaiting departure with her spouse.A review of the policy titled Accidents and Incidents-Investigating and Reporting, revised 2/27/2026, indicated that Assuring that appropriate and immediate interventions are implemented, and corrective actions are taken to reduce the risk of recurrences and improve the management of resident care.A review of the policy titled Elopement, revised October 2023, indicated that This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to reduce the risk of accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Further review of item 1. The facility is equipped with keypad door locks to avoid elopements. Item 2. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.A review of the policy titled Dementia Care dated February 2023 indicated that It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. Further review of item 2. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Item 4. If needed, the environment will be modified to accommodate individual resident care needs. Item 5. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness, and will be reviewed/revised as necessary.The facility implemented the following actions to remove the IJ:1. On 6/7/2026, the facility conducted a thorough search of the facility and grounds, and R1 could not be located. At 9:09 pm, 911 was called, and at 9:12 pm, a police officer arrived to obtain information regarding the resident. Per the emergency phone call at 9:27, R1 was seen on one of their cameras, and at 9:47 pm, R1 was located in the parking lot of some apartments, one block from the facility, and was examined by EMS. No injuries were noted, but in an abundance of caution, per the facility's request, she was transported to the emergency room (ER) to be examined. R1 returned to the facility with no new orders. On 6/7/2026, the DON, Administrator, Corporate, the responsible party, and the Medical Director (MD) were notified. On 6/7/2026, a facility-wide audit of all exit doors was completed by the Maintenance Director, and his statement says they were functioning, latching, and locking properly. He changed the west wing door code by the MDS office, and the code was not given to anyone because at that time we suspected that the resident may have exited through that door, as staff reported that the door was not fully latched when they were searching for R1 in the building. 2. On 6/8/2026, an Emergency Quality Assurance (QA) meeting was conducted with the Interdisciplinary Team, and the circumstances surrounding the elopement were reviewed. A root cause analysis was started, and the facility continued to investigate the elopement. The Maintenance Director reviewed the camera footage, and the resident was seen on camera in the lobby at 7:53 pm going from [NAME] Hall to East Hall. The Maintenance Director requested to review the camera footage at a business that is adjacent to the facility. Once the footage was reviewed, R1 was observed at 8:00 pm in their parking lot. On 6/8/2026, exit monitoring to ensure proper door functioning was initiated Monday through Friday to be completed by the Maintenance Director or the Assistant Maintenance Director. On 6/17/2026, the Maintenance Director educated the DON and the Infection Preventionist/Staff Development nurse on how to check the doors to ensure that they are auto-closing, locking when closed with no delay, and that the interim audible alarms are working on the four doors they were added to. The RN Weekend Supervisor will be trained when he comes to work on Saturday (he is not able to come prior) by the Maintenance Director. If the RN Supervisor is not available to check the doors on the weekend, the DON or the Infection Preventionist/Staff development nurse will do exit monitoring. 3. On 6/15/2026, a CNA was observed exiting the breakroom with several snacks in her arms/hands, and the door did not fully shut. This was observed by the DON. The breakroom does have a keypad door lock to enter and exit the breakroom from the hallway of the facility, as well as an automatic closer. There is also an external door to exit the building into the parking lot from the breakroom that does not have a keypad lock on it.On 6/15/2026, signage with a red stop was placed on every exit door stating Please Do Not Let Residents Leave the Building. Please check that the door is securely locked before your departure. This sign was placed on all 11 facility exits and the inside of the breakroom door to remind staff to ensure the door locks.On 6/15/2026, the facility completed a comprehensive security and physical plant assessment. It was determined that one of the 11 doors had an audible door alarm. On 6/15/2026, Interim Audible Alarms were placed on the breakroom door, the door exiting the breakroom into the parking lot, the main entrance into the East Wing, and the Main Entrance by the Administration Hall. The door leading to the Courtyard has a functioning alarm.4. On 6/16/2026, the Maintenance Director replaced the automatic door closer to the breakroom, and it now shuts even if both hands are occupied. It was tested after closing, and it could not be pushed open. On 6/16/2026, the Maintenance Director changed the door codes to the main door on the East Wing and the door that leads from the hall to the breakroom. The staff will only have the codes for the following doors: The main entrance by the administration hall, the door to the courtyard, the main entrance door on the east wing, and the door that leads into the breakroom. All the doors listed have the interim audible alarm now, except for the courtyard, which has a functioning alarm. On 6/16/2026, the door codes for the six remaining doors were changed and will not be shared with staff. On 6/16/2026, the Maintenance Director changed the time for the doors to lock (dwell time) to one second on all 10 of the 10 exit doors with keypads5. On 6/16/2026, for each of the nine residents identified at risk for wandering/elopement, their care plan wandering and/or elopement care plan and interventions were reviewed by the Regional Nurse Consultant to ensure appropriate safeguards were in place.On 6/16/2026, the Regional Nurse Consultant completed a 100% review of all residents to identify those residents identified as being at risk for wandering or elopement. No new residents were identified, and two residents that were on the list were removed (their assessment no longer identified them at risk); a total of nine residents were identified at risk; however, they are not exit-seeking, they wander within the facility. The wandering list at the desk was updated. 6. As of 6/17/2026, education was started for CNAs, LPNs, and RN's only. As of 6/17/2026, the following education has been completed: 25 out of 27 nurses (19 LPNs and six RNs for a total of 93%); 37 out of 43 CNAs were educated for a total of 86%. Education included the Accidents and Incidents Investigating and reporting policy, and an education sheet titled Elopement Response and Notification Education All Staff (however, it was only used for nursing at this time). The remaining two LPNs are PRN (as needed), and the remaining three CNAs, two are full-time, and four are PRN and could not be reached will be educated by the DON or the Infection Preventionist/Staff Development nurse before their next shift.As of 6/17/2026, education was done for all departments other than nursing on Elopement Response and Notification Education for All Staff: nine out of nine Dietary for a total of 100%; two out of two Maintenance staff for a total of 100%; 13 out of 14 Housekeeping and Laundry staff for a total of 93%; Activities staff two out of two for a total of 100%; Administrative staff six out of six were educated for a total of 100%, 10 out of 10 Therapy staff for a total of 100%. The remaining one housekeeping and laundry staff member has no phone, so will be educated by the DON or the Infection Preventionist/Staff Development before the next scheduled shift. As of 6/17/2026 20 out of 22 nurses (16 LPNs six RNs for a total of 91%), 33 out of 38 for a total of 87%, nine out of nine Dietary staff for a total of 100%; two out of two Maintenance staff for a total of 100%; 13 out of 14 Housekeeping and Laundry for a total of 93%; Activities staff two out of two for a total of 100%; Adminstartive staff six out of six were educated for a total of 100%, Therapy staff 10 out of 10 for a total of 100% were educated on the Interim Audible Alarms that were placed, the new signage reminding people not to let residents out of the building, and new signage to be sure that doors latch when you enter and exit placed on the breakroom door. The remaining one housekeeping and laundry staff member has no phone, so will be educated by the DON or the Infection Preventionist/Staff Development before the next scheduled shift. 7. All corrective actions will be completed on 6/17/2026, and the facility alleges that the IJ will be removed on 6/18/2026. State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows:1. A review of the Resident Census Checklist dated 6/7/2026 demonstrated that all residents were accounted for between 9:10 pm and 9:15 pm except R1. Written statements from CNAs, nursing staff, and the Maintenance Director described the facility search efforts and were consistent with surveyor interviews conducted on 6/15/2026. A review of the Police Report documented a missing adult report initiated on 6/7/2026 at 9:09 pm and indicated R1 was located at 9:50 pm by the Fire Department on the North 5th Avenue walking trail. The report documented an EMS evaluation with no apparent injury and transport to the emergency department at the facility's request. A review of the Emergency Department After Visit Summary confirmed R1 arrived on 6/7/2026 at 10:24 pm, was discharged on 6/8/2026 at 3:08 am in stable condition, had no medication changes, and returned to the facility.A review of the EMR revealed documentation dated 6/7/2026 showing notification of the DON by the RN Unit Supervisor at 8:45 pm, notification of the responsible party by the DON at 10:15 pm, and notification of the attending physician at 10:30 pm. The Administrator's written statement documented notification by the DON on 6/7/2026. Surveyor interviews conducted on 6/15/2026 corroborated the documented notifications.A review of maintenance documentation dated 6/7/2026 demonstrated that all facility exit doors were inspected and found to be functioning, latching, and locking appropriately. Documentation and an interview with the Maintenance Director on 6/15/2026 confirmed that the code to the west wing exit door near the MDS office was changed following identification of the door as a possible exit point. A review of the facility map dated 6/7/2026 identified all facility exit doors inspected during the assessment.2. A review of Emergency Quality Assurance Process Improvement (QAPI) meeting records dated 6/8/2026 demonstrated attendance by the Administrator, DON, Business Office Manager (BOM), Infection Preventionist (IP), Treatment Nurse, MDS Coordinator, Activities Director, Social Services Director, Medical Records staff, Maintenance Director, and Human Resources. Meeting documentation reflected review of the elopement event, initiation of a root cause analysis, implementation of interim corrective actions, addition of the event to the QAPI program, installation of door signage and alarms, staff education, and initiation of plans to upgrade door locking systems. A review of camera footage images dated 6/7/2026 showed R1 inside the facility at 7:53 pm and outside the facility in an adjacent parking lot at approximately 8:01 pm.A review of door-monitoring records demonstrated daily exit-door audits completed and signed by the Maintenance Director on 6/8/2026, 6/9/2026, 6/10/2026, 6/11/2026, 6/12/2026, 6/15/2026, 6/16/2026, 6/17/2026, and 6/18/2026. Audit documentation identified each exit door inspected and verified door closure, latching, locking, and alarm functionality. Education records dated 6/17/2026 documented training provided by the Maintenance Director to the DON and IP/Staff Development Nurse regarding door-monitoring procedures. Interviews conducted on 6/18/2026 confirmed understanding of the monitoring process and education.3. Direct observation by the surveyor, DON, and Maintenance Director on 6/15/2026 confirmed a CNA exited the breakroom carrying multiple items, and the door failed to fully latch. Observation further confirmed that the breakroom exterior exit door did not contain a keypad lock.Direct observation on 6/18/2026 confirmed laminated stop signs were posted on all 11 facility exit doors and on the interior breakroom door. The signage instructed staff not to permit residents to leave the building and to verify doors were securely locked upon exit.A review of the facility security assessment dated [DATE] identified only one exit door equipped with an audible alarm. Observation by the surveyor on 6/15/2026 confirmed the presence of a single functioning audible alarm in the lobby area.Direct observation on 6/18/2026 confirmed installation and functionality of interim audible alarms on the breakroom hallway door, breakroom exterior exit door, east wing main entrance, and administration hallway main entrance. Observation also confirmed the courtyard door alarm remained operational. Maintenance records and an interview with the Maintenance Director on 6/18/2026 corroborated the installation of the alarms.4. A review of maintenance records dated 6/16/2026 documented the replacement of the breakroom automatic door closer. Direct observation on 6/18/2026 confirmed the door closed and latched automatically when released and remained secured after closure.Direct observation and staff interviews conducted on 6/18/2026 confirmed implementation of new access codes for the east wing entrance and breakroom hallway door. Staff consistently identified only authorized employee access points. Maintenance records dated 6/16/2026 documented the code changes.Staff interviews conducted on 6/18/2026 with nursing, dietary, housekeeping, administrative, and maintenance personnel confirmed employees did not have access to the codes for the six restricted exit doors. Maintenance documentation dated 6/16/2026 verified the code changes.Direct observation conducted with the Maintenance Director on 6/18/2026 confirmed all ten keypad-controlled exit doors were programmed to relock within one second following closure. Maintenance records dated 6/16/2026 documented completion of the programming changes.5. A review of the EMR on 6/16/2026 confirmed that wandering and elopement care plans for all nine residents identified as at risk for wandering or elopement were reviewed by the Regional Nurse Consultant and contained individualized interventions. A review of facility elopement risk assessments and the Elopement/Wanderer Binder on 6/16/2026 confirmed completion of a 100% resident review. Documentation demonstrated that nine residents were identified as being at risk for wandering/elopement and included current photographs. Assessment review verified that no additional residents were required for inclusion, and two residents were appropriately removed based on reassessment findings.6. A review of education records and sign-in sheets dated 6/7/2026 through 6/17/2026 demonstrated completion of education regarding Elopement Response and Notification and the Accident/Incident Investigation and Reporting Policy for 98 of 103 active staff members. Training records identified attendees, dates of completion, educational content, and instructors. Staff interviews conducted between 6/15/2026 and 6/18/2026 confirmed receipt and understanding of the education.A review of education records dated 6/7/2026 through 6/17/2026 demonstrated completion of Elopement Response and Notification education for dietary, maintenance, housekeeping/laundry, activities, administration, and therapy staff. Training records documented attendance, dates completed, and educational content. Interviews conducted by the surveyor confirmed staff understanding of their responsibilities related to resident elopement prevention and response.A review of education records and sign-in sheets dated 6/15/2026 through 6/17/2026 demonstrated completion of education for 93 of 103 active staff members regarding interim audible alarms, exit-door signage, and door-latching expectations. Educational records identified attendees by name, department, date, and trainer. Interviews with staff from nursing, dietary, housekeeping, activities, maintenance, and administration, conducted between 6/15/2026, 6/18/2026, and 6/23/2026, confirmed understanding of the new procedures and security measures.7. The IJ was identified by the survey team on 6/16/2026, and both the DON (in person) and the Administrator (via phone) were notified on 6/16/2026 at 2:53 pm. The facility immediately initiated corrective actions to protect all residents from the identified risk. The IJ Removal Plan was submitted on 6/17/2026. The facility alleged IJ removal effective 6/18/2026 following implementation of interim audible alarms, restriction of staff access to exit-door codes, replacement of the breakroom door closer, completion of resident elopement-risk reviews, implementation of daily exit-door monitoring, and education of staff rega

Based on interviews, record review, and review of the facility policy titled Policy and Procedure Abuse, Neglect, and Exploitation, the facility failed to keep one of three sampled residents (R) (R10) free of sexual abuse by another resident, R11. This failure had the potential to cause physical and psychosocial harm to R10. Findings included:A review of the facility policy titled Policy and Procedure Abuse, Neglect, and Exploitation with a revised date of 9/17/2025, revealed that it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. It is noted that sexual abuse is non-consensual sexual contact of any type with a resident. Prevention of Abuse, Neglect, and Exploitation: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. A review of the electronic medical record (EMR) for R10 revealed she was admitted to the facility with diagnoses that included unspecified altered mental status, unspecified depression, generalized anxiety disorder, and dementia with psychotic disturbance. A review of the Quarterly Minimum Data Set (MDS) assessment for R10 dated 3/23/2026 revealed the following:Section B, Hearing, Speech, and Vision: adequate hearing and vision, clear speech, can be understood, and usually understands.Section C, Cognitive Patterns: Brief Interview for Mental Status (BIMS) score was 0, indicating severe cognitive impairment.Section D, Mood: Mood score of 17, indicating moderately severe depression. A review of the Care Plan for R10 revealed the following concerns:Focus: behavior problem (crying, verbal aggression, and agitation) related to (r/t) dementia.Focus: resistance to care (restorative exercises) r/t anxiety.Focus: impaired cognitive function/dementia (staff assessment) or impaired thought processes r/t Alzheimer's dementia.Focus: communication problem r/t cognitive deficits; she is understood and usually understands.Focus: uses antidepressant medication r/t depression.Focus: restorative nursing for impaired cognition, unsteady gait/balance.The focus concerns were complete with appropriate goals and interventions. A review of the Sexual Expression and/or Intimacy-Capacity to Consent Interview, dated 3/7/2025, revealed the following questions and answers:*Who do you wish to initiate sexual contact with? Answer: Yeah, Yes, oh Lord . I have no idea.*Are you currently in a relationship with this person? Answer: Fine*Do you believe that your current partner is your spouse? Answer: Yes*Do you know what it means to have sex? Answer: I don't know. I always have such a good answer.The interview did not express a decision as to R10's ability to consent to a sexual relationship, but her answers were inappropriate. A review of the EMR for R11 revealed he was admitted to the facility with diagnoses that included other stimulant abuse, a history of cerebral infarction without residual effects, transient ischemic attacks (TIAs), and vascular dementia. He was discharged to the local hospital on 4/3/2026. A review of the Quarterly MDS assessment for R11, dated 3/4/2026, revealed the following:Section C, Cognitive Patterns: BIMS score of 11, indicating moderate cognitive impairment.Section D, Mood: Mood score of zero (0), indicating no depression.Section E, Behaviors: none. A review of the Care Plan for R11 revealed the following focus concerns:Focus: behavior problem-he pulls out his penis in public areas (11/22/2024).Goal: Will have fewer episodes of inappropriate behavior by review date (revised 3/9/2026).Interventions: administer Provera and Depakote as ordered per MD (Medical Doctor) for hypersexual behavior (1/16/2026); anticipate and meet his needs (11/22/2024); consult with facility psychiatrist to eval and treat for hypersexual behaviors (1/16/2026); if reasonable, discuss his behavior-explain/reinforce why behavior is inappropriate and/or unacceptable (11/22/2024); intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; remove from situation and take alternate location as needed.Focus: Expresses public displays of affection with another female resident (holding hands, kissing, hugging, touching, etc.) while sitting in the lobby (6/17/2025).Goal: will have fewer episodes of PDA by review date (revised 3/9/2026).Additional interventions: assist him in developing more appropriate methods of interacting with female residents (6/17/2025); give positive reinforcement for appropriate behaviors (6/17/2025); provide a program of activities that is of interest and encourage him to participate (6/17/2025).Focus: Impaired cognitive function: BIMS score=11 or impaired thought processes r/t history of alcohol abuse (revised 11/10/2025).Goal: will remain oriented to person, place, situation, and time through the review date (revised 3/9/2026).Interventions: administer medications as ordered; monitor/report PRN (as needed) any changes in cognitive function, specifically changes in decision-making ability, memory, recall, and general awareness, difficulty expressing self, difficulty in understanding others, level of consciousness, and mental status (4/20/2023).Focus: Antidepressant medications r/t anxiety (revised 12/18/2025).Goal: will have no adverse reactions through the next review date (revised 3/9/2026).Interventions: administer medications as ordered by the physician; consider psychologist intervention (12/18/2025).Focus: Has conflict with a particular female resident and attempts to get her agitated (3/5/2025).Goal: will not cause other residents to become agitated for 90 days.Interventions: attempt to keep him from the other resident; explain to him why his behavior is unacceptable; intervene as needed to protect others from potential harm. A review of a facility document dated 1/14/2026 revealed an allegation of resident-to-resident sexual abuse in which the Employee Services Manager (ESM) witnessed R11 attempt to get R10 to open her mouth so he could insert his penis in the hall outside of his office. R11 did not expose his genitals, but the HRPM overheard him tell R10 what he wanted her to do. R11 stepped away when the HRPM approached. Staff were immediately educated that R10 and R11 should never be together. The Social Worker (SW) and Administrator spoke with R11 and informed him that he was not to go over to the [NAME] Side, where R10 lives, unless he was unaccompanied. The allegation was reported timely to the State Survey Agency (SSA) and investigated thoroughly, including a timeline containing appropriate notifications (responsible party, Nurse Practitioner, and local law enforcement). Police investigation revealed R10 did not recall the incident. A review of the subsequent investigation, dated 1/22/2026, substantiated the reported allegation. R11 was placed on 1:1 observation for 48 hours, then every fifteen-minute check to monitor his whereabouts. A review of a facility document dated 4/3/2026 revealed an allegation of resident-to-resident sexual abuse, which staff witnessed R11 expose his penis to R10. The staff member immediately intervened and told R11 to put his penis back into his pants. R11 returned to his room, and staff initiated 1:1 supervision. Local law enforcement was notified and informed that the facility that R11 had an outstanding warrant several years ago, and he was given a notice of immediate discharge and taken to the local jail. The subsequent investigation report dated 4/10/2026 revealed a thorough investigation, which included a timeline with a witness account by [NAME] FFF, notifications to responsible parties, Nurse Practitioner, and local law enforcement. The allegation of inappropriate sexual behavior was substantiated, and R11 was already discharged to the local jail. During an interview with Certified Nursing Assistant (CNA) ZZ on 6/23/2026 at 12:15 pm, she stated the facility provided in-services on abuse and other topics every pay period, mostly in-person. She named the Abuse Coordinator (AC) as the Administrator who had two hours to report abuse allegations to the SSA, five days to complete the investigation, and a suspension for the accused staff member. She stated that if she encountered an abusive situation, she would make sure the resident(s) was/were safe and then report to the AC. During an interview with CNA OO on 6/23/2026 at 12:48 pm, she stated that the facility provided education on abuse prevention and reporting at least every pay period and as needed. She named the AC as the Administrator who had two hours to report abuse allegations to the SSA, five days to complete the investigation, and a suspension for the accused staff member. She stated that if she encountered an abusive situation, she would make sure the resident(s) was/were safe and then report to the AC. During an interview with the Activities Director on 6/23/2026 at 12:55 pm, she stated that the facility provided education on abuse prevention and reporting at least every pay period and as needed. She named the AC as the Administrator who had two hours to report abuse allegations to the SSA, five days to complete the investigation, and a suspension for the accused staff member. She stated that if she encountered an abusive situation, she would make sure the resident(s) was/were safe and then report to the AC. During an interview with LPN WW on 6/23/2026 at 1:05 pm, she stated that the facility provided education on abuse prevention and reporting at least every pay period and PRN. She stated that the Administrator was the AC who had two hours to report abuse allegations to the SSA, five days to complete the investigation, and, if the alleged perpetrator (AP) was a staff person, he/she would be suspended pending the outcome of the investigation. During an interview with LPN HHH on 6/23/2026 at 2:45 pm, she stated that the facility provided in-service education r/t abuse at least quarterly and PRN. She stated the AC was the Administrator who had two hours to report abuse allegations to the SSA, five days to complete the investigation, with the accused staff person suspended or placed on leave during the investigation period. Regarding R11, she stated he was alert and cognitively intact, but she did not witness any sexual behaviors or verbiage on his part when she took care of him. During an interview with the admission Coordinator on 6/23/2026 at 3:15 pm, she stated that the facility only began checking the Sex Offender Registry last year for potential new admissions. She stated they did not check the Sex Offender Registry for their current resident population. During a joint interview with the Administrator and Director of Nursing (DON) on 6/23/2026 at 3:30 pm, each stated their goal was to do everything possible to keep their residents safe from any form of abuse. They each confirmed that they present staff education with each pay period, which included abuse prevention and reporting. The DON stated that R11 had an outstanding arrest warrant, which they were not aware of, but allowed for an immediate discharge. She stated R11 only targeted R10 because, as he told staff, she reminded him of his ex-wife.

Based on observations, record review, staff interviews, and review of the facility policy titled Medication Administration-General Guidelines, the facility failed to ensure accurate administration of medications for three of 32 medication opportunities observed, resulting in a medication error rate of 9.37%. This deficient practice had the potential to negatively impact residents (R), leading to complications of their current health status. Findings included:During an observation on 6/22/2026 at 8:40 am, Licensed Practical Nurse (LPN) WW revealed medication administration discrepancies for R14 and R13.* LPN WW administered One Daily Multivitamin with Minerals, which did not match the ordered medication. A review of the electronic medical record (EMR) revealed that R14 had a physician order for Multiple Vitamin tablet, give 1 tablet by mouth one time daily for weight loss.* LPN WW administered an Aspirin 81 milligrams (mg) chewable tablet, which was not the ordered dosage form. A review of the EMR revealed that R13 had a physician order for Aspirin EC (enteric-coated) 81 mg delayed-release tablet, give 1 tablet by mouth one time daily for essential (primary) hypertension.* LPN WW administered a Memantine 5 mg tablet, which did not match the ordered strength of 10 mg. A review of the EMR revealed that R13 also had a physician order for Namenda (Memantine HCl) 10 mg tablet, give 1 tablet by mouth twice daily for vascular dementia.During an interview on 6/22/2026 at 1:08 pm, LPN WW confirmed that regarding medication discrepancies made during medication administration observations. LPN WW reviewed the medications and acknowledged that the multivitamin available for administration did not match the physician's order. She stated that the medication available was a multivitamin with minerals, while the physician's order specified a multivitamin. She confirmed that the medication available was not the same as the medication ordered. LPN WW also acknowledged a discrepancy involving Aspirin. She stated that the physician's order specified enteric-coated Aspirin; however, the medication available for administration was chewable Aspirin. Regarding Namenda, LPN WW stated that the physician's order and Medication Administration Record (MAR) reflected Namenda 10 mg; however, the medication supplied by the pharmacy and linked to the MAR was Namenda 5 mg. Observation of the blister pack revealed that 18 doses had been removed from the card. LPN WW stated she was unsure why the discrepancy existed and acknowledged that she had not identified the incorrect medication strength before the survey observation.During an interview on 6/22/2026 at 4:56 pm, the Director of Nursing (DON) revealed that medications administered should match the physician's orders. Regarding the Namenda discrepancy, the DON stated that the MAR reflected an order for Namenda 10 mg; however, a 5 mg tablet had been linked to the order in the MAR. The DON stated it appeared that when the medication was received and entered into the system, the 10 mg order may have been incorrectly associated with the 5 mg medication supplied by the pharmacy. The DON stated the facility had already initiated staff education regarding medication administration and the identification of medication discrepancies. She reported that nurses are expected to compare physician orders, the MAR, and the medication available for administration and to resolve any discrepancies before administering medications. The DON stated that when a discrepancy is identified, nursing staff are expected to take immediate corrective action, including contacting the pharmacy, physician, or other appropriate healthcare providers for clarification. The DON further stated that recent education included reinforcement of the Five Rights of Medication Administration. She reported that the facility's expectation is a zero-percent medication error rate.A review of the facility's policy titled Medication Administration-General Guidelines, dated 4/1/2025, indicated that medications are administered as prescribed in accordance with good nursing principles and practices. Review of item 4. FIVE RIGHTS - Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication is put away. a. Check #1: Select the Medication - label, container, and contents are checked for integrity, and compared against the medication administration record (MAR) by reviewing the 5 Rights. b. Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights. Further review of item 5. The medication administration record (MAR) is always employed during medication administration. Before administration of any medication, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged, indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. When a medication order is changed, and the current supply can continue to be used, the container should be flagged right away and the order change communicated to the provider pharmacy so that the next supply of the medication is labeled with the current directions.

Based on observations, staff interviews, and review of the facility policies titled, Legionella Water Management Program and Handwashing/ Hand Hygiene, the facility failed to develop an effective water management program and failed to perform hand hygiene or wash hands when entering and exiting resident rooms when serving lunch trays. The deficient practice of not developing an effective water management program had the potential to affect the health and safety of all residents that reside in the facility and failing to perform hand hygiene or hand washing to affect 64 residents who received a food tray from the kitchen. The facility census was 66 residents.Findings include: Review of facility's undated policy titled Handwashing/ Hand Hygiene with a revised date of February 2021 revealed under Policy Statement: The facility considers hand hygiene to be the primary means of preventing the spread of infection. Under Policy Interpretation and Implementation: .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.7. Use an alcohol-based hand rub containing at least 62% (percent) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .o. Before and after assisting a resident with meals. Review of the facility policy titled Legionella Water Management Program with an acceptance date of 5/6/2025 revealed under Policy Interpretation and Implementation: 1. As part of the infection prevention and control program, our facility has a water management program which is overseen by the water management team. 1. Review of the Water Management Program binder provided by the Maintenance Director revealed a map of a facility tracing the water flow, but it was from a different facility. Review of a separate binder revealed that water temperatures were checked weekly. An interview on 8/28/2025 at 12:36 pm with the Maintenance Director revealed that he checked water temperatures every week including resident rooms, shower rooms, and any rooms that had sinks in them. He also drained water heaters once a month. He stated that they did not test the water for legionella. The Maintenance Director confirmed that the facility map in the provided binder was not for this facility and confirmed that they did not have a written diagram of the water flow or a map tracing water flow for this facility. An interview on 8/28/2025 at 2:13 pm with the Administrator confirmed there was no other water management program binder for the facility other than what was already provided. She confirmed there was no map or written diagram of the water flow for the facility. She stated that the Maintenance Director was responsible for the water management program. She was not aware of any testing for legionella for the facility. She stated that potential negative outcomes of not having an effective water management program could lead to residents, staff and visitors getting legionella and becoming sick. 2. Observation on 8/28/2025 at 12:30 pm revealed two Certified Nursing Assistants (CNAs), CNA BB and CNA CC, passing lunch trays from an open tray cart to residents in their rooms during lunch in the facility's East hallway. CNA BB was observed taking a lunch tray into resident room [ROOM NUMBER] without washing or sanitizing her hands upon entering or exiting the resident room. She was additionally observed failing to wash or sanitize her hands when entering and exiting room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. CNA CC was observed taking a resident's lunch tray without washing or sanitizing her hands when entering and exiting resident room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. During an interview on 8/28/2025 at 12:50 pm with CNA BB, she revealed that alcohol-based hand sanitizers were available on the walls inside the residents' rooms and in the hallways. She stated that she was required to sanitize her hands between serving each resident. However, she acknowledged that she failed to wash or sanitize her hands between residents while serving lunch trays. CNA BB noted that she received weekly training on proper hand washing techniques. During an interview on 8/28/2025 at 1:00 pm with CNA CC, she revealed that she was required to sanitize her hands each time she entered a resident's room with a tray and again when she exited. She added that she didn't need to sanitize her hands between serving residents as long as she didn't touch the resident or anything in their room. CNA CC acknowledged that she failed to wash or sanitize her hands between residents while serving lunch trays. She said that she received bi-weekly in-service training that includes hand hygiene. During an interview on 8/28/2025 at 12:50 pm with the Administrator, she discussed the importance of hand hygiene. She stated that she was unaware that staff members were not practicing proper hand hygiene while distributing meal trays to residents. She said she expected all staff handling resident trays to perform hand hygiene between each resident, regardless of whether they had touched anything while in the resident's room or not. The Administrator further noted that failing to practice hand hygiene could result in infection control issues and potential gastrointestinal illnesses.

Based on observations and staff interviews, and review of the facility policy titled, Preparing Pureed Foods, the facility failed to prepare pureed food in a manner that preserved the nutrient value of resident meals. The deficient practice had the potential to affect 15 of 15 residents receiving an oral pureed diet.Findings include:A review of the facility policy titled Preparing Pureed Foods last revised March 2024 revealed under Procedure: 1. Prepare food following the recipe for the regular textured foods. Pureed food should have the same flavor as their regular texture counterpart.Review of the recipe for Pureed Spaghetti Noodles dated March 2024 revealed instructions were:1. Place spaghetti noodles in a food processor.2. Add 2% (percent) white milk and butter or margarine and process until smooth.3. Add thickener and process briefly until mixed.Observation and interview on 9/27/2025 at 9:30 am with Head [NAME] (HC) AA revealed that HC AA filled a plastic pitcher with an unmeasured amount of water. She then placed a serving of spaghetti noodles for each resident on the puree diet into the food processor bowl and began to puree them. As she pureed the noodles, she gradually added small increments of water from the pitcher until it was all used, continuing to puree until the desired consistency was achieved.During an interview on 8/28/2025 at 8:30 am with HC AA in the dining room, HC AA explained that the facility had 15 residents on a pureed diet. She described her process for making puree, which involved gathering all the ingredients, beginning the pureeing process, and washing the food processor between recipes. HC AA mentioned that she used puree recipes and had been doing this for so long that she had memorized them. HC AA acknowledged that she did not refer to the puree recipes while preparing the meals observed. She further verified using water to puree the noodles when the recipe called for milk. She explained this choice by mentioning that warming the milk takes longer and did not puree as quickly as water. HC AA stated that she understood she was supposed to follow the recipes.During an interview on 8/28/2025 at 9:10 am with the Certified Dietary Manager (DM) in the dining room, the DM stated that she expected her staff to adhere to the puree recipes when preparing pureed foods. She acknowledged that she was not aware that the recipes were not being followed and confirmed that she did not provide oversight to ensure that staff complied with the recipes.During an interview on 8/28/2025 at 12:50 pm with the Administrator in her office, the Administrator stated that she was unaware that the kitchen staff were not following the recipes for preparing pureed food. She said that her expectation was for the staff to adhere to the puree recipes when preparing meals for residents on a pureed diet. She also mentioned that failing to follow these recipes could compromise the nutritional value of the food.

Based on observations, interviews, and a review of the facility policy titled Food Storage Guidelines, the facility failed to discard food items past the best-by date. This deficient practice had the potential to affect 66 of 66 residents receiving an oral diet.Findings include:Review of facility policy titled Food Storage Guidelines last revised August 2017 revealed under Procedure: .2. Discard will be up to the expiration and/or Used By Date on the Product.Observation on 8/26/2025 at 10:00 am of the walk-in cooler revealed a box containing one open bag of bacon with a best by date of 8/23/2025. Continued observation of the walk-in cooler revealed a rolling cart containing six 240 ml (milliliter) boxes of whole milk, which had a best by date of August 2025.Observation on 8/26/2025 at 10:10 am of the dry food storage revealed three 14 ounce boxes of thickened cranberry cocktail juice with a best by date of July 2025.During an interview on 8/26/2025 at 10:01 am, the DM confirmed the opened box of bacon had a best by date of 8/23/2025, the six boxes of whole milk had a best by date of August 2025, and the three 14-ounce boxes of thickened cranberry cocktail juice had a best by date of July 2025.During a follow-up interview on 8/27/2025 at 10:08 am with the DM, she explained that all kitchen staff were responsible for checking the expiration dates of stored food items. She expected the kitchen staff to check these dates on Mondays and Tuesdays each week, as new supplies were delivered on those days. The DM also mentioned that she did not currently have a method in place to oversee whether the stored food items were being rotated and discarded according to their best by dates.During an interview on 8/29/2025 at 12:50 pm with the Administrator, she explained that she was unaware that expired food items were not being removed and discarded properly. She expected the kitchen staff to rotate kitchen goods and check expiration dates regularly. When items expired, she expected them to be pulled and discarded. The Administrator further noted that failing to discard expired food could lead to residents contracting foodborne illnesses or experiencing gastrointestinal issues.

Based on observations, staff interviews, and review of the facility policy titled, Maintenance Service, the facility failed to maintain a safe, clean, comfortable, homelike environment in two of 25 rooms on East Hall (room [ROOM NUMBER] and room [ROOM NUMBER]) and free of black substance in one of 34 rooms on [NAME] Hall (room [ROOM NUMBER]). Specifically, ceiling tiles were stained with brown and black marks. The deficient practice had the potential to compromise the hygiene and safety of the room environments, negatively impacting the health and well-being of residents.Findings include: 1. Observation on 8/26/2025 at 10:58 am and 8/27/2025 at 3:46 pm of room [ROOM NUMBER] revealed brown stains on ceiling tiles above the bed and above the window. Observation on 8/26/2025 at 10:35 am and 8/27/2025 at 3:45 pm of room [ROOM NUMBER] revealed brown stains on ceiling tile above the bed. Interview and observation on 8/28/2025 at 11:24 am with the Maintenance Director of room [ROOM NUMBER] and room [ROOM NUMBER] revealed there had been leaking from the roof and they were working with the roofers to patch things up. He stated he agreed it's not a homelike environment and would get the ceiling tiles replaced. He stated 75-80% (percent) of the time that staff members did let him know about concerns in rooms, but it was getting better now. They were using agency staff in the past. He stated they have plans in the future to renovate the building and would do one room at a time. Interview on 8/28/2025 at 2:13 pm with the Administrator revealed when asked about her expectations for providing a safe, clean, comfortable, homelike environment for the residents, she stated that they were currently working on the roof and were changing out ceiling tiles as needed. She stated there was a schedule on an electronic system that the Maintenance Director followed; but she also expected him to make rounds every day. She expected him to check ceiling tiles after heavy rain due to known roof issues. She further stated that potential negative outcomes included respiratory issues due to air quality and mold as well as safety hazards. 2. An observation on 8/26/2025 at 10:43 am in room [ROOM NUMBER] on the [NAME] Hall revealed a buildup of black substances on the ceiling by the window in the corner of the room. Further observation revealed black marks on the wall behind the bed. An observation on 8/28/2025 at 9:59 am revealed a buildup of black substances on the ceiling by the window in the corner of the room. Further observation revealed black markings on the wall behind the bed. An interview and observation on 8/28/2025 at 11:24 am with the Maintenance Director confirmed the presence of the black substances on the ceiling tile and stated it was probably mildew. He stated that he did not realize the ceiling was like that, that it was not good, and that it needed to be changed. He stated a possible negative outcome could be the smell and ingesting it could affect the resident's health.

Based on observations, record review, resident and staff interviews, and review of facility policy titled, Medication Administration, the facility failed to assess one of 41 sampled residents (R) (R12) for self-administration of medication. The deficient practice had the potential to result in negative outcomes such as medication errors, incorrect dosages, or access by other residents. Findings include: Review of the facility's policy titled Medication Administration indicated under Preparation and General Guidelines: .B. Administration.14. Residents are allowed to self-administer medication when specifically authorized by attending physician and in accordance with procedures for self-administration of medication.A review of the electronic health record (EHR) for R12 revealed the resident was admitted to the facility with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypercapnia, type 2 diabetes mellitus, ischemic heart disease, and heart failure.A review of the quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Additional findings included partial to moderate assistance needed with several activities of daily living (ADLs), with independence in oral hygiene and set-up assistance with toileting.Review of physician orders dated 4/27/2024 indicated R12 was prescribed Arnuity Ellipta Inhalation Aerosol Powder Breath Activated (fluticasone furoate) 100 micrograms (mcg), one puff orally daily for chronic respiratory failure with hypercapnia. Further review of physician orders revealed no orders for self-administration of medications.Review of the EHR on 8/26/2025 revealed no documentation of a self-administration assessment for R12.Interview and observation on 8/26/2025 at 10:05 pm revealed an orange and white container of Arnuity Ellipta inhalation powder on R12's bedside table. R12 revealed the inhaler was her asthma medicine. She reported the nurse, Licensed Practical Nurse (LPN) DD, brought the inhaler in the morning, left it at bedside for use, and returned later to retrieve it. R12 stated this occurred frequently.Interview and observation on 8/26/2025 at 10:26 pm with LPN DD revealed she tended to leave the inhaler at the bedside for R12's use and came back to pick it up after she delivered medications to other residents. She acknowledged this was not the usual protocol and identified a potential negative outcome of another resident accessing the medication. She confirmed medications should not be left at the bedside.Interview on 8/28/2025 at 12:06 pm with the Director of Nursing (DON) revealed there were no residents in the facility who were authorized to self-administer medications. She stated she was aware of the inhaler being left at the bedside and that staff were instructed not to leave medications at bedside due to risks, including wandering residents obtaining access.Interview on 8/28/2025 at 2:14 pm with the Administrator revealed there were no physician orders in place permitting residents to self-administer medications. She acknowledged being aware of the incident and stated medications should not be left at the bedside. She identified potential negative outcomes, including unauthorized access, infection control concerns if not stored properly, and the possibility of residents using medications more frequently than prescribed.

Based on observations, resident and staff interviews, and record review, the facility failed to protect one of 41 sampled residents (R) (R28) from an accident with a fall. Specifically, R28 fell from a wheelchair to the floor.Findings include:Review of the electronic medical record (EMR) revealed resident R28 was admitted to the facility with diagnoses including but not limited to history of falling, acquired absence of right leg below knee, contracture, left ankle, other long term (current) drug therapy, and other reduced mobility.Review of R28's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicates R28 is moderate cognitively impaired. Section GG (Functional Status) revealed R28 requires extensive assistance for activities of daily living (ADLs) with two or more-person assistance with transfers. Mobility not rated.Review of R28's care plan dated 6/27/2025 indicated a focus of R28 has potential for injury and is at risk for falls. Most recent Morse Fall Score (scoring system to help determine how likely a person is to experience a fall, ranging from 0 to 125, the higher the score, the more likely a fall will occur) is 40. R28 requires assistance of 2 staff with Full Body Lift for transfers and has a wheelchair for mobility and a lap buddy (a cushioned devise that fits in a wheelchair and assists with reminding a person not to get up by themselves) while in wheelchair to enable her to sit upright. Goal of R28 will have no falls with injury requiring hospitalization by/through the next review date. Interventions of 2 persons when in shower or use of shower bed for showers, encourage her to leave lap buddy in place until ready for transfers, initiate neuro (neurological)-checks per protocol if indicated, be sure R28's call light is within reach and encourage R28 to use it for assistance as needed, ensure bed/wheelchair is locked during transfer, ensure/educate to keep bed in lowest position, as she allows. Resident able to control bed, fall Risk Assessment upon admission, readmission, and quarterly, keep room and common areas free from clutter, keep personal care items within easy reach, therapy to screen quarterly and prn (as needed).Observation and interview on 8/26/2025 at 3:51 pm with R28 revealed a purple area surrounding her left eye and a purple area in the center of her forehead. When asked about the purple areas, R28 revealed she fell out of the wheelchair and had to go to the hospital. R28 further revealed she had to get stitches but could not express how she fell out of the chair.An interview on 8/23/2025 at 12:23 pm with Certified Nursing Assistant (CNA) EE confirmed she was the CNA working when R28 fell. CNA EE revealed R28 was not in the correct wheelchair and the wheelchair buddy was not fitted for her and not on the wheelchair properly. When the R28 was finished eating, CNA EE put R28 in her room and let her know she was going to get the lift and help to put her in the bed. When CNA EE came back, R28 was on the floor. CNA EE stated the nurse at the time was at the nurses' station and yelled R28 had fallen on the floor. When CNA EE came, they both observed R28's leg wrapped up/caught in the back of the wheelchair, her face was on the floor, and there was a lot of blood on the floor. R28's family and EMS (emergency medical services) were called and EMS got R28 off the floor and she left with them to go to the hospital. An interview on 8/26/2025 at 12:48 pm with the Director of Nursing (DON) revealed she was not in the building when the fall happened. The DON further revealed the Unit Manager on duty at the time did the investigation. The DON revealed she found out on Saturday (the day after the fall) via phone by the agency nurse who was present in the building. She revealed the staff told her about the fall and R28 being transported to the hospital. The DON stated she then notified the Administrator there was a fall and the resident was sent out to the hospital.An interview on 8/26/2025 at 1:40 pm with the Administrator confirmed she received a text from the DON on 8/16/2025 at 6:48 pm and stated she knew the resident was sent to the hospital and there was nothing for her to do. The Administrator further revealed R28 hit her head, and she was awake, alert and bleeding when she was sent out.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Comprehensive Care Plan, the facility failed to develop and implement a comprehensive care plan for eye glasses and tobacco use for one of four residents (R) (R50) care plans reviewed. The deficient practice had the potential for unmet care needs for R50.Findings include:Review of the facility policy titled Comprehensive Care Plan revised January 2021 revealed under Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care.Review of R50's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicates R50 had moderate cognitive impairment. Section B (Hearing, Speech, and Vision) revealed R50 had impaired vision.Review of R50's care plan indicated a focus initiated on 7/17/2025 that documented R50 had impaired visual function and wears reading glasses at times. Goals included R50 will be maintained in a safe environment as evidenced by no injury related to visual impairment for 90 days. Interventions included but were not limited to ensure reading glasses are available.Further review of R50's care plan revealed no evidence of tobacco usage on the care plan.Review of an Activities Assessment-Initial/admission dated 7/7/2025 revealed that R50 has a current interest in reading and audiobooks. Further review of the assessment revealed that the resident states that she wears reading glasses only.In an interview and observation on 8/26/2025 at 10:25 am with R50, she stated that she needed glasses and had not seen her glasses since she moved into the facility. An observation made at this time revealed a can of chewing tobacco on table. R50 stated she used it once a day and usually had it on her table so she could use it when she wanted. She further stated she usually had someone open it as she has limited function of her hands.In an interview on 8/27/2025 at 12:40 pm with R50, she repeated that she needed glasses. She stated that she used her glasses to be able to read and see things she usually cannot see clearly, such as her television.An interview on 8/27/2025 at 1:02 pm with Licensed Practical Nurse (LPN) GG revealed when asked about R50's glasses, that the resident might have come to the facility with reading glasses, but she had not seen her wear them. She was not aware of any visual impairment for R50. When asked about the tobacco, LPN GG stated that R50 typically had pouches of tobacco, gets them herself, and puts them in her mouth herself. She stated that staff help to open the canister; and R50 was able to get the pouches out and removed them herself. She confirmed the tobacco was kept at R50's bedside. She further stated that staff did not do anything to monitor her use of tobacco.An interview on 8/28/2025 at 9:47 am with LPN JJ revealed she has not seen any glasses for R50. When asked about R50's tobacco, she stated that she was not sure if the tobacco should be kept at the bedside, but she thought that the tobacco should be care planned.An interview on 8/28/2025 at 10:01 am with LPN KK revealed she had not seen any glasses for R50.An interview on 8/28/2025 at 10:30 am with Unit Manager (UM) FF revealed that R50 came into the facility with glasses. She had not seen R50 with any glasses recently but would try to look for them. She confirmed that R50's care plan stated to ensure reading glasses were available for R50. She confirmed the CNAs could see the kardex with the exact wording and that CNAs were prompted to see the care plan every shift. She further stated that nurses would have to look for it in the care plan. When asked why the care plan was not being followed, Unit Manager FF could not explain why the care plan was not being followed. When asked about the tobacco canister, UM FF stated she was aware of the chewing tobacco and that staff assisted with opening the can for R50; and they provided a cup and disposed of the cup after R50 was finished with the tobacco. UM FF further stated it was typically kept at her bedside. When asked if the tobacco use was care-planned, she stated that the care plan for tobacco use was dated 8/27/2025, the second day of the survey. She did not know why it was not on the care plan prior to the surveyor's initial observation.In an interview on 8/28/2025 at 11:40 am with the Director of Nursing (DON), she stated that she expected her staff to follow care plans. She further stated that CNAs have to acknowledge the plan of care every shift. When asked about the tobacco, the DON confirmed that it should be part of R50's care plan.

Based on interviews and record reviews, the facility failed to ensure that resident care equipment was maintained in safe operating condition for one of six residents (R) (R1) reviewed for accidents. Harm was identified to have occurred on 2/24/2024, when R1 fell from a faulty shower bed and sustained a closed right peritrochanteric femur fracture requiring admission to an acute care hospital. Findings included: A review of the electronic medical record (EMR) revealed that R1 was initially admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia following cerebral infarction, Alzheimer's Disease, and morbid (severe) obesity. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that staff was not able to conduct the Brief Interview for Mental Status (BIMS) assessment for R1 due to the resident being rarely or never understood and revealed that R1 was dependent on staff for showers/bathing. A review of the progress notes dated 2/24/2024 revealed that at 4:28 pm, Licensed Practical Nurse (LPN) AA was called to R1's room and it was noted the resident was on floor, parallel to closet doors, with their right leg at right angle. It was documented that whining sounds were heard coming from the resident. The progress note documented that there were two Certified Nursing Assistants (CNA bb and CNA CC) in the room, and they reported they were preparing R1 for a shower. They reported that R1 had been lying on the shower bed for a few minutes when the support part of the head section became dislodged, which caused R1 and the lift pad to slide off the bed. It was noted that during the assessment, R1 remained conscious, the staff used the lift pad to realign R1's right leg, and R1 was transported by Emergency Medical Services (EMS) to an emergency room (ER). A review of the nursing note dated 2/29/2024 at 7:00 pm revealed that R1 had arrived back at the facility from the hospital at approximately 6:55 pm with a diagnosis of a closed pertrochanteric right femur fracture. During an interview with the Administrator on 6/20/2024 at 10:20 am she stated that she was aware of the incident involving R1 on 2/24/2024. She stated that the shower bed came assembled when it was delivered by the supplier three months ago. She stated that, as it related to the incident involving R1, the PVC (polyvinyl chloride) C-Clamp came undone and caused the head of the bed to fall and the mat slid down backward onto the floor while the two CNAs were adjusting R1 on the shower bed. The administrator confirmed that there had not been any routine maintenance or safety inspections done on the shower bed before this incident occurred. During an interview with the Maintenance Director on 6/20/2024 at 12:45 pm, it was confirmed that there were no routine inspections of the shower bed prior to the incident on 2/24/2024. They stated that they added self-locking nuts and bolts to the C-Clamp to the shower bed for modification purposes, and stated the nursing staff don't need to raise the head of the bed to shower the residents now. The bolts prevented it from moving at all. A review of the PVC Owner's Manual for the shower bed revealed, Do not make any modifications to this device. Use only the provided casters and accessories with this device. Use of third-party casters or accessories may pose a risk to the user and void the warranty . Anticipated Usable Product Life is based on normal use with proper maintenance, cleaning, and storage. You should still inspect, monitor, and care for the devices as described in this guide, as the device may need to be replaced sooner than expected in particular situations . F689 crossed reference with F908 S/S=G

Based on observations, interviews, and record reviews, the facility failed to provide an environment free from accident hazards for one of six residents (R)(R1) reviewed for accidents. Harm was identified to have occurred on 2/24/2024, when R1 fell from a faulty shower bed and sustained a closed right peritrochanteric femur fracture requiring admission to an acute care hospital. Findings included: A review of the electronic medical record (EMR) revealed that R1 was initially admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, aphasia following cerebral infarction, peripheral vascular disease, chronic pain, vascular dementia, anxiety, Alzheimer's Disease, morbid (severe) obesity, muscle weakness, and age-related osteoporosis. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed that staff was unable to complete the Brief Interview for Mental Status (BIMS) assessment for R1, meaning the resident is rarely or never understood. A review of the progress notes revealed that on 2/24/2024 at 4:28 pm, Licensed Practical Nurse (LPN) AA was called to R1's room and it was noted the resident was on the floor, parallel to closet doors, with her right leg at a right angle and that R1 was making whining sounds. The progress note further documented that the head of the shower bed was closest to the room entrance with the foot of the bed pointing towards the window in the room; the Certified Nursing Assistant (CNA) reported they (CNA BB and CNA CC) were preparing for R1's shower; and R1 had been laying on the shower bed for a few minutes when the support part of the head section became dislodged, which caused R1 and the lift pad to slide off the bed. It was noted that during the assessment, R1 remained conscious and was pulled away from the doors with the use of the lift pad already under her; this helped to realign her right leg with her body; and R1 was transported by Emergency Medical Services (EMS) to an emergency room (ER). A review of a nursing note dated 2/24/2024 at 5:50 pm revealed the family of R1 called the facility and informed them that R1 had sustained a right hip fracture. A review of the hospital medical records dated 2/24/2024 revealed that R1 sustained a closed right peritrochanteric femur fracture. Per the record, R1's x-rays revealed a fracture of the proximal right femoral diaphysis and proximal tibial fracture with likely extension into the medial tibial plateau as a result of a fall from a shower chair at the facility. A review of a nursing note dated 2/29/2024 at 7:00 pm revealed that R1 had arrived back at the facility from the hospital at approximately 6:55 pm with an admitting diagnosis of a closed pertrochanteric right femur fracture. During an interview with the Administrator on 6/20/2024 at 10:20 am, she stated that the shower bed came assembled when it was delivered by the supplier and all they had to do was roll out the mat on top of the bed. The Administrator stated on 2/24/2024, two CNAs were adjusting R1 on the shower bed. The PVC (polyvinyl chloride) C-Clamp came undone. This caused the head of the bed to fall and R1 and the mat slid down backward onto the floor. The administrator confirmed the facility had this shower bed for approximately three months before this incident happened and there had not been any maintenance or safety inspections done on the shower bed before that incident occurred. During an interview with LPN AA on 6/20/2024 at 11:51 am, he stated that he was the floor nurse at the time of the incident when R1 fell off the shower bed. He stated that one of the CNAs who'd been helping with the transfer came to tell him that R1 had fell and their right leg was at a right angle parallel to the closet. He stated that R1 was moaning and was scared and was sent out to the hospital. A phone interview was conducted with CNA BB on 6/20/2024 at 12:08 pm. CNA BB stated that they were helping another CNA with R1. CNA BB stated when they arrived at the resident's room, they went to the resident's right side, and the shower bed and Hoyer lift were already in the room in place and ready to be used. CNA BB stated they were then at the head of the shower bed to put the hooks through the second set of [NAME] on the lift pad. The wheels had been locked on the bed, but they believed the bed position was too low so R1 was pulled up on the shower bed and then the shower mat ended up being pulled up further than the resident. CNA BB further stated that the other CNA got in front, where the resident's feet were, and then they heard a snap sound. R1 slid down with her leg above their head and their pelvis facing the closet. An interview with the Maintenance Director was completed on 6/20/2024 at 12:45 pm, and they stated that they added self-locking nuts and bolts to the C-Clamp to the shower bed for modification purposes, and stated the nursing staff don't need to raise the head of the bed to shower the residents. The bolts prevented it from moving at all. During a phone interview with CNA CC on 6/20/2024 at 3:37 pm, confirmed that they were present when R1 fell from the shower bed. They stated that they did not receive specific training related to the use of the shower bed and that they had not used that specific shower bed much since it was newer. They said that the position was adjusted higher up than the previous shower bed they used. A review of the PVC Owner's Manual for the shower bed revealed, Do not make any modifications to this device. Use only the provided casters and accessories with this device. Use of third-party casters or accessories may pose a risk to the user and void the warranty . Anticipated Usable Product Life is based on normal use with proper maintenance, cleaning, and storage. You should still inspect, monitor, and care for the devices as described in this guide, as the device may need to be replaced sooner than expected in particular situations . A review of Safety Inspection log sheets for Shower Bed/Chair was reviewed and revealed that there were no inspections done before the 2/24/2024 incident. F689 crossed reference with F908 S/S=G

Based on observations, interviews, record review, and review of the facility's policy titled Emergency Pharmacy Service and Emergency Kits, the facility failed to ensure that an emergency medication kit (E-Kit) was readily available for use in a resident emergency for one of two medication rooms (Medication Room West) observed. Findings included: A review of the facility's policy and procedure titled Emergency Pharmacy Service and Emergency Kits, dated 4/1/2016, indicated that emergency pharmacy services are available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. An emergency supply of medications, including emergency drugs, antibiotics, controlled substances, and products for infusion is supplied by the provider pharmacy in limited quantities in portable, sealed containers, in compliance with applicable state regulations. As soon as possible the nurse records the medication on the medication order form and calls the pharmacy for replacement of the kit and flags the kit with a color-coded lock to indicate the need for replacement of kit. During an observation on 6/19/2024 at 11:18 am with the Assistant Director of Nursing (ADON) in the medication room West, a (red) color-coded E-Kit was observed in the refrigerator. Closer observation of the E-Kit revealed that it had been accessed and opened on 5/2/2024. The pharmacy record inside the E-Kit recorded Humalog (diabetes medication) was pulled out and utilized. During a concurrent observation and interview on 6/19/2024 at 11:20 am, the ADON stated that the refrigerated (red) color-coded E-Kit was opened, dated 5/2/2024, and was not replaced by the pharmacy. The ADON further stated that the process for replacing the E-Kit was to call the pharmacy and notify them of the usage and replacement needed as soon as possible to ensure there were always correct medications available.

Based on interviews and record reviews, the facility failed to ensure adequate blood glucose monitoring for residents receiving insulin. This deficient practice affected one of five residents (R) (R55) reviewed for unnecessary medications. Findings included: A review of R55's medical record revealed an initial admitted [DATE]. His medical history included type 2 diabetes, metabolic encephalopathy, and Alzheimer's Disease with late onset. An annual minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 5, indicating that R55 presents with severely impaired cognition. The MDS also indicated that R55 received insulin injections. During an interview on 6/19/2024 at 9:15 am, R55 stated that facility staff were not checking his blood glucose very often and that he would like it to be checked more frequently. A review of a medical provider progress note dated 3/18/2024 revealed an entry that indicated R55 would like his sugar checked more often, says he will cooperate with labs [sic]. A preliminary review of R55's physician orders revealed no active orders to monitor his blood glucose. Orders were noted for Levemir (a long-acting insulin) 20 units to be given subcutaneously at night and Novolog (a fast-acting insulin) six units to be given subcutaneously three times daily. A review of R55's discontinued physician orders revealed an order, dated 3/19/2024 to monitor his blood glucose. The order was discontinued on 4/23/2024 when R55 was transferred to the hospital. A preliminary review of R55's blood sugar flow records revealed the last entry was on 6/15/2024 at 11:12 am. The result was 256 mg/dL. Before this entry, the last documented blood glucose check was on 4/17/2024 at 6:31 am. The result was 375 mg/dL. On 6/20/2024 at 11:45 am, an interview was conducted with Licensed Practical Nurse (LPN) II. She confirmed that she was assigned to care for R55 and she was familiar with his care needs. LPN II confirmed that R55 did receive insulin injections and stated that nursing staff monitored R55's blood sugar every morning. When asked to review R55's blood glucose monitoring orders and results, LPN II reviewed the medical record and stated she would need to do some research. On 6/20/2024 at 12:05 pm, LPN II explained that R55 was transferred to the hospital due to an unrelated event in April 2024 and that the order to monitor the resident's blood glucose was not reinstated upon his return. On 6/21/2024 at 10:45 am, an interview was conducted with R55's Attending Physician (AP). The AP confirmed that the facility could be monitoring R55's blood glucose levels if he was receiving fast-acting insulin three times daily. The AP explained that R55 did have a history of refusing to have his blood glucose checked but added that attempts should be made, and refusals should be documented.

Based on observations, staff and resident interviews, and record review, the facility failed to provide the necessary care and services to maintain good oral hygiene for one of 31 sampled residents (R) (R55) reviewed for Activities of Daily Living (ADLs). Specifically, the facility failed to provide the resident with oral hygiene supplies, staff assistance, and/or reminders to complete oral hygiene care. Findings included: A review of the electronic medical record (EMR) revealed that R55 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including but not limited to dementia with behavioral disturbance, metabolic encephalopathy, and Alzheimer's disease with late onset. A review of R55's annual Minimum Data Set (MDS) assessment, dated 5/21/2024, revealed R55 presented with a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating severe cognitive impairment. Section GG (Functional Abilities and Goals) of the assessment indicated R55 was independent with oral hygiene. A review of R55's Care Plan revealed a focus area for self-care deficits related to Alzheimer's Disease and fatigue with intervention, dated 7/4/2023, directed nursing staff to assist and remind the resident to complete oral care in the morning and at night. During an observation and interview conducted on 6/19/2024 at 9:15 am, R55 was observed with a foul odor emanating from his mouth when he spoke, and an accumulation of a buildup of a thick discolored substance was observed on his teeth. The resident stated that the staff did not assist him with oral hygiene. He stated, They don't help me with a [expletive] thing! He confirmed that even if he asked, the staff did not assist with oral care. R55 was then asked whether he knew where his oral hygiene supplies (i.e., toothbrush, toothpaste, etc.) were kept and R55 stated, I have no idea. You can look in there, while pointing to his room. An observation of R55's s room and restroom revealed no oral hygiene supplies. During an interview conducted on 6/19/2024, at 9:35 a.m. with Certified Nursing Assistant (CNA) FF, she confirmed that she was familiar with R55's care needs. When asked whether he needed reminders to brush or assistance with brushing his teeth, CNA FF stated, He does that himself. When asked whether R55 had any difficulties with his memory, CNA FF stated, Yeah, he does forget some stuff and just wanders around pretty much all day. When asked whether R55 had a toothbrush and/or toothpaste in his room so that he would be able to brush his teeth if he remembered to do so, CNA FF looked in R55's room and restroom and confirmed there were no oral hygiene supplies. During an interview on 6/20/2024 at 11:45 am, Licensed Practical Nurse (LPN) II confirmed she was familiar with R55's care needs. However, when asked whether R55 was able to remember to brush his teeth or if he was able to physically carry out that task, LPN II stated, You know, I don't know. I'd have to check. During an interview on 6/21/2024 at 10:15 am, the Assistant Director of Nursing (ADON), reviewed R55's care flow records and confirmed there was no documented evidence that R55 was assisted with oral hygiene or encouraged to complete oral care.

Based on observations, interviews, and record review, the facility failed to ensure expired medications were properly discarded in two of two medication rooms (Medication Room East and Medication Room West). Findings included: During an observation of the Medication Room East with a Licensed Practical Nurse (LPN) JJ on 6/20/2024 at 12:12 pm, there were 32 Acetaminophen (pain/fever medication) suppositories (an opened box) located inside the refrigerator with an expiration date of September 2023. During an observation of the Medication Room [NAME] with LPN JJ on 6/20/2024 at 12:15 pm, there were five Acetaminophen suppositories located inside the refrigerator with an expiration date of September 2023. During an interview on 6/20/2024 at 12:30 pm, LPN JJ stated that the expired Acetaminophen suppositories should not have been stored in either medication room refrigerator due to the risk of administering expired medications to the residents. A review of a record, provided by the facility, revealed that five residents (R2, R10, R33, R36, and R57) had physician's orders for Acetaminophen suppositories to be given every six hours as needed for elevated temperature.

Based on observations, interviews, and policy review, the facility failed to label, and date stored and opened food items; failed to ensure the three-compartment sink had proper sanitizing solution concentration; and failed to ensure dietary staff properly washed dishware in three-compartment sink to prevent food borne illness. 49 of 51 residents were receiving an oral diet. Findings include: 1) Review of the facility policy titled Food Storage Guidelines revealed: date, label, and cover all non-perishable food items upon delivery and as items are removed from the original box or package. Date, and label each large condiment container. Date, cover, and label all food items to be stored in the freezer and coolers. Observation on 11/18/22 at 8:32 a.m. of the reach-in refrigerator revealed several bags of liquid eggs out of the original box and placed in a large gray bin, there was no date on the bin indicating date liquid eggs were out of package. During interview on 11/18/22 at 8:32 a.m. the Certified Dietary Manager (CDM) confirmed that the bin with the bags of liquid eggs had no date when the bags were taken out of original box. The CDM revealed that staff are to put a date on food items when removed from the package. Observation on 11/18/22 at 8:35 a.m. of the dry storage area revealed the can rack had three large cans of sweet potatoes that had no date of when delivered and taken out of box. During interview on 11/18/22 at 8:35 a.m. the CDM confirmed that the three cans of sweet potatoes did not have a date of delivery and expects staff to date when putting stock away. Observation on 11/18/22 at 8:45 a.m. of the bulk flour, sugar, and corn meal storage revealed that they were in a storage drawer in the food prep area. A 22-pound sugar bag was opened with no date. During interview on 11/18/22 at 8:45 a.m., dietary cook AA confirmed that there was no date on the large sugar bag and the cook stated that it should have been dated after opening. 2) Review of the facility policy titled Pot & Pan Sink/Three Compartment Sink revealed: it is the policy of the facility that the proper procedure be followed to ensure cookware is washed, rinsed, and sanitized properly to avoid cross contamination. Continued review of the policy revealed: The dietary staff will check and record the amount of sanitizer in the third well to ensure the proper level of sanitizer has been achieved (200ppm). Review of the document titled Procedure for Sanitizing Sink revealed: add bleach until test strip reads between 50-100ppm. Observation on 11/18/22 at 8:55 a.m. of the three-compartment sink revealed that there was a poster over the sink with information for quaternary sanitizing solution and the concentration was indicated as 100-400ppm (parts per million). Dietary cook AA assisted with testing the concentration of the sanitizing solution. The test strips used were not for ppm but for pH (potential hydrogen). There was no information available for dietary staff know what pH the sanitizing solution should be. During interview on 11/18/22 at 8:55 a.m. the CDM do not realize that the test strips used to test the sanitizing solution concentration in the three-compartment sink had changed to pH. The CDM stated the test strips are new, they recently were delivered earlier in week. The CDM confirmed that she does not have any information for usage of the new pH strips and had no information for staff as to what the pH level should be of the sanitizing solution in the three-compartment sink. During interview on 11/19/22 at 8:55 a.m. the CDM revealed that she contacted the chemical supplier regarding the new test strips and information for using the new pH strips. The CDM revealed the information the chemical supplier provided was not for the new test strips they received. The CDM showed email attachment she received for staff education and the test strips shown in the poster are not the test strips that the facility currently has. Continued interview with the CDM revealed that she is not able to provide written guidelines as to the use and proper pH concentration of the sanitizer solution in the three-compartment sink. During an interview on 11/19/22 at 12:05 p.m. CDM revealed that she is no longer using quaternary sanitizing solution in the three-compartment sink due to not able to get verification on how to read the new testing strips. The CDM stated that she has changed to using bleach/chlorine and has in-serviced dietary staff on how to use the bleach for sanitizing in the three-compartment sink. Continued interview revealed the CDM obtain information on-line regarding the proper concentration level for using bleach/chlorine as a sanitizer. The CDM stated that they do have chlorine test strips to use. Observation on 11/20/22 at 9:10 a.m. of the dietary cook AA wash the food processor bowl, blade, and lid in the three-compartment sink revealed that she washed the dishware in soapy water and rinsed. Dietary cook AA then placed the bowl and blade back on the food processor base and was going to puree the next food item without putting dishware in the bleach/chlorine sanitizing solution. During interview on 11/20/22 at 9:10 a.m., dietary cook AA confirmed that she did not properly sanitize the food processor dishware before starting next puree food item. Dietary cook AA stated that she does this process often of not sanitizing food processor dishware between processing food items. During an interview on 11/20/22 at 9:15 a.m. the CDM revealed she expects staff to wash and sanitize the food processor bowl, blade, and lid between food items. She expects staff to wash like any other dish in the three-compartment sink. Observation on 11/20/22 at 9:43 a.m. of the three-compartment sink revealed dietary cook AA assisting with testing the bleach/chlorine sanitizing solution concentration. The test strip revealed 10ppm. Continued observation revealed dietary staff stirred the bleach/chlorine solution in the sink and re-tested and again concentration registered as 10ppm. This sanitizing solution was used to wash the food processor bowl, blade, and lid during puree observation. During interview on 11/20/22 at 9:43 a.m. dietary cook AA confirmed that the bleach/chlorine sanitizing solution registered 10ppm on the test strip and it should be 50-100ppm. During interview on 11/20/22 at 9:43 a.m. the CDM also confirmed that the chlorine test strip registered 10ppm and should be 50-100ppm. The CDM revealed that staff will drain the sanitizing sink and re-do the bleach/chlorine solution.

Based on observations and interviews the facility failed the maintain the walk-in freezer in proper working condition as evidenced by ice build-up on a food storage rack. Facility census was 51. Findings include: Observation on 11/18/22 at 8:40 a.m. of the walk-in freezer revealed ice build-up adhered to the top shelf of the metal storage rack underneath the air condenser. The ice build-up was about two feet in length with four mounds of ice that were four to six inches in height and two to three inches in diameter. Continued observation revealed two cardboard boxes containing frozen food under the ice. During an interview on 11/18/22 at 8:40 a.m., the Certified Dietary Manager (CDM) stated that maintenance has knowledge of the ice build-up in the walk-in freezer. The CDM revealed it is unknown if a repair man has been contacted to look at the problem in the walk-in freezer and fix the issue. The CDM stated that the ice is removed by maintenance, and they remove the ice when she requests. Observation on 11/20/22 at 9:30 a.m. of the walk-in freezer revealed the ice build-up remained after CDM and maintenance have been notified. During an interview on 11/20/22 at 9:30 a.m. the CDM revealed that she spoke with the Assistant Director of Maintenance on 11/18/22 about the ice build-up and put in a work order. The CDM stated that maintenance is planning to remove the ice build-up during the week after kitchen hours. During an interview on 11/20/22 at 9:55 a.m. the Director of Maintenance revealed that he had no knowledge that the walk-in freezer had an ice build-up. He stated that the CDM submitted a work order for the walk-in freezer on 11/18/22.

Based on observation, interview and facility policy review, the facility failed to ensure one of three Certified Nursing Assistants (Staff II) implemented infection control procedures according to facility policy and procedures and national standards. Staff II removed soiled linens from the room of a resident that was under observation for possible COVID- 19. Staff II carried the soiled linens in the hallway, without placing them in a bag first. This deficient practice had the potential to expose residents and other staff to potential infections. Findings include: Observations were made in the facility on 12/28/20 at 2:10 PM, with Licensed Practical Nurse (Staff JJ), to find out which residents were on isolation precautions. As we approached the room of R#6, Staff JJ revealed the resident was on contact/airborne isolation precautions. At that time, Staff II came out of R#6's room with a hand full of unbagged laundry. Staff II saw Staff JJ and the surveyor standing outside the room, and proceeded back into the room stating, Oh, I've been caught. Staff II then came out of the room and took the unbagged laundry to the laundry bin in the middle of the hall. The laundry bin was positioned two doors down the hall from R#6's room, in which Staff II exited from. During an interview on 12/28/20 at 2:15 PM, Staff JJ was asked if carrying unbagged laundry out of a potentially infected resident's room was appropriate infection control practice. Staff JJ responded it was not appropriate and the linen should have been bagged. During an interview on 12/28/20 at 2:20 PM, Staff II was asked if it was appropriate to carry unbagged linen out of the resident's room, especially a potentially infected residents' room. Staff II stated it was never appropriate to take unbagged laundry out of the room of any resident. Staff II was asked why the linen was not bagged. Staff II stated, I forgot to bring a bag in (the room) with me. During an interview on 12/28/20 at 2:40 PM, the Administrator was asked what the expectation was when working with potentially infected residents and handling the linens. The Administrator stated, I think you know what my expectations are. Staff should bag all laundry when bringing it out of any room. During an interview on 12/28/20 at 3:45 PM, the Director of Nursing (DON) was asked about the unbagged laundry being carried out of a potentially infected resident's room. The DON responded that it was basic infection control (procedure) to bag all laundry that came out of a resident's room. The DON further revealed that R#6 was on observation precautions, since the resident's previous roommate had tested positive for the COVID-19 virus on 12/24/20. Review of facility policy titled, Laundry and Bedding, Soiled, revised July 2009. Under the section titled Policy Statement revealed . Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen . It was noted under the section titled Policy Interpretation and Implementation, . 2. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. 3. Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items .

Based on observation, staff interview and review of facility policy titled Vials and Ampules of Injectable Medications the facility failed to label one vial of Tuberculin Purified Protein Derivative (PPD) with an opened date and dispose of one box of expired suppositories in one of two medication rooms. The facility census was 91. Findings include: Review of facility policy titled Vials and Ampules of Injectable Medications dated [DATE], revealed opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this triggered expiration date are both important to be recorded on multi dose vials. At a minimum the date opened must be recorded. Observation on [DATE] at 11:15 a.m. of the West Hall medication room refrigerator with Licensed Practical Nurse (LPN) AA revealed one vial of Tuberculin Purified Protein Derivative/ Aplisol 5 TU/ 0.1 milliliters (ml) opened with no date opened on the vial or the box. There were no additional vials of PPD in the Medication refrigerator. LPN AA revealed the PPD vial should be discarded 30 days after opening but there was no way to identify when it was opened. Continued observation revealed one stock box of acetaminophen 650 milligram (mg) suppositories containing 47 suppositories, with a manufacturers expiration date of ,[DATE]. LPN AA confirmed the expiration date and revealed the stock medications are checked by the nurses when administering and by the consultant pharmacist monthly, but the expiration on the acetaminophen suppositories had not been noticed. There were no additional stock boxes of acetaminophen 650 mg suppositories in the medication room. Interview [DATE] at 11:20 a.m. with the West Hall Unit Manager confirmed the PPD vial had not been dated when opened and it was the facility policy to record a date on the vial of any multi-dose medication when opening. The Unit Manager acknowledged the acetaminophen suppositories should have been discarded over five months ago. Interview [DATE] at 4:32 p.m. with the Administrator revealed the policy indicates nurses are to date any multi- dose vial when they open it and the policy had not been followed.